vial of fentanyl opioid with syringe

Overdose rates, driven by synthetic opioids such as fentanyl, spiked in the latter half of 2019 and early 2020 as the nation went into lockdown.

The Other Epidemic: COVID-19 and Opioid Overdose

By Charlie Severance-Medaris | July 12, 2021 | State Legislatures News | Print

Just as states across the country began to celebrate milestones in their fight against COVID-19, with some seeing deaths and hospitalizations falling to record lows, the spread of the Delta variant has caused a spike in new cases. In the last week, the U.S. averaged about 19,455 new cases a day, a 47% increase from the previous week, according to Johns Hopkins University data.

Adding to lawmakers’ concerns, the Centers for Disease Control and Prevention is reporting that opioid overdose deaths increased 6% in 2019 over 2018.

Overdose rates, driven by synthetic opioids, spiked in the latter half of 2019 and first few months of 2020 as the nation went into lockdown. Over 81,000 drug overdose deaths occurred in the United States in the year ending in May 2020, the highest number of overdose deaths ever recorded in a 12-month period, according to the CDC.

There are likely several reasons for this increase in death during the pandemic, including disruptions to the drug market, leading people who use drugs to purchase them from new and unfamiliar sources; reduction in the ability to obtain naloxone (the opioid overdose reversal drug); and barriers to accessing treatment for substance use disorders.

Old Problem

While overdose rates may be at new highs now, the nation has been grappling with this epidemic for more than two decades. Overdose deaths have quadrupled since 1999. Deaths by opioid overdose have largely driven this increase, with over 70% of the 70,630 overdose deaths in 2019 involving an opioid. The steady rise in drug overdose deaths began with deaths from prescription opioids in what researchers term the “first wave” of the epidemic. These drugs, believed to be safe and effective ways to manage pain, were prescribed in the late 1990s and early 2000s.

The first wave gave way to the second wave of the epidemic by 2010, driven by a much more potent opioid—heroin, which is about twice as powerful as morphine. Since the drug is usually injected, it has led to outbreaks of many bloodborne illnesses, such as viral hepatitis and HIV, in communities with high rates of use.

The third and deadliest wave of the epidemic began in the mid-2010s, driven by the synthetic opioids fentanyl and carfentanil. Fentanyl, originally developed for severe, cancer-related pain, is 50 to 100 times more powerful than morphine. Carfentanil, the most powerful opioid available, is 10,000 times more potent than morphine. Though both are available through legal means, most overdose deaths involve illegally manufactured synthetics. These synthetics are often added to other opioids, such as heroin, to lower the overall cost of the drug while maintaining potency. But many people who use drugs may not know they contain these synthetics. The nation was struggling with the effects of the third wave of the opioid epidemic when the COVID-19 pandemic struck.

States Respond

States have been busy trying to address these trends while preserving important safety protocols around COVID-19. One strategy has been to increase access to behavioral health care and substance use disorder treatment through telehealth. Louisiana expanded the types of health providers who can perform telepsychiatric evaluations. Minnesota allowed initial evaluations and prescriptions to be completed through a telehealth visit and increased the number of take-home doses of medication assisted treatment a provider can prescribe.

States have also worked to increase access to naloxone. New Hampshire, for instance, allows settlement money obtained from opioid manufacturer lawsuits to reimburse the cost of obtaining or administering naloxone, and Virginia included a $1.6 million appropriation for the state to purchase naloxone as part of its fiscal year 2020-21 budget.

Other states, recognizing that prescription opioids still account for about 25% of all opioid overdose deaths, are requiring a naloxone co-prescription with certain opioid prescriptions. While these laws do not require that a patient fill that prescription, the National Institutes for Drug Abuse found that co-prescriptions were associated with fewer opioid-related emergency department visits, especially among patients receiving high doses of prescription opioids. New Mexico requires prescribers to co-prescribe naloxone if prescribing an opioid medication for at least five days. Ohio requires prescribers to offer naloxone when a patient’s prescription dosage is 80 or more morphine milligram equivalents of an opioid medication per day; a similar Arizona law sets the prescription dosage at 90 or more morphine milligram equivalents.

While daunting in scope, many of these interventions have been shown to save lives. In one study, state enactment of a Good Samaritan law, allowing laypersons to acquire and administer naloxone, was associated with a 15% reduction in the incidence of opioid overdose deaths. As the COVID-19 pandemic eases, states have a variety of tools available to address rising overdose rates. Additional examples of legislation designed to prevent opioid misuse and overdose can be found in NCSL’s Injury Prevention Database.

Charlie Severance-Medaris is a policy specialist in NCSL’s Health Program.

This project is supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $313,000 with 100% funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, CDC/HHS or the U.S. government.

Additional Resources