^{Compiled by Megan J. Wolff, PhD MPH
Last Updated: July 6, 2020}

Prior to the onset of Covid-19, small gains had begun to emerge amidst the opioid overdose crisis. A reduction in deaths due to prescription opioids and a slight increase in available services had helped to ease the mortality rate. It is very likely that the coronavirus pandemic has reversed these gains.

At the end of 2018, the most recent period for which data are available, overdose deaths due to opioids had fallen by 2%.¹

• The decrease coincided with a slight rise in American life expectancy, which had been declining since 2015 as a direct result of the opioid overdose epidemic.²
• It also accompanied a 14% decline in deaths involving prescription opioids.³

Access to treatment for opioid use disorders has been gradually expanding.

• Between January 2016 and April 2018, almost 19,000 new providers obtained waivers to prescribe buprenorphine, an opioid replacement therapy with high efficacy and low overdose risk.⁴
• Buprenorphine can be prescribed and administered in an office-based setting, increasing its availability and lowering stigma.
• While the number of patients receiving buprenorphine services is unknown (the Substance Abuse and Mental Health Services Administration [SAMHSA] does not collect this information), a total of 46,857 providers were authorized to offer the treatment.⁵

Nevertheless, these preliminary gains remained associated with a serious and deadly epidemic.

• 46,802 Americans perished from overdoses involving opioids in 2018.⁶
• This represents an estimated 130 deaths every day. ⁷
• Many regions have remained particularly hard-hit.
• West Virginia, the state with the highest opioid death rate, reported 923 deaths.⁸
• In New York City alone, 2,301 people died from opioid-related causes.⁹

• SAHMSA estimates that 2.1 million Americans have an opioid use disorder, placing them at highly elevated risk for overdose.

Though deaths involving prescription opioids have been trending downward, fatalities due to synthetic opioids such as fentanyl are rising.

• Synthetic opioids (principally fentanyl) were reported present in more than 31,000 fatal overdoses, or two-thirds of all opioid-involved deaths in 2018.¹⁰
• This represented a 10% increase over 2017.¹¹
• Many of these synthetic opioids were mixed with other drugs, contributing to a rise in death rates associated with other substances.
• Half of cocaine overdose deaths in 2018 included mention of synthetic opioids. ¹²
• One quarter of psychostimulant overdoses (specifically methamphetamine) involved synthetic opioids. ¹³
• The presence of synthetic opioids is often unknown to those who ingest them, increasing the likelihood of overdose.

COVID-19

The emergence of Covid-19 has profoundly disrupted public and private life, including access to addiction treatment and services. Federal data will not be available until December of 2020 or January of 2021, but preliminary reporting suggest a national spike in overdoses since the pandemic began, which is accelerating as it persists.

• Data from ambulance teams, hospitals and police show that suspected overdoses nationally jumped 18% in March, 29% in April and 42% in May. ¹⁴

Experts agree that the increase in overdoses stems from the significant stressors and new barriers to care imposed by the presence of Covid-19.

• “There is a serious risk that system-level gains in expanding access to medication for opioid use disorder, conducting clinical research, and exacting legal reparations against opioids manufacturers will all reverse.”¹⁵
• “If it weren’t for covid, these opioid deaths are all we’d be talking about right now.”¹⁶

A Relapse Trigger

• Addiction experts have been referring to Covid-19 as a “national relapse trigger.” ¹⁵
• Factors likely to promote relapse include:
• Disruptions in access to addiction treatment medicines
• The inability to attend recovery meetings in person
• Loss of jobs, which are themselves linked to maintaining health habits ¹⁶
• An overabundance of unstructured time
• Coping strategies that include a return to familiar routines and long-standing habits
• Isolation imposed by social distancing ¹⁷
• Profound stress and anxiety imposed by the epidemic, which is itself a primary driver of relapse

Preliminary Evidence

• In the absence of official data, providers and advocates are drawing worrisome conclusions from trends in treatment and access, many of which suggest that fewer patients are accessing services.
• An unpublished review of data from 4 large hospitals in New York City showed that addiction consultations and treatment referrals had decreased by half during March and April, 2020, as compared to the same months in 2019. ¹⁸
• Inpatient treatment centers and community group homes have experienced a decline in patients, as individuals depart due to concerns about contracting the virus.
• In May, some inpatient treatment providers reported that they had about 50% fewer patients than they had pre-pandemic. ¹⁹
• The number of civil commitments to addiction treatment through the courts was down by more than 50%. ²⁰
• On June 20, 2020, American Addiction Centers, Inc., (a multistate drug rehabilitation and treatment chain) filed for Chapter 11 bankruptcy protection after mandatory stay-at-home orders drove down inpatient admissions and outpatient visits. ²⁰
• Nationwide, walk-in clinics and syringe exchange programs offering harm reduction have been limited or closed. ²²
• Some clinics offering services online have reported an uptick in requests from states where access to sterile injection supplies has dried up. ²³


