key: cord-0850608-mdk37yqz
authors: DiGennaro, C.; Garcia, G.-G.; Stringfellow, E.; Wakeman, S.; Jalali, M. S.
title: Changes in Characteristics of Opioid Overdose Death Trends during the COVID-19 Pandemic
date: 2021-02-03
journal: nan
DOI: 10.1101/2021.02.01.21250781
sha: 61b0dffea425cf03f85437d8b9706fa69528a8d9
doc_id: 850608
cord_uid: mdk37yqz

Background and Aims: There are limited reports analyzing opioid overdose (OD) mortality data during the COVID-19 pandemic. There is also great heterogeneity in outcomes across states, necessitating assessments of the effects of COVID-19 on OD deaths on a state-by-state level. This report aims to analyze overall trends in OD deaths in Massachusetts during COVID-19. Design: Using individual-level death records in Massachusetts, we identified and analyzed OD mortality trends during the COVID-19 pandemic as compared to 2018 and 2019. We analyzed the period between March 24 (stay-at-home order in 2020) and August 11 (latest reliable data). We also estimated the correlation between OD deaths and COVID-19 case fatality rates at the county level. Setting: Massachusetts. Participants: A total of 2,342 OD deaths were analyzed. Measurements: The outcomes studied were OD deaths and COVID-19 case fatality rates. Findings: OD deaths involving cocaine and amphetamines increased from 2019 to 2020, by 20% (276 vs. 330; P<0.01) and 79% (33 vs. 59; P<0.01), respectively, but were steady from 2018 to 2019. Heroin's presence continued to decrease (238 in 2018, 161 in 2019, 102 in 2020; P<0.001); however, fentanyl was present in more than 90% of OD deaths, reflecting its continued domination of the illicit opioid supply in Massachusetts. Prescription opioid presence was stable. 79% of OD decedents were White and 6% were Black in 2019, as compared to 74% and 10% in 2020 (P=0.01). We found no significant correlation between COVID-19 case fatality and OD death rates. Conclusions: Increased deaths involving stimulants and alcohol reflect concerning trends in the era of COVID-19. Rising OD death rates among Black residents underscore that interventions focused on racial equity are necessary. Surveillance efforts must utilize up-to-date data to measure COVID-19 impacts on OD death and respond to imminent threats in real time.

The COVID-19 pandemic has revealed deep cracks in the U.S. health care system, social support structures, and economy. Meanwhile, another epidemic is increasingly deadly; nearly 51,000 people died of an opioid overdose (OD) in 2019 (1). Additionally, deaths involving cocaine and stimulants have risen (2), and alcohol consumption has increased (3) . The opioid OD crisis has evolved into one of the leading causes of death over the last 20 years, and the COVID-19 pandemic may have yet-unobserved impacts on its trajectory. Acknowledging the potential of COVID-19 to thwart harm reduction and treatment access, experts predicted an OD surge . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 3, 2021. ; https://doi.org/10.1101/2021.02.01.21250781 doi: medRxiv preprint exacerbated by isolation, economic instability, and volatility in opioid tolerances and supply (4) (5) (6) (7) .

Preliminary results in California (through April 18) and Indiana (suspected ODs through July 24)

show increases in daily OD deaths (8, 9) . States' OD and COVID-19 trajectories differ greatly (10) , necessitating assessments of the relationship between the pandemic and ODs on a stateby-state level. In this report, we analyze opioid OD mortality trends in Massachusetts during the COVID-19 pandemic as compared to 2018 and 2019, using the latest available mortality data from the state.

We obtained individual-level data for deaths recorded from 2018 to 2020 from the Massachusetts Registry of Vital Records and Statistics. We used ICD-10-CM codes to identify opioid OD as a cause of death (T40.1, T40.2, T40.4, and T40.6) (11) and restricted the study period to March 24 (stay-at-home order enacted) to August 11. At the time of our analysis, data after August 11, 2020 were considered provisional.

