Substance use harms during Covid-19

This is blog 3 of 10 blogs in the overdose awareness and prevention series.

Overdose risks: impact of the Covid-19 pandemic

What impact is the Covid-19 pandemic having on substance use rates?
Are changes in substance use behaviours increasing the risks of overdose deaths?
How can community members and businesses get involved in overdose awareness-building and overdose prevention measures?

Get involved by participating in International Overdose Awareness Day.

Covid-19 and drug-induced deaths (overdose)

Overdose deaths have been steadily increasing for many decades; long before the pandemic changed our day-to-day existence.

There is a lot of misunderstanding about overdose deaths in our communities (watch a very short video on overdose statistics and trends).

Researchers indicate we could experience significant losses in overdose statistics, particularly of prescription medicines and polysubstance use occurring in response to pandemic-related anxieties or sleep disruptions.

The pandemic is certainly having an impact on population mental health and substance-use behaviours.

Whether it’s related to having more time on our hands, economic uncertainty, or the extra stress of home-schooling responsibilities — substance use is on the rise.
And when substance use increases?
So, too, do the risks of accidental drug-induced deaths in our communities.

Now, more than ever, we need to ensure further research funding and community advocacy for overdose prevention measures – including supporting the efforts of the Penington Institute (based in Australia).

The need for overdose prevention

Overdose statistics: drug-induced death statistics (CDC and related sources)

Deaths from overdose toxicity and/or polysubstance use have been steadily increasing in recent years.

In America alone, deaths from overdoses doubled in the years 2000-2015.
There was also a notable rise in drug-induced deaths from 2019-2020, compared to preceding years.

With substance use behaviours and unintentional overdose deaths increasing in response to the Covid-19 pandemic — there is so much more that needs to be done.

Download the latest Australian overdose statistics report (2021)

*Australian Overdose Report publication date: 31st of August 2021.

Watch the video describing the latest overdose statistics (2021 Australia statistics and a global overview)

A leading cause of deaths amongst all age groups

Did you know that approximately 3 of every 4 overdose fatalities is unintentional (accidental)?

Overdose prevention is an important and attainable goal because accidental overdoses can be prevented.

Research from the Penington Institute indicates many overdose deaths are preventable. But we need to ensure everyone in our community understands what the risks are, how to minimise those risks, and how to recognise the signs of an overdose reaction — and what to DO (and NOT do) if you’re a first responder.

How to get involved – support overdose prevention research by the Penington Institute

Before we delve further into the issues of drug overdose increases relating to the pandemic, please get involved in overdose awareness-building efforts and support research by the Penington Institute.
Find out more by clicking on this link for International Overdose Awareness Day (August 31, 2021).

Drug-induced deaths are predominantly unintended.

The theme of International Overdose Awareness Day is “Time to Remember. Time to Act.”

Please donate to support Penington Institute’s important drug overdose prevention research and life-saving overdose awareness education resources.

This series of blogs aims to increase community awareness of:

the increase in drug-induced deaths in recent decades
contributing factors to the increase in substance use and overdose rates
the risks of elevated toxicity levels linked with polysubstance use and/or non-medical use of prescription medications and APIs (e.g. opioids)
the impact of the Covid-19 pandemic on substance use behaviours and overdose fatalities
International Overdose Awareness Day initiatives and evidence-based overdose prevention resources which are available from the Penington Institute (Australia)

Snapshot of overdose statistics related to the Covid-19 pandemic

CDC reports on overdose statistics indicate over 90,000 Americans lost their lives to overdoses in the 12 month period between June 2019 and May 2020.

This overdose data, including several months of the beginning of the pandemic, indicates a significant increase in overdoses, compared to approximately 73,000 to 80,000 drug-induced deaths in the preceding period.
2021 deaths related to overdoses are likely to rise (again) compared to 2020 statistics, according to preliminary data from the CDC and research from the Penington Institute (read more, below).

The number of overdose deaths in the US could, by the end of 2021, potentially reach 100,000 drug-induced fatalities in a single year (an estimate based on preliminary CDC data and mental health care centre reports of increased substance use/alcohol consumption in relation to pandemic-related changes).