• Nationwide, reporting suggests that opioid overdose deaths are rising nationwide.
• At least 30 states have reported increases in opioid-related mortality. ²⁴
• Local officials, too, report spikes in overdose calls and deaths. ²⁵
• In Franklin County, OH, the county coroner reported a 50% increase in fatal overdoses from January to mid-April. ²⁶
• Niagara County, NY, reported a 35% increase in fatal overdoses from Jan 1 – April 6 over the prior year. ²⁷
• In Jacksonville, FL, the fire and rescue chief reported a 20% increase in overdose calls from February through March. ²⁸
• In Arkansas, State Drug Director Kirk Lane reported a rise in the number of Narcan administrations in March and April, and observed that the number of life-saving encounters by law enforcement had “more than tripled.” ²⁹


• Given the high level of disruption to lives and services, it is difficult to determine whether overdoses are the result of lost services, abundant relapse triggers, or a combination of many factors.
• Dr. Nora Volkow, director of the National Institute on Drug Abuse, noted that coroners and medical examiners are overwhelmed with cases of Covid-19, and may not have the resources to follow up on overdose deaths
• "We do not know [whether more people are overdosing in connection with Covid-19],” Volkow remarked. "In many cases, we will likely never know." ³⁰

The National Response

Health officials have mounted an early and robust response in hopes of mitigating the impact of the coronavirus pandemic on the opioid crisis.

• On January 31, 2020, the Secretary of Health and Human Services (HHS) declared a public health emergency around the Coronavirus.
• The Assistant Secretary for Mental Health and Substance Use immediately requested a loosening of regulatory requirements surrounding access to medication treatment for opioid use disorders.
• These affected two key areas of treatment:
• The use of telehealth to initiate and monitor medication assisted therapies (MAT) ³¹
• The ability of treatment programs to dispense extended quantities of the addiction treatment medications methadone and buprenorphine to patients whom providers deem stable, so they will not have to visit clinics daily, and to make “doorstop” deliveries of take-home medication for patients impacted by quarantine ³²


• On March 16, 2020, the DEA granted these exceptions for the duration of the public health emergency. ³³
• DEA-registered practitioners can now prescribe buprenorphine to new and existing patients through telehealth, without an initial in-person visit.
• New patients requiring methadone must still initiate treatment in person, but existing methadone patients can be maintained through telehealth.


• Other agencies also loosened their requirements to ensure access to care during the epidemic.
• Federally, the Office of Civil Rights recommended suspension of penalties for noncompliance with HIPAA telehealth requirements. ³⁴
• The Centers for Medicare and Medicaid Services (CMS) authorized states to reimburse a broad range of telehealth services at the same rate as in-person visits, including behavioral health. ³⁵


• On March 31, 2020, the DEA issued guidance to all states, providing flexibility for physicians managing patients with opioid use disorder.

The decision to implement these changes is left to the discretion of state governors, and the guidelines have thus far been adopted unevenly. Nevertheless, preliminary reports from states embracing the measures suggest rapid implementation.

• In Maryland, Governor Larry Hogan issued an executive order authorizing the new telehealth reimbursement on March 20, even before the release of the DEA guidelines. ³⁷
• In Kentucky, Governor Andy Beshear not only authorized the changes, but signed an executive order on April 2nd providing telehealth treatment to nonviolent offenders with a history of substance use whose sentences he had suspended to promote social distancing. ³⁸
• In Massachusetts, more than 15,000 patients became authorized to take methadone at home for up to 28 days at a time.
• After two months, fewer than 20 reports had been made of lost or stolen doses, and there had been no reports of death due to methadone overdose ³⁹
• In New York City, the Health + Hospitals Corporation established a virtual buprenorphine clinic accessible by phone (212- 562-2665). Opioid treatment centers became authorized to dispense 28-day supplies of methadone. ⁴⁰

Addiction specialists remain deeply concerned about the fate of patients struggling with substance use disorders in the midst of the pandemic. A clearer picture of how the pandemic has affected overdoses will emerge as state and federal numbers are gathered and released in the coming months.

---

¹ Hedegaard H, Miniño AM, Warner M. “Drug Overdose Deaths in the United States, 1999–2018.” NCHS Data Brief, no 356. Hyattsville, MD: National Center for Health Statistics. 2020.

