Table 1 Characteristics of and Main Findings from the Studies Included in the Systematic Review

Centers for Disease Control and Prevention (2020) (Government Document)

United States of America (July 31, 2018 – May 31, 2020)

United States of America

Provisional drug overdose deaths, provisional synthetic opioid overdose deaths, provisional cocaine overdose deaths, provisional psychostimulant overdose deaths

Provisional drug overdose deaths were derived from death records received by the National Center for Health Statistics, which represent incomplete, underestimated counts derived from preliminary data that meet certain quality criteria and vary depending on the jurisdiction and 12-month ending period. Importantly, these counts were adjusted for incomplete reporting, and presented according to 12-month ending periods (counts of deaths occurring in the 12-month period ending in the indicated month). Provisional drug overdose deaths were defined as deaths with the ICD-10 Codes X40-X44, X60-X64, X85 and Y10-Y14 as underlying causes-of-death. Based on the involvement of other drug classes, provisional drug overdose deaths were further classified as provisional synthetic opioid overdose deaths (ICD-10: T40.4), provisional cocaine overdose deaths (ICD-10: 40.5) and provisional psychostimulant overdose deaths (ICD-10: T-43.6).

Approximately 81,230 provisional drug overdose deaths occurred in the United States in the 12-months ending in May 2020, which represented an 18% increase from the 12-months ending in June 2019. When examining by subnational jurisdictions, similar percentage changes in provisional drug overdose deaths amounted to more than 20% in 25 states and the District of Columbia, 10 to 19% in 11 states and New York City and 0 to 9% in 10 states. Increases per month in provisional drug overdose deaths were largest between the 12-months ending in March 2020 and the 12-months ending in April 2020 (2146 deaths) and between the 12-months ending in April 2020 and the 12-months ending in May 2020 (3388 deaths). The average increase per month in provisional drug overdose deaths amounted to 2348 deaths post COVID-19 (12-months ending in March 2020 to 12-months ending in May 2020) compared with 680 deaths pre COVID-19 (12-months ending in June 2019 to 12-months ending in February 2020). Compared with the 12-months ending in June 2019, provisional synthetic opioid overdose deaths were 38.4% higher in the 12-months ending in May 2020. When examining the subnational jurisdictions (N = 38), similar percentage changes amounted to more than 50% in 18 states, 25 to 49% in 11 states, 10 to 24% in 7 states and less than 1% in 1 state. The average increase per month in provisional synthetic opioid overdose deaths amounted to 2198 deaths post COVID-19 (12-months ending in March 2020 to 12-months ending in May 2020) compared with 770 deaths pre COVID-19 (12-months ending in June 2019 to 12-months ending in February 2020). Compared with the 12-months ending in June 2019, provisional cocaine overdose deaths were 26.5% higher and psychostimulant overdose deaths were 34.8% higher in the 12-months ending in May 2020. The average increase per month in provisional cocaine overdose deaths amounted to 653 deaths post COVID-19 (12-months ending in March 2020 to 12-months ending in May 2020) compared with 250 deaths pre COVID-19 (12-months ending in June 2019 to 12-months ending in February 2020). The average increase per month in provisional psychostimulant overdose deaths amounted to 758 deaths post COVID-19 (12-months ending in March 2020 to 12-months ending in May 2020) compared with 350 deaths pre COVID-19 (12-months ending in June 2019 to 12-months ending in February 2020).

Georgia Department of Public Health (2020) (Government Document)

Georgia, United States of America (December 2019 – June 2020)

State of Georgia

Drug-involved overdose deaths, opioid-involved overdose deaths, heroin-involved overdose deaths and fentanyl-involved overdose deaths

Drug-involved overdose deaths were based on death certificates from the Georgia Department of Public Health Vital Records, which included residents that died inside or outside of Georgia. Drug-involved overdose deaths were defined as those with ICD-10 Codes X40-X44, X60-X64, X85, Y10-Y14 as underlying causes-of-deaths (see [53] for additional details on the derivation of opioid-involved overdose deaths, heroin-involved overdose deaths and fentanyl-involved overdose deaths).

Drug-involved overdose deaths between March 15, 2020 and June 27, 2020 (444 deaths) were 9% higher compared with between December 1, 2019 and March 14, 2020 (484 deaths). A similar pattern of findings was evident for opioid-involved overdose deaths (25.3% [273 deaths to 342 deaths]), heroin-involved overdose deaths (32.3% [93 deaths to 123 deaths]) and fentanyl-involved overdose deaths (61.4% [140 deaths to 226 deaths]).

Giesel et al. (2020) (Government Document)

Minnesota, United States of America (January 2017 – June 2020)

State of Minnesota

Drug overdose deaths, opioid-involved drug overdose deaths, synthetic opioid-involved drug overdose deaths, prescription opioid-involved drug overdose deaths, heroin-involved drug overdose deaths, psychostimulant-involved drug overdose deaths, benzodiazepine-involved drug overdose deaths, cocaine-involved drug overdose deaths.

Drug overdose deaths were preliminarily derived from death certificates by the Injury and Violence Prevention Section in the Minnesota Department of Health.

