Drug Overdose Deaths Before and After Shelter-in-Place Orders During the COVID-19 Pandemic in San Francisco

This cross-sectional study evaluates the association of the shelter-in-place order with fatal drug overdoses in San Francisco, California.


Introduction
Fatal drug overdoses have been a growing public health crisis for years prior to the COVID-19 pandemic. 1 In December 2020, the US Centers for Disease Control and Prevention (CDC) issued an advisory that overdose deaths had reached an all-time high, citing increasing synthetic opioidrelated deaths. 2 It is unknown how COVID-19 and health orders to mitigate transmission may be associated with this increase. In this study, we aimed to describe overdose deaths in San Francisco before and after the initial COVID-19 shelter-in-place order to elucidate whether characteristics of fatal overdoses changed during this time to guide future prevention efforts.

Methods
We performed a cross-sectional study of unintentional fatal overdoses in San Francisco for the 8.5 calendar months before and after the shelter-in-place order on March 17, 2020. Research was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. The University of California, San Francisco institutional review board approved decedent research, waiving informed consent; data were not deidentified.
Using data from the Office of the Chief Medical Examiner (OCME), we evaluated unintentional overdose deaths involving fentanyl, heroin, medicinal opioids, methamphetamine, and cocaine.
Demographic and toxicological outcomes were identified from forensic findings; cause-of-death determination methods have been previously published. 3,4 Housing information was collected from OCME investigations and analyzed using a county-level database of social service interactions. We compared overdose death features using χ 2 tests and calculated normalized death rates using postpandemic overdose deaths and 2019 US Census Bureau data. 5 To account for temporal variation and illustrate prepandemic trends, we present overdose deaths by month between 2017 and 2020.
Statistical significance was set at P < .05, and all tests were 2-tailed. Statistical analysis was conducted in Stata version 16.1 (StataCorp).

Results
In the 8.5 months before and after San Francisco's COVID-19 shelter-in-place order, 365 and 537 people experienced fatal overdoses, respectively, for a total of 902 deaths. The median (interquartile range) number of weekly overdose deaths was 10 (7-12) before the shelter-in-place order vs 15 (11-18) after the order, representing a 50% increase. Differences in decedent age and sex between time periods were not significant (Table). While the proportion of Black decedents slightly decreased after the shelter-in-place order, the death rate was still disproportionately high (272 per 100 000 Black

Discussion
In this cross-sectional study, we found a continued increase in drug overdose deaths in San Francisco since the onset of COVID-19, with a 50% increase in weekly median overdose deaths. Of note, between March 17 and November 30, 2020, San Francisco recorded 537 drug overdose deaths, while recording 169 deaths due to COVID-19 in the same time period. 6 The number of fatal overdoses among people experiencing homelessness during COVID-19 doubled.
This follows the increasing trend in 2019 overdose deaths because of fentanyl, which is also associated with the increase in 2020. However, societal disruption related to COVID-19 is likely contributing, as it disproportionately affects people experiencing poverty and marginal housing.
Likewise, overdose deaths among Black individuals in San Francisco have been persistently and disproportionally high. Preventing fentanyl-related deaths is of paramount importance, as deaths continue to increase amid the COVID-19 pandemic 2 ; however, an ongoing focus on methamphetamine in our region is also needed.
This study was constrained to 1 geographic region, used OCME data (limiting covariate adjustment), and was cross-sectional, precluding causative statements. San Francisco has had a low COVID-19 mortality rate compared with other municipalities and adopted a comprehensive response to the pandemic. Our findings suggest that to complement a strong public health response to COVID-19, there must be more robust overdose prevention for people who use drugs, particularly for people experiencing homelessness, people who identify as Black, and people who use fentanyl and/or stimulants.