² Life expectancy for the U.S. population in 2018 was 78.7 years, an increase of 0.1 year from 2017. Xu J, Murphy SL, Kochanek KD, Arias E. “Mortality in the United States, 2018.” NCHS data brief 355. January 2020.

³ Hedegaard H, Miniño AM, Warner M. “Drug Overdose Deaths in the United States, 1999–2018.” NCHS Data Brief, no 356. Hyattsville, MD: National Center for Health Statistics. 2020.

⁴ Christi A. Grimm, OIG Report, “Geographic Disparities Affect Access to Buprenorphine Services for Opioid Use Disorder” Jan 2020. OEI-12-17-00240.

⁵ Christi A. Grimm, OIG Report, “Geographic Disparities Affect Access to Buprenorphine Services for Opioid Use Disorder” Jan 2020. OEI-12-17-00240.

⁶ Scholl, Lawrence, Puja Seth, Mbabazi Kariisa, Nana Wilson, and Grant Baldwin, “Drug and Opioid-Involved Overdose Deaths— United States, 2013–2017,” Morbidity and Mortality Weekly Report, No. 67, January 4, 2019, pp. 1419–1427.

⁷ CDC, “Understanding the Epidemic,” December 2018.

⁸ The six states with the highest rates of overdose mortality in 2018 were West Virginia (51.5 per 100,000), Delaware (43.8 per 100,000), Maryland (37.2 per 100,000), Pennsylvania (36.1 per 100,000), Ohio (35.9 per 100,000), and New Hampshire (35.8 per 100,000). https://www.cdc.gov/drugoverdose/data/statedeaths.html

⁹ New York State Department of Health, “New York State - County Opioid Quarterly Report” Published January, 2020.

¹⁰ Ahmad, F. B., L. A. Escobedo, L. M. Rossen, M. R. Spencer, M. Warner, and P. Sutton, “Provisional Drug Overdose Death Counts,” National Center for Health Statistics, 2019. As of January 30, 2018: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm Wilson N, Kariisa M, Seth P, et al. Drug and Opioid-Involved Overdose Deaths—United States, 2017-2018. MMWR Morb Mortal Wkly Rep 2020; 69:290-297.

¹¹ Hedegaard H, Miniño AM, Warner M. “Drug Overdose Deaths in the United States, 1999–2018.” NCHS Data Brief, no 356. Hyattsville, MD: National Center for Health Statistics. 2020.

¹² Pardo, Bryce, Jonathan P. Caulkins, Beau Kilmer, Rosalie Liccardo Pacula, Peter Reuter, and Bradley D. Stein, “The Synthetic Opioid Surge in the United States: Insights from Mortality and Seizure Data.” Santa Monica, CA: RAND Corporation, 2019.

¹³ Pardo, Bryce, Jonathan P. Caulkins, Beau Kilmer, Rosalie Liccardo Pacula, Peter Reuter, and Bradley D. Stein, “The Synthetic Opioid Surge in the United States: Insights from Mortality and Seizure Data.” Santa Monica, CA: RAND Corporation, 2019.

¹⁴ William Wan & Heather Long, “‘Cries for help’: Drug overdoses are soaring during the coronavirus pandemic,” Washington Post, July 1, 2020.

¹⁵ Becker, W. C., & Fiellin, D. A. (April 2, 2020). "When epidemics collide: Coronavirus disease 2019 (COVID-19) and the opioid crisis", Annals of Internal Medicine.

¹⁶ Natalia Derevyanny, spokeswoman for the medical examiner’s office in Cook County, IL. In William Wan & Heather Long, “‘Cries for help’: Drug overdoses are soaring during the coronavirus pandemic,” Washington Post, July 1, 2020.

¹⁷ Jan Hoffman, “With Meetings Banned, Millions Struggle to Stay Sober on their Own,” NYT March 26, 2020. “When we provide treatment, we talk about relapse triggers,” noted Dr. Tim K. Brennan, director of the Addiction Institute at Mount Sinai West in New York City in an interview with CNN. I’m hard-pressed to think of a bigger relapse trigger than what we’re going through now as a country.” Fernando Alfonso, III, “The Pandemic is Triggering Opioid Relapses Across Appalachia,” CNN, May 14, 2020.

¹⁸ Dr. Lawrence Weinstein, chief medical officer at American Addiction Centers (AAC) in Fernando Alfonso, III, “The Pandemic is Triggering Opioid Relapses Across Appalachia,” CNN, May 14, 2020.