We extracted all substances present at the time of death from the text of medical examiners' final reports, sorting substances into seven relevant categories: prescription opioids (hydrocodone, hydromorphone, oxycodone, oxymorphone, codeine, dihydrocodeine, levorphanol and tramadol), heroin, fentanyl (and its analogues), alcohol, benzodiazepines, amphetamines (including methamphetamine), and cocaine. Only deaths involving opioids were . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted February 3, 2021. ; https://doi.org/10.1101/2021.02.01.21250781 doi: medRxiv preprint 5 analyzed. We also obtained COVID-19 case and death counts across all Massachusetts counties from the COVID-19 Data Repository at the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University, which is publicly accessible (12) .

To identify changing trends in OD deaths from 2018-2019, we assessed differences in distributions of age and daily OD death counts using the Mann-Whitney U test and differences in sex, manner of death, race, and substance variables using Pearson's Chi-Square Test of Independence. In a follow-up to our main analysis, we further assessed the relationship between COVID-19 severity and opioid OD deaths by computing Pearson's correlation between COVID-19 case fatality rates and the percentage change in opioid OD deaths per 100,000 people at the county level.

Analyses were performed using R version 4.0.3. This study was deemed exempt from review by Mass General Brigham's institutional review board. The analysis was not pre-registered and the results should be considered exploratory.

During the March 24 to August 11 analysis period, there were 809 recorded opioid OD deaths in 2018, 768 deaths in 2019, and 765 deaths in 2020. Population characteristics and results are described in Table 1 .

From 2019 to 2020, heroin's presence decreased (21% vs. 13%, P<0.001); however, the presences of alcohol (22% vs. 27%, P=0.03), amphetamines (4% vs. 7%, P=0.009), and cocaine . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 3, 2021. ; https://doi.org/10.1101/2021.02.01.21250781 doi: medRxiv preprint 6 (36% vs. 43%, P=0.004) increased. From 2018 to 2019, the presence of heroin had also decreased (29% vs. 21%, P<0.001); however, there was no evidence for changes in the presence of amphetamines (3% vs. 4%, P=0.09), alcohol (20% vs. 22%, P=0.33), or cocaine (33% vs. 36%, P=0.28). 

Mar 24-Aug 11

Mar 24-Aug 11

Mar 24-Aug 11 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 3, 2021. 

During COVID-19, the opioid OD crisis has remained a formidable foe to public health. Between CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 3, 2021. ; https://doi.org/10.1101/2021.02.01.21250781 doi: medRxiv preprint 8 fentanyl was present in more than 90% of opioid ODs during all three periods, reflecting its continued domination of the illicit opioid supply (14) , especially in Massachusetts.

Further, the proportional increase in Black OD decedents mirrors recent reports of disproportionate and increasing harm caused by the opioid overdose crisis to Black communities (15) , which had begun to materialize before the onset of COVID-19. Still, Black people, along with other minoritized groups, have also been disproportionately affected by COVID-19 (16) . Systemic racism evident in decreased access to health care, safe occupational conditions, income and wealth, and educational opportunities, present prior to the overdose crisis' rise and certainly prior to the COVID-19 pandemic, has been exacerbated by the compounding crises. However, the compounded effect in this study uniquely harmed Black people; while Latino/Hispanic people are 1.7 times more likely to be infected, 4.1 times more likely to be hospitalized, and 2.8 times more likely to die from COVID-19 (17), we observed no significant proportional increase in OD deaths compared to 2019. More research is needed to characterize the causal effects of racism at the intersection of COVID-19 and the opioid overdose crisis.

Recent research (8, 9) indicates increased daily opioid-related mortality following the pandemic's onset. Additionally, there are reports of increased initiation and use of substances to cope with the impacts of COVID-19 (18) . We observed a steady trend in daily opioid overdoses in Massachusetts, which is nonetheless notable given that the state was finally beginning to see a decrease in overdose fatality prior to COVID-19 (19).

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 3, 2021. ; https://doi.org/10.1101/2021.02.01.21250781 doi: medRxiv preprint

In light of inconclusive evidence for an increase in opioid OD trends across the state, we investigated whether there was a relationship between COVID-19 severity and opioid OD deaths at the county level. This analysis revealed no evidence that COVID-19 case fatality rate and increase in opioid OD death rates are correlated. Although we used a longer study period of confirmed ODs than prior research (8, 9) , the relationship between COVID-19 case fatality rates and opioid OD death rates may still evolve.

