Unintentional Opioid Overdose Death Characteristics in Illinois Before and During the COVID-19 Era, 2017 to 2020

We characterized Illinois unintentional opioid overdose deaths from July 2017 through June 2020 using the Centers for Disease Control and Prevention State Unintentional Drug Overdose Reporting System (SUDORS). Illinois SUDORS includes 42 counties, representing 91% of the state’s overdose deaths; trained abstractors enter data using death certificates, medical examiner and autopsy reports, and postmortem toxicology testing (eMethods in the Supplement). This study was approved by the Northwestern University institutional review board and adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.

We described key decedent and death scene characteristics over 6-month intervals, with attention to the January to June 2020 interval containing the pandemic start. Decedent characteristics included demographics, postmortem toxicology, and recent encounters with key touchpoints within the previous month¹: emergency departments (EDs), hospitals, jails/prisons, and supervised residential treatment. Death scene characteristics included overdose location, bystander presence, and interventions performed.

There were 6058 opioid overdose deaths from July 2017 to June 2020. The Table summarizes decedent demographics. The Figure displays population-adjusted opioid overdose deaths over time, alongside hospitalizations for opioid overdose. Deaths and hospitalizations were stable from July 2017 to June 2019 and increased from July 2019 to June 2020.

Decedents were increasingly Black and Hispanic over time and exceeded White decedents by January to June 2020; decedents were also increasingly aged 60 years or older. In January to June 2020, 174 (13.5%) had a recent touchpoint encounter compared with 133 (11.8%) in July to December 2019. Toxicology testing results were increasingly positive for fentanyl, reaching 1056 (82.1%) by January to June 2020; prescription opioid positivity remained stable.

During the January to June 2020 period coinciding with COVID-19, most overdose deaths occurred in the decedent’s home (787 [61.2%]) with bystanders present (647 [50.3%]), similar to preceding periods. Some death scene characteristics were marginally lower in January to June 2020 compared with July to December 2019: bystander cardiopulmonary resuscitation (93 [14.4%] vs 92 [16.1%]), ED transportation (306 [23.8%] vs 319 [28.3%]), and naloxone administration (465 [31.8%] vs 449 [34.0%])—although these rates were not dissimilar to earlier periods. Several decedent characteristics relating to previous opioid use disorder (OUD) reached their lowest rate in January to June 2020, such as any previous overdose (110 [8.6%]) or OUD treatment (152 [11.0%]), despite higher rates of recent touchpoint encounters.

Several study findings warrant further discussion. First, the proportion of Black, Hispanic, and older adult decedents has continued to increase. It is imperative that we address known racial disparities in access to buprenorphine and linkage to treatment after nonfatal overdose²; we must also devote attention to identifying OUD among older adults. Second, fentanyl is now pervasive in the drug supply and far more prevalent in postmortem toxicology results than prescription opioids. Greater resources should be devoted to the provision of fentanyl test strips and take-home naloxone, particularly from key touchpoints encountered by 1 in 7 decedents in this study. Third, several indicators of previous OUD nadired in the COVID-19 period, despite higher rates of recent touchpoint encounters. Harm reduction initiatives, such as naloxone distribution, should more broadly target individuals without a history of prior overdose. Finally, most overdoses occur in a decedent’s home and with bystanders present. Future interventions should equip and empower persons who use opioids and their surrogates to use opioids safely in communion and with resources to reverse overdose.

These findings are limited to a single state and rely on death certificate and medical examiner reports, which may be incomplete. However, they serve as the first characterization of decedent characteristics during the COVID-19 era and demonstrate that opioid overdose deaths began to increase in late 2019 in Illinois with decedent characteristics largely continuing existing trends. These data may inform missed opportunities for overdose prevention and development of carefully tailored harm reduction policies.

Accepted for Publication: September, 26, 2021.

Published: November 12, 2021. doi:10.1001/jamahealthforum.2021.3699

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Kim HS et al. JAMA Health Forum.

Corresponding Author: Howard S. Kim, MD, MS, 211 E Ontario St, Ste 200, Chicago, IL 60611 (howard.kim@northwestern.edu).

Author Contributions: Drs Kim and Mason had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Kim, Feinglass, McCarthy, Mason.

Acquisition, analysis, or interpretation of data: Kim, Feinglass, Lank, Mason.

Drafting of the manuscript: Kim, Feinglass.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Kim, Feinglass.

Obtained funding: Kim.

Administrative, technical, or material support: Kim, Mason.

Supervision: Kim.

Conflict of Interest Disclosures: Dr Kim receives unrelated grant support from R01HS027426. Dr Mason receives unrelated grant support from NU17CE924941.

Funding/Support: This research was supported by the Davee Foundation (Dr Kim) and an anonymous donor (Dr Mason). Data were collected through Centers for Disease Control and Prevention (CDC) Federalwide Assurance (NU90TP921958).

Role of the Funder/Sponsor: The Davee Foundation and the anonymous donor did not have any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The CDC did not have any role in the design and conduct of the study; analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. However, the CDC operates the data collection system which receives and manages individual state SUDORS data prior to distributing cleaned and streamlined data back to individual states.

Disclaimer: Dr Kim is an Associate Editor at JAMA Network Open and is not involved in the editorial process at JAMA Health Forum. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the CDC or the Department of Health and Human Services.

Data Sharing Statement: The Illinois Department of Public Health (IDPH) is the custodian of Illinois SUDORS data. Data requests should be submitted to IDPH directly at: www.dph.illinois.gov/data-statistics/irb.