The Pandemic Stay-at-Home Order and Opioid-Involved Overdose Fatalities

In response to the COVID-19 pandemic, Illinois enacted a stay-at-home order on March 21, 2020; the order was lifted on May 30, 2020. This report describes trends in opioid-involved overdose deaths over a 3-year period and highlights the number of deaths during the 11-week Illinois stay-at-home order. Trends in substance involvement are also examined.

Prior to the pandemic, Cook County, Illinois, had already experienced 2 years of high levels of opioid-involved overdose deaths, with a disturbing increase beginning in late 2019 and early 2020.¹ Adding to this, people with substance use disorder (SUD), many of whom already experienced trauma and the effects of incarceration, also faced major disruptions in in-person treatment and recovery services during the early stages of the pandemic. For most people with SUD, the pandemic compounded an already tenuous situation with massive losses of service sector jobs and health insurance, and loss of in-person social support, resulting in increased anxiety, depression, and social isolation.² The pandemic also led to interruptions and changes in the drug supply. Increasing use of illicit fentanyl had already been contributing to an increase in overdose deaths in Cook County.³ Fatal overdose risk is amplified when powerful, illicitly manufactured opioids are substituted for less potent drugs, which may have been unavailable during lockdown.

Loss of support groups and services may have led some in recovery to relapse, which can result in loss of drug tolerance. Social distancing may have led to solitary use of opioids in places with no bystanders available to administer naloxone, which can reverse opioid overdose effects when given in time. These challenges for persons with SUD during the COVID-19 pandemic occurred in the context of rising overdose mortality rates beginning in late 2019 and were exacerbated during the early months of the pandemic.⁴

This report provides estimates of opioid-involved overdose deaths in Cook County, with a population of more than 5.1 million living in Chicago and surrounding suburbs. The report describes trends over 3 years in weekly opioid overdose deaths to highlight changes before, during, and after the Illinois COVID-19 stay-at-home order. Some of the data in this article have been reported previously.⁴ This report includes an expanded period, extending the time after the stay-at-home order by 3 additional months; a broadened consideration of the preexisting trend in increased fatalities; and new data on a select set of substances involved in opioid overdoses tied to COVID-19–sensitive periods.

Data from the Cook County Medical Examiner’s Office case archive including deaths with opioid involvement occurring during January 1, 2018–December 31, 2020, were reviewed.⁵ Cause of death determinations were made by forensic pathologists at the Cook County Medical Examiner’s Office, which has jurisdiction over all probable drug overdose deaths in Cook County. The cause of death was determined based on autopsy and toxicology findings, which were used to determine the trends in the presence of fentanyl, heroin, methadone, methamphetamine, benzodiazepine, or ethanol, as a percentage of all weekly opioid-involved overdose deaths.

Weekly opioid overdose deaths were examined for 4 periods: (1) the 100 weeks between January 5, 2018, and December 3, 2019; (2) the 15 weeks before the stay-at-home order was issued: December 4, 2019, to March 20, 2020; (3) the 11 weeks during the stay-at-home order: March 21-June 5, 2020; and (4) the 29 weeks after the order was lifted: June 6-December 23, 2020.

A total of 4283 opioid overdose fatalities occurred in Cook County from January 2018-December 2020, ranging from 12 to 53 weekly (eFigure in the Supplement). There was a mean of 23.0 deaths per week during the initial 100-week period (2018-2019), with little apparent seasonal variation. During the subsequent 15 weeks beginning in December 2019, deaths increased to a mean of 35.1 per week, followed by an even more pronounced increase during the 11-week stay-at-home order: 44.1 mean weekly deaths. In the 29 weeks after the stay-at-home order was lifted mean weekly deaths sharply declined and then began to increase toward the end of the period, at 32.7 deaths. Although deaths have declined below the peak weekly numbers seen during the stay-at-home period, opioid overdose deaths following the stay-at-home period remain elevated above pre-2020 levels.

The Table presents the prevalence of specific drugs measured as a proportion of deaths in each period. There was a steady increase in the proportion of deaths with fentanyl present, from 73.9% in 2018-2019 to 81.9% in the 29-week post-lockdown period, and a steady decrease in the proportion of deaths with heroin present, from 53.7% of deaths in 2018-2019 to 32.2% of deaths in the last period of 2020.

Table.  Changes by Period in Substances Involved in Opioid-Related Overdose Deaths in Cook County, Illinois, January 2018-December 2020

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As the COVID-19 pandemic continued, outreach, treatment, and recovery organizations were able to resume some services and initiate others, including online counseling, expanded options for and access to medication for addiction treatment via telehealth, and creation of online support groups for persons in recovery. However, the trend in fentanyl-related overdose deaths that began prior to the pandemic will require major new initiatives.

Detailed recommendations about overdose prevention strategies during COVID-19 are available at the CDC’s Health Alert Network.⁶ Among these efforts are opioid prescription management programs, which seek to reduce long-term prescriptions or use of multiple clinicians. There are a number of programs to provide expanded naloxone take-home and prescriptions for patients, family, and friends. Measures beyond pandemic response include the development of public health informatics to identify optimal health system “touchpoints” for reaching persons with opioid use disorder, or overdose encounters.⁷ Health system initiatives include emergency department counseling on the potential need for multiple doses of naloxone due to increased fentanyl potency and efforts to increase primary care physician and federally funded community health clinic buprenorphine medication to treat addiction. There is an urgent need for safe injection sites, which have been associated with reduced overdose deaths when evaluated internationally.⁸ These sites practice harm-reduction strategies such as use of fentanyl test strips and safe syringes.

Addiction treatment must go beyond “detox” programs to recovery programs based on integrated mental health care, medication for addiction treatment, and postdischarge patient navigation and counseling. Crucial for the longer term will be decriminalization of the use of illicit opioids and integration of addiction treatment into mainstream health care coverage.⁹ This will be vital for incentivizing programs offering a greater capacity for community-based behavioral health and wrap-around social services related to housing, employment, and childcare. Decriminalization of personal opioid use could also reduce the enormous costs of policing, criminal prosecution, and incarceration, and by reducing stigma, get more people with SUD to more freely seek treatment. The health equity lessons of the COVID-19 pandemic can help inform an urgent response to the increasing devastation of the opioid crisis.

Corresponding Author: Maryann Mason, PhD, Buehler Center for Health Policy and Economics, Feinberg School of Medicine, Northwestern University, 420 E Superior St, Ninth Floor, Chicago, IL 60611 (maryann-mason@northwestern.edu).

Published Online: April 23, 2021. doi:10.1001/jama.2021.6700

Conflict of Interest Disclosures: None reported.