Massachusetts took several steps to ensure ongoing access to treatment and harm reduction resources, which may explain the non-significant increase in fatal ODs. For example, the state increased access to medications for opioid use disorder and issued guidance for OD rescue during the pandemic, potentially reducing opioid overdose deaths (20) . In contrast, California, which observed increases in opioid OD deaths, did not enact statewide methadone expansion . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 3, 2021. ; https://doi.org/10.1101/2021.02.01.21250781 doi: medRxiv preprint This analysis had limitations, chiefly that up-to-date opioid-related mortality data are not available, so our findings only reflect trends through August 11, 2020. Policies to mitigate the effects of COVID-19 are informed by detailed real-time infection and mortality data (23). Drug OD data, however, are collated more slowly than COVID-19 data; state data are finalized on a three-to four-month lag in Massachusetts and evidence suggests that these lags could be even greater in other states (24). There are several challenges to collecting opioid OD data, including barriers to complete information about specific drugs present and lengthy delays in finalizing death certificates. Additionally, requirements to report ODs in a timely manner differ among states (25). Our ongoing work aims to link several up-to-date data sources to better characterize and forecast the impacts of COVID-19 on the opioid OD crisis.

COVID-19 has impacted the public health landscape in several ways which will continue to be characterized over the coming years. Analysis of available data reveals signals of increased stimulant and alcohol presence in opioid ODs in Massachusetts. Stimulant and opioid-related deaths were becoming more frequent prior to the pandemic, but COVID-19 may have exacerbated their rise. Alcohol use has also increased, and the interaction between this and existing opioid use may amplify already-dangerous trends in opioid ODs. COVID-19 has brought about social isolation and existential distress for even the most fortunate members of society.

Evidence of rising substance use and related health harms emphasizes the need for rapid and low-threshold access to effective medication treatment, psychosocial support, and harm reduction resources. Prevention, treatment, and harm reduction interventions must be rooted in a race equity framework and address the broader contextual factors of homelessness, lost . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted February 3, 2021. ; https://doi.org/10.1101/2021.02.01.21250781 doi: medRxiv preprint economic opportunity, and societal despair. Lastly, improved data surveillance is needed to decrease the time between signal and action.

Changes in Adult Alcohol Use and Consequences During the COVID-19 Pandemic in the US

Mitigating and learning from the impact of COVID-19 infection on addictive disorders

An overdose surge will compound the COVID-19 pandemic if urgent action is not taken

When Epidemics Collide: Coronavirus Disease 2019 (COVID-19) and the Opioid Crisis

Collision of the COVID-19 and Addiction Epidemics

Opioid Overdose-Related Emergency Department Visits and Accidental Deaths during the COVID-19 Pandemic

Pandemic on Drug Overdoses in Indianapolis

Changing dynamics of the drug overdose epidemic in the United States from

International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity

Using International Classification of Diseases (ICD) Codes to Assess Opioid-Related Overdose Deaths

An interactive web-based dashboard to track COVID-19 in real time

The rise in non-fatal and fatal overdoses involving stimulants with and without opioids in the United States

COVID-19, and Public Health

The Opioid Crisis in Black Communities

COVID-19 Racial and Ethnic Health Disparities

COVID-19 hospitalization and death by race/ethnicity

Mental health, substance use, and suicidal ideation during the COVID-19 pandemic-United States

COVID-19 Public Health Guidance and

The authors declare no competing interests. 

We thank Rosalie Pacula for providing critical feedback on the analysis. We also thank Elizabeth Beaulieu, Huiru Dong, Simin Falsafi, Nicole Poellinger, and Celia Stafford for sharing their constructive comments on earlier versions of this manuscript. No funding was used to conduct this analysis.

1.NATIONAL CENTER FOR HEALTH STATISTICS. Provisional Drug Overdose Death Counts, 2020. Directives; 2020.. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 3, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)The copyright holder for this preprint this version posted February 3, 2021. ; https://doi.org/10.1101/2021.02.01.21250781 doi: medRxiv preprint