The COVID-19 outbreak has upended the U.S. economy and health system in the middle of another public health crisis — the opioid epidemic.

Before COVID-19 ever reached the United States, drug overdose mortalities were already reaching record highs at the end of 2019. Opioids account for a significant majority of these deaths, which are just one indicator of the epidemic’s impact. Recent increases have largely been driven by the explosive rise of synthetic opioids such as fentanyl that now affect nearly every racial and ethnic community and all regions of the country.

Experts have warned that the pandemic is likely to exacerbate the opioid epidemic and those troubling mortality trends, with concerns centered on economic disruption, increased social isolation, and reduced access to treatment. States must now confront these increased risks just as their financial resources are dwindling because of COVID-related revenue shortfalls that will likely require significant budget cuts.

Overdose Mortality Has Historically Been Associated with Economic Disruptions

Research indicates that local economic conditions may be a strong predictor of drug-related deaths. Multiple studies have found an association between increased local or state unemployment rates and accidental poisonings such as drug overdoses, as well as links between county-level opioid overdose mortality rates and unemployment or factory closures.

The immediate economic upheaval and unemployment surge introduced by COVID-19 is unprecedented in scale and speed, making it difficult to draw direct parallels. However, it seems clear that many regions will experience sustained levels of economic downturn.

Looking at state-level unemployment trends and opioid mortality rates together allows us to see which states may be battling severe economic conditions alongside an already large opioid-related burden. Sixteen states reported opioid overdose death rates above the U.S. average in 2018 (14.6 per 100,000 people) and have also experienced sizable unemployment spikes of at least 5.5 percentage points in the past year (mainly since February).

COVID-19 Threatens Opioid Treatment Access in Multiple Ways

The pandemic has introduced large and unprecedented challenges for opioid response efforts across the country.

As social isolation has increased overdose risk for substance users, delivery system disruptions are impacting their ability to access opioid-related treatment, which has typically been facilitated through in-person clinic visits. State shutdowns have not only made it more difficult for patients to reach providers, but physical distancing and safety concerns have meant that fewer patients may be seen simultaneously at facilities.

At the same time, some addiction treatment specialists are struggling to stay afloat financially as patient volume has dropped and other facility costs have risen because of COVID-19. This could worsen as states, which help fund addiction treatment through Medicaid and other targeted programs, deal with the impact of the recession on their budgets. Because the pandemic has severely disrupted economic activity, states will confront significant revenue shortfalls that require budget cuts to health and social services. Many are already reducing funding for opioid-related programs as they feel the financial pain.

Looking Ahead

Though more data are needed, at this point a wide range of reporting strongly suggests that initial fears of increased overdoses and related mortality during the pandemic are being realized. Upticks across states and counties have already been detected through data collection initiatives and provisional state-level reports. Many experts are pointing specifically to the effects of synthetic opioids, and warning about the growing impact on Black and Latino communities.

The federal government and states are being pressed to act now. With the pandemic still posing significant challenges to in-person care, initial efforts have included important policy changes that make it easier to evaluate patients and prescribe addiction medications, including via telemedicine. But states also will face large budget cuts in the months and years ahead because of projected revenue shortfalls, alongside the unemployment increases that have been associated with more overdose mortality.

One key policy tool available to states is Medicaid expansion, which has been associated with a wide range of positive insurance coverage, treatment access, and mortality outcomes for substance-use patients. With the federal government funding 90 percent of the cost, Medicaid expansion can be a key source of external funding for states to sustain opioid care providers and facilitate better access for patients. Florida, South Carolina, and Tennessee, which have high overdose rates and unemployment increases, have yet to expand Medicaid.

But even expansion states are already cutting opioid-related services, and the extended economic downturn necessitates broader federal funding and support. Without coordinated and significant action, we risk reducing access to substance-use treatment just as our opioid-related care needs are at their peak.