There has been an alarming increase in the number of non-fatal overdoses and drug-induced deaths

Some of these increases relate directly, or indirectly, to the impacts of the Covid-19 pandemic on substance use behaviours and illicit drug supply chains.

In terms of the full impact of the Covid-19 pandemic on substance use overdose deaths, as noted by the Penington Institute’s CEO, John Ryan, in the 2020 Annual Overdose Report:

“Because of the careful but slow work of classifying drug-related deaths, the empirical effects of COVID-19 on our overdose toll will not be seen until the OD Report 2022 – and for several years beyond that. But, as evidence from overseas shows, COVID-19 is accelerating trends and exacerbating risk factors that are already detectable in this year’s Report. “

Source: 2020 Annual Overdose Report (Penington Institute)

Latest overdose statistics and causes of death

Download the latest Australian overdose statistics report (2021)

Australia (AU) overdose statistics – preventable deaths

In terms of overdose deaths in Australia (2020 overdose fatalities), over 2,000 individuals lost their lives — and friends and families lost their loved ones, in a single year.

This number is expected to rise as the full impacts of the Covid-19 pandemic continue to emerge over the next few years and decades.

Most of these deaths were accidental (unintended) overdose scenarios that could have been prevented.
The most common substances in overdose deaths were opioids (including synthetic opioids) and Benzodiazepines.
Polysubstance use (polydrug use) was a contributing factor to the majority of overdose fatalities.

Let’s review what’s happening in the United States (US) in terms of overdose statistics.

In the United States, the number of Emergency Room (ER) visits linked to overdose effects continues to rise.
There were nearly one million non-fatal overdose cases treated in Emergency Rooms in the US in a single year (2017 data).

In addition to nearly one million hospital emergency room visits for drug overdose toxicity (US statistics), there appears to be an alarming rise in the number of overdose deaths in these early post-pandemic years.

Post-pandemic changes to drug use, substance use harms, and drug-induced deaths (overdoses)

The impact of the Covid-19 pandemic on overdose risks

CDC overdose statistics indicate an alarming increase in drug-induced fatalities (drug overdoses) in 2020 and the first half of 2021
Data comparisons on drug-induced deaths (overdose fatalities) in pre-pandemic years (2018-2019 and prior years) suggest the pandemic is having an impact on substance use behaviours, overdose risks, and drug-induced death rates.

As explored in Blog 1 of 10 in this blog series, overdose death rates are impacted by a number of factors.

Factors include but are not limited to:

diverted (stolen) pharmaceutical products (active ingredients/APIs such as opioids)
non-medical use of prescription medications
polysubstance use
dosing errors

The majority of drug overdose deaths are unintended.

A large number of these fatalities involve synthetic opioids and/or polysubstance use toxicity.

Concurrent intake of multiple substances – known as polysubstance use – impacted an estimated 37.2% of overdose cases reported in the United States (CDC, 2017-2019 statistics).
That equates to nearly 4 of every 10 overdose patients (presenting to emergency rooms) being impacted by polysubstance/drug use toxicity (or other detrimental drug-drug interactions)

While up to 4 in 10 patients presenting to Emergency Rooms for overdose care were experiencing polysubstance-use toxicity — the percentage of drug-induced deaths relating to polysubstance use was as high as 7 in 10 overdose deaths.

These are often preventable deaths. Many people who inadvertently overdose could be helped with urgent emergency care.

But recognising a suspected overdose toxicity reaction — and knowing what to do to help the person, isn’t a skill-set that everyone in our community has (at least, not yet).

It is hoped that building awareness of overdose risks, and helping everyone in our community know what to do (and not do) if they are a first responder, will help reduce the number of drug-induced deaths.

Overdose deaths in the US primarily involved a combination of opioids, alcohol, and other substances – including other illicit drugs, diverted pharmaceutical supplies, and/or NMU of prescription medications.

Polysubstance use can result in deadly levels of toxicity. Read blog 1 of 10 blogs in support of increasing awareness of overdose risks and overdose prevention.

Click here to support the Penington Institute’s research into overdose awareness and prevention education.

