Historic numbers of overdose deaths in the face of the COVID-19 pandemic

Like many other public health crises, the opioid epidemic has only been further exacerbated by the COVID-19 pandemic. In a statement released this month, the CDC reported 81,000 overdose deaths in the 12 months preceding May 2020 - the highest number of overdose deaths ever recorded in a 12 month period in the United States.

This alarming increase has also occurred here in San Francisco. According to the City and County of San Francisco Office of the Chief Medical Examiner, an estimated 636 people have died of an accidental overdose in San Francisco between January and November 2020 (this is a preliminary estimate and subject to change; final overdose data for 2020 will be released in mid-2021). So far, this represents a 44% increase from the 441 overdose deaths caused by opioids, methamphetamine, or cocaine reported in 2019.

Why are fatal overdoses spiking in the United States?

The reasons for this increase may vary by region. The fentanyl crisis had already appeared to peak in some areas of the U.S. (e.g., the Northeast) and mortality might have decreased were it not for the disruptions of COVID-19. In contrast, many western states only recently began to see the spike in overdose mortality associated with fentanyl. In San Francisco, for example, overdose deaths were expected to increase in 2020, regardless of COVID-19 and the associated precautions. There was, however, an additional spike in overdose deaths in May-June of 2020 that corresponded with a shelter-in-place order, including overdose deaths in hotels designated for COVID-19 isolation and quarantine, says Dr. Phillip Coffin, Medical Director of the Center on Substance Use and Health.

COVID-19 has only amplified many of the pre-existing issues in the opioid epidemic, one of the worst public health crises in the history of the United States. “It’s a small wave riding on top of a tsunami that continues to devastate,” says Dr. Dan Ciccarone, a professor of medicine at the University of California, San Francisco.

According to substance use experts interviewed by The New York Times, other factors that may have contributed to the rise in overdose deaths corresponding with shelter-in-place orders include:

• Social isolation: Harm reduction messaging has long advocated for people to use together as a way to prevent fatal overdoses. In the case of an overdose, there is another person around to administer the opioid overdose reversal medication naloxone (commonly known as Narcan). However, this strategy conflicts with the call to remain socially distant, shelter-in-place, and quarantine due to COVID-19. Individuals may be using drugs alone more often during the pandemic, putting them at increased risk of fatal overdose.

• Decreased income: Many Americans have lost their source of income during the pandemic. For people who use drugs, this may mean they are unable to maintain usual purchasing and consumption habits. Decreased use leads to lower tolerance, meaning what may have been a normal dose for someone who was regularly using could now be fatal, especially if they use alone.

• Decreased availability of services: Many services, such as rehabilitation centers, medical offices, and syringe exchanges, have stopped or decreased usual operations during the pandemic. These changes may result in decreased support and resources for people who use substances. This also may have limited naloxone availability as these services often distribute free naloxone.

• Changes in availability and potencies of substances: The unpredictable drug supply and changes in potency can make it hard to predict the strength of drugs. Fluctuations in the drug supply may also disrupt people’s usual drug use, which may affect their tolerance and increase the risk of overdose when they do use drugs again.

How has the City and County of San Francisco responded to the rise in overdose deaths?

Since the pandemic, San Francisco has expanded harm reduction and treatment services, including: “providing emergency shelters for higher risk adults and families; lowering barriers to increase access to substance use treatment, including giving providers more flexibility in initiating and continuing care; and intensifying overdose prevention measures...” Read more about San Francisco's interventions during the pandemic here.

Naloxone continues to play a key role in fatal overdose prevention. In the first eight months of 2020, naloxone was reported to have been administered to reverse at least 2,155 potentially fatal overdoses (compared to the 2,610 reversals in all of 2019). By the end of August, the DOPE Project and the San Francisco AIDS Foundation had set up 150 naloxone stations in 27 Shelter in Place hotels and Isolation and Quarantine units for people experiencing homelessness. Additionally, the San Francisco Police Department reported Tenderloin officers are using naloxone “more frequently than ever.” Without the increased access and use of naloxone, the fatal overdose numbers would likely be much higher.

What can I do as a San Francisco resident?

• Learn how to recognize and respond to an overdose.

• Carry naloxone!

- In San Francisco, the Community Behavioral Health Services (CBHS) Pharmacy (1380 Howard Street) will provide anyone with free naloxone nasal kits and teach you how to use it during an overdose. The pharmacy is open Monday-Friday from 9:00am to 3:30pm.

- View Harm Reduction Coalition’s Naloxone Finder. The Naloxone Finder is meant for people who use drugs to locate free naloxone.

• Advocate for housing and other social services for people who use drugs.

• Slow the spread of COVID-19 by following county, state, and national guidelines of social distancing and shelter-in-place.

Where can I get more information?

For more information, check out Harm Reduction Coalition (particularly, Opioid Overdose Basics Training Guide and Safer Drug Use During the COVID-19 Outbreak), the Drug Policy Alliance, and the CDC’s Opioid Dashboard.