Drug overdose deaths between April 2020 and June 2020 (277 deaths) were 30% higher compared with between January 2020 and March 2020 (213 deaths). The analogous percentage increase amounted to 13% between April 2019 and June 2019 (198 deaths) compared with between January 2019 and March 2019 (175 deaths), and 31% between January 2020 and June 2020 (490 deaths) compared with between January 2019 and June 2019 (373 deaths). Compared with between January 2019 and June 2019, between January 2020 and June 2020 opioid-involved drug overdose deaths increased 55% (from 197 deaths to 305 deaths), synthetic opioid-involved drug overdose deaths increased 74% (from 140 deaths to 244 deaths), prescription opioid-involved drug overdose deaths increased 56% (from 62 deaths to 97 deaths) and heroin-involved drug overdose deaths increased 52% (from 50 deaths to 76 deaths). Compared with between January 2019 and June 2019, between January 2020 and June 2020 psychostimulant-involved drug overdose deaths increased 55% (from 111 deaths to 172 deaths), benzodiazepine-involved drug overdose deaths increased 85% (from 39 deaths to 72 deaths) and cocaine-involved drug overdose deaths increased 67% (from 24 deaths to 40 deaths).

Glober et al. (2020) (Peer-Reviewed Manuscript)

Marion County, Indiana, United States of America (January 1, 2019 – July 7, 2020)

Marion County

Suspected accidental drug overdose deaths

Suspected accidental drug overdose deaths were sourced from the Marion County Coroner’s Office. In the event of pending toxicology results, circumstantial information (e.g. scene investigation), medical history and social history were used in the determination, as documented in the coroner’s reports.

Suspected accidental drug overdose deaths increased by 47% from 8.4 deaths per week in the 122-day period preceding March 25, 2020 to 12.4 deaths per week in the 105-day period following March 25, 2020 (p = 0.006). Suspected accidental drug overdose deaths increased by 104% from 6.1 deaths per week between March 25, 2019 and July, 24, 2019 to 12.4 deaths per week between March 25, 2020 and July 7, 2020 (p = <  0.001). Based on the time series from January 1, 2019 to March 24, 2020, autoregressive integrated moving average models further demonstrated that there was a several week period in between the stay-at-home order (March 25, 2020) and full state reopening when the suspected accidental drug overdose deaths per week were above the 99% confidence intervals of the forecast.

Ontario Drug Policy Research Network, Office of the Chief Coroner for Ontario/Ontario Forensic Pathology Service, Public Health Ontario, and Centre on Drug Policy Evaluation (2020) (Government Document)

Ontario, Canada (December 01, 2019 – June 30, 2020)

Province of Ontario

Opioid-related deaths

Opioid-related deaths were based on investigations of the Chief Coroner of Ontario and Ontario Forensic Pathology Service. These deaths were defined as acute intoxication or toxicity deaths that resulted from the direct contribution of an opioid (either alone or in conjunction with other substances). These deaths included both confirmed and suspected deaths (those with pending cause-of-death determination, but with evidence of drug involvement [i.e. evidence of drug use or drug paraphernalia at the scene and detection of opioids in post-mortem toxicology]).

Opioid-related deaths between March 16, 2020 and June 30, 2020 (695 deaths [46 deaths per week]) were 38.2% higher compared with between December 1, 2019 and March 15, 2020 (503 deaths [34 deaths per week]).

Overdose Mapping Application System (2020) (Independent Research Report)

United States of America (July 15, 2018 – May 06, 2020)

United States of America (Participating agencies from 48 states, District of Columbia and Puerto Rico)

Suspected fatal drug overdoses

Suspected fatal drug overdose deaths were entered in real-time to an electronic platform by first responders at the scene of incident, or pulled directly through record management systems (e.g. law enforcement) using an application program interface.

Rolling average of suspected fatal drug overdoses in the past 30 days increased by 11.39% from 2019 to 2020.

Rodda et al. (2020) (Peer-Reviewed Manuscript)

San Francisco, California, United States of America (January 01, 2020 – April 18, 2020)

City of San Francisco

Opioid overdose-related accidental deaths

Opioid overdose-related accidental deaths were sourced from the Office of the Chief Medical Examiner, which captured deaths with fentanyl, norfentanyl, 6-monoacetylmorphine, morphine and/or codeine detected in blood to determine their relevance in causation of drug toxicity.

Opioid overdose-related accidental deaths were higher between March 16, 2020 and April 18, 2020 (1.47 deaths per day [50 deaths in 34 days]) compared with between January 01, 2020 and March 15, 2020 (0.95 deaths per day [71 deaths in 75 days]). Opioid overdose-related accidental deaths per day were higher in January, February, March and April of 2020 compared with January, February, March and April of 2018 and 2019.

Slavova et al. (2020) (Peer- Reviewed Manuscript)

Kentucky, United States of America (January 14, 2020 – April 26, 2020)

State of Kentucky

Emergency medical services opioid overdose runs for suspected opioid overdose with death at the scene

Emergency medical services overdose runs for suspected opioid overdose with death at the scene were sourced from the Kentucky State Ambulance Reporting System.

Emergency medical services overdose runs for suspected opioid overdose with death at the scene between March 06, 2020 and April 26, 2020 (18 runs) were 50% higher compared with between January 14, 2020 and March 05, 2020 (12 runs).

System for Opioid Overdose Surveillance (2020) (Independent Research Report)

Michigan, United States of America (March 2019 – September 2020)

State of Michigan (12 counties with available data)

Suspected fatal opioid overdoses

Suspected fatal opioid overdoses were determined based on the electronic death database, Medicolegal Death Investigation Log (MDILog), as well as reports from county medical examiners. These deaths were determined by death investigators and updated daily to the System for Opioid Overdose Surveillance.

Suspected fatal opioid overdoses between March 1, 2020 and September 16, 2020 were 15% higher compared with suspected fatal opioid overdoses between March 1, 2019 and September 16, 2019.