The changing dynamics of drug-induced deaths and unintentional overdose risks

Deaths from drug overdoses (USA) – Overdose Reports 2019, 2020, 2021

Over 90,000 people died from overdose toxicity according to the CDC’s 2019-2020 report (preliminary statistics).
The CDC reports for overdose fatalities indicates a dramatic increase in overdose deaths compared to prior years.
But overdose deaths have steadily risen since the year 2000.
A majority of overdose deaths in recent years have been linked to drugs such as illicit opioids/synthetic opioids, and NMU of prescription opioids; but other drugs are also at play – including GHB and Ecstasy tainted with other toxic chemicals (or of unknown potency/toxicity levels).

Source/further reading: CDC report on overdose statistics (2020).

CDC chart depicting the increase in drug overdose deaths (2021 overdose statistics)

2021 overdose statistics – preliminary data reported by the Center for Disease Control (CDC).

Source: Excerpted from the Center for Disease Control (CDC) report on overdose statistics as of January 2021 (provisional data).

Overdose statistics related to opioids/synthetic opioids

Excessive dosing of nearly any toxic medicine – whether that’s a prescription drug, an illicit drug, alcohol, or a mix of all three – can lead to overdose toxicity. And overdose toxicity can result in an overdose fatality (drug-induced death). The risk of death from an overdose reaction is particularly elevated if medical attention is not available (or not sought) in a timely manner. A suspected overdose needs to be treated as an urgent emergency scenario – call 000 or other relevant emergency care numbers.

Of the estimated drug-induced deaths in the USA in 2019 (~ 73,000-80,000), an estimated 73% of those overdose deaths were linked with synthetic opioid use.

This is the 3^rdof 10 articles/blogs discussing drug overdose statistics and polydrug use harms.

Scroll down for further overdose research information (and click the links below to read the other blogs if you haven’t read them yet). Clicking on an article link below will open the article in a new tab in your browser.

Click here to read Blog 1 of 10 (non-medical use of prescription medications).
Click here to read Blog 2 of 10 (factors contributing to the increase in overdose fatalities).
You are currently reading the 3rd blog in this series on overdose awareness and prevention research.
Click here to read Blog 4 of 10 (synthetic opioids and overdose risks).
Additional blogs on Overdose Awareness resources and Prevention research being published in late August 2021.

A growing public health problem involves the use of illicit substances with undetermined potency.

What is well-known about these illicit drugs, however, is that their toxicity levels have led to millions of Emergency Room visits and hundreds of thousands of unintended overdoses.

Illicit drug supply chains become a ‘deadly dosing guessing game’ — including unintended overdoses from NMU of prescription drugs (epilepsy medication being one example) diverted for ‘party’ purposes.

Tragically, these ‘parties’ often end up in emergency rooms at the hospital, or in a mental ward, or at the morgue.

Illegal supply chains of ‘party drugs’ (GHB, Ecstasy), of synthetic opioids and/or garage-mixed party drugs, mean individuals have very little — if any — grasp on what it is they’re actually consuming. What we need more of — to help combat these issues — are measures to reduce harms. Community-wide efforts to help people to fully understand the risks (drug safety education), and innovative ways to identify fatally-contaminated products so that consumers aren’t heading to the morgue instead of to their next dancing/music venue. But with supply chains underground, and no current legal way for people to test these substances before making a decision – the situation’s dire.

Pandemic increases in substance use and illicit substance use – the epidemic is getting worse.

There’s been a major change in substance-use behaviours in the past 2 decades.

Social and behavioural changes have resulted in higher numbers of drug-induced deaths, most of which are unintentional. The impact of the global pandemic isn’t helping.

These changes in overdose risks are influenced by a combination of social changes occurring in relation to the Covid-19 pandemic.

More individuals engaging in NMU of prescription medications
Higher numbers of people drinking alcohol and more alcohol advertising expenditures (noting regional and cultural variances)
Polysubstance use involving extremely potent chemicals (APIs/opioids) than in the past
Deadly chemicals and other contamination of ‘street drugs’ or ‘party drugs’
Unknown strengths of drug products (e.g. GHB/Ecstasy) sold by unregulated parties (e.g., varying levels of active ingredients and various deadly