¹⁹ “Some of the social distancing or physical distance measures that have been put in place make it much more difficult for people to maintain their recovery,” notes Dr. Michael Genovese, Chief Medical Officer of Acadia Behavioral Healthcare Network, “because for anybody, being isolated from others can lead to feelings of depression, feelings of anxiety, feelings of isolation," Fernando Alfonso, III, “The Pandemic is Triggering Opioid Relapses Across Appalachia,” CNN, May 14, 2020.

²⁰ Referrals had dropped from 41.8 per month on average to 21 in March and 11 in April. Personal communication, Jonathan Avery, MD, June 12, 2020.

²¹ Deborah Becker, “The Pandemic Has Changed Addiction Treatment, Some Hope for Good,” WBUR May 21, 2020.

²² Deborah Becker, “The Pandemic Has Changed Addiction Treatment, Some Hope for Good,” WBUR May 21, 2020.

²³ Jeff Montgomery, “Covid-19 Fallout Puts Addiction Center into Ch.11,” Law360, June 22, 2020.

²⁴ Harmeet Kaur, “The opioid epidemic was already a national crisis. Covid-19 could be making things worse,” CNN, May 7, 2020.

²⁵ These include Ohio, Kentucky, and West Virginia. More harm reduction programs around the country are beginning to mail syringes and naloxone to people who use opioids. Harmeet Kaur, “The opioid epidemic was already a national crisis. Covid-19 could be making things worse,” CNN, May 7, 2020

²⁶ AMA Issue Brief, “Reports of increases in opioid-related overdose and other concerns during COVID pandemic,” updated June 30, 2020.

²⁷ Harmeet Kaur, “The opioid epidemic was already a national crisis. Covid-19 could be making things worse,” CNN, May 7, 2020.

²⁸ Harmeet Kaur, “The opioid epidemic was already a national crisis. Covid-19 could be making things worse,” CNN, May 7, 2020.

²⁹ “Niagara County is experiencing increase in drug overdose calls amid Covid-19 Pandemic,” WIVB News, April 9, 2020.

³⁰ Jenese Harris, “Jacksonville overdose calls increase 20% in March,” WJXT News4JAX, April 13, 2020.

³¹ “We would see about 5 to 10 per month, but we are seeing an excess of 20 to 25 now. ” Laura Monteverdi, “Number of Narcan ‘saves’ triple during Covid-19 Pandemic,” THV11 News, April 22, 2020.

³² Harmeet Kaur, “The opioid epidemic was already a national crisis. Covid-19 could be making things worse,” CNN, May 7, 2020.

³³ Research shows that use of telehealth to treat OUD is as effective as in-person visits on patient outcomes, while expansion of telehealth has been shown to significantly increase access to OUD treatment. Wanhong Zheng et al., “Treatment Outcome Comparison Between Telepsychiatry and Face-to-face Buprenorphine Medication-assisted Treatment for Opioid Use Disorder: A 2-Year Retrospective Data Analysis,” Journal of Addiction Medicine 11 (2017):138-144; ASPE Issue Brief, “Using Telehealth to Support Opioid Use Disorder Treatment,” November 2018.

³⁴ Pew Charitable Trusts, “Ensuring Access to Evidence-Based Opioid Use Disorder Treatment During COVID-19 Public Health Emergency,” April 15, 2020.

³⁵ William McDermott to Elinore McCance-Katz, US Department of Justice, Drug Enforcement Division, March 16, 2020.

³⁶ Office for Civil Rights, “FAQs on Telehealth and HIPAA during the Covid-10 nationwide public health emergency,”

³⁷ Pew Charitable Trusts, “Ensuring Access to Evidence-Based Opioid Use Disorder Treatment During COVID-19 Public Health Emergency,” April 15, 2020.

³⁸ Jon Avery & Joseph Avery, “Covid-19 and the ‘Other’ Public Health Crisis in NYC,” Psychology Today, 6/6/2020.

³⁹ Order of the Governor of the State of Maryland, Number 20-03-30-01 Authorizing Reimbursement of Audio-Only Health Care Services. March 20, 2020.

⁴⁰ Katherine Marks, project director of Kentucky Opioid Response Effort. Fernando Alfonso, III, “The Pandemic is Triggering Opioid Relapses Across Appalachia,” CNN, May 14, 2020.

⁴¹ Deborah Becker, “The Pandemic Has Changed Addiction Treatment, Some Hope for Good,” WBUR May 21, 2020.

⁴² Jon Avery & Joseph Avery, “Covid-19 and the ‘Other’ Public Health Crisis in NYC,” Psychology Today, 6/6/2020.