COVID-19 and the Drug Overdose Crisis

Uncovering the Deadliest Months in the United States, January-July 2020

Joseph Friedman, MPH; Samir Akre, BS


Am J Public Health. 2021;111(7):1284-1291. 

In This Article

Abstract and Introduction


Objectives: To determine the magnitude of increases in monthly drug-related overdose mortality during the COVID-19 pandemic in the United States.

Methods: We leveraged provisional records from the Centers for Disease Control and Prevention provided as rolling 12-month sums, which are helpful for smoothing, yet may mask pandemic-related spikes in overdose mortality. We cross-referenced these rolling aggregates with previous monthly data to estimate monthly drug-related overdose mortality for January through July 2020. We quantified historical errors stemming from reporting delays and estimated empirically derived 95% prediction intervals (PIs).

Results: We found that 9192 (95% PI = 8988, 9397) people died from drug overdose in May 2020—making it the deadliest month on record—representing a 57.7% (95% PI = 54.2%, 61.2%) increase over May 2019. Most states saw large-magnitude increases, with the highest in West Virginia, Kentucky, and Tennessee. We observed low concordance between rolling 12-month aggregates and monthly pandemic-related shocks.

Conclusions: Unprecedented increases in overdose mortality occurred during the pandemic, highlighting the value of presenting monthly values alongside smoothed aggregates for detecting shocks.

Public Health Implications: Drastic exacerbations of the US overdose crisis warrant renewed investments in overdose surveillance and prevention during the pandemic response and postpandemic recovery efforts.


Unofficial data sources, proxies, and provisional records indicate that overdose deaths in the United States are spiking during the COVID-19 pandemic.[1–4] National Emergency Medical Services (EMS) data—disaggregated by week—show very-large-magnitude increases in overdose during the pandemic period, reaching more than double baseline values by May 2020.[2] Syndromic surveillance data from emergency departments show similar increases in visits for overdose, as well as mental health conditions and intimate partner violence.[5] Several states have also published provisional mortality records for the same period, demonstrating large-magnitude spikes in overdose deaths.[6,7] A similar pattern is likely to be present at the national level. However, given limitations of provisional overdose mortality reporting, the magnitude of the increase cannot yet be determined from official mortality statistics.

In December 2020, the Centers for Disease Control and Prevention (CDC) released an emergency advisory showing that from June 2019 to May 2020, 81 320 people died of a drug overdose in the United States—representing an increase of 18.0% over the previous 12 months.[8] However, this 12-month period covered only the first 3 months of pandemic-related disruptions—March through May 2020. As provisional trends are disaggregated by month, any large spikes occurring during the pandemic would be combined with—and potentially masked by—9 months of lower prepandemic values.

In a typical year, the practice of providing rolling aggregate trends is useful for stabilizing rates—especially in states with small populations—given numerous challenges in overdose surveillance. Mortality records are contributed by all 50 US states and the District of Columbia to the National Center for Health Statistics, where they are analyzed centrally.[9] The lag time between a death's occurrence and the date upon which it is reported to the central repository is generally longer for overdose than other causes of death[10] and can vary by state.[9] Therefore, provisional estimates of overdose mortality are typically released on at least a 6-month lag. Even then, modeling is undertaken to correct estimates for additional underreporting.[11] Provisional records consequently include both "reported" deaths for a given period as well as "predicted" deaths, which are estimated by observing previous reporting delays and assuming they will affect current death levels in a similar fashion.[11] In this context, reporting rolling 12-month sums can help to insulate estimates against stochasticity or shocks, which could stem from shifts in reporting lags, and also adjust for seasonality, as all 12 months of each calendar year are always included in each estimated rate.[9,11]

Nevertheless, during an unprecedented event such as the COVID-19 pandemic—in which the potential exists for drastic month-to-month shifts—we argue that there is value in assessing the existing data for the presence of shocks alongside smoothed trends. We estimated the original monthly mortality values underlying aggregated provisional trends to determine how many individuals died of overdose in March through July of 2020, as the pandemic dramatically changed life in the United States.