Understanding the short- and long-term effects of the COVID-19 pandemic on the overdose crisis

Overdose has risen sharply during the COVID-19 pandemic, highlighting an urgent need to understand the impact of disasters on overdose. We need research to identify the types of policy measures that can prevent a similar increase in overdose in future disasters. We also need to understand why certain communities are particularly vulnerable to experiencing rises in overdose during and after a disaster, so that we can optimally target prevention and disaster response efforts. We propose to use Big Events Theory as a framework to: 1) study the COVID-19 pandemic and its effects on overdose and related outcomes; 2) identify policy responses to COVID-19 that affected individual-level overdose risk; and 3) examine how the pandemic's impact on overdose risk varied across communities and populations. We hypothesize that COVID-19 containment policies (e.g., workplace closings) contributed to social isolation, increasing the risk of consuming drugs alone and limiting access to treatment and harm reduction services, thus increasing overdose risk. In contrast, public health (e.g., take-home methadone waivers) and economic support policy responses to COVID-19 (e.g., housing eviction moratoria) may have eased access to health services for people who use drugs (PWUD) and alleviated economic difficulties arising from the pandemic, blocking health and economic pathways through which the pandemic could increase overdose risk. We hypothesize that communities with more structural sources of despair (e.g., high rates of unemployment, poverty), and those that concurrently experienced other major societal crises (natural disasters, political conflict, mass shootings) were more vulnerable to the effects of COVID-19 on overdose. In contrast, social and economic policies enacted before the pandemic to protect vulnerable populations (e.g., higher state Medicaid income threshold) may have reduced the impact of the pandemic on overdose risk. Our Aims are to: (1) Determine how individual overdose risk in localities (overall and by race/ethnicity) changed over 2019-2025 after county-level elevations in COVID-19 health burden (hospitalizations, deaths). (2) Determine which county- and state-level policies targeting COVID-19 infection containment, public health of PWUDs, and economic support during the pandemic mediated relations between changes in county-level COVID-19 burden and changes in overdose incidence, overall and by race/ethnicity. (3) Identify which community conditions affected the strength of the relationships between changes in county-level COVID-19 burden and individual overdose risk, overall and by race/ethnicity, including: a) pre-existing community structural characteristics (e.g., poverty rate); b) pre-existing policies to protect vulnerable populations (e.g., state Medicaid program income threshold); and c) intersecting crises. We will build a multi-center cohort of ~2.4 million patients aged 18+ in six PCORnet® networks across the country to track the impact of community COVID-19 burden on individual overdose risk. Our study findings will inform the response to the current overdose crisis and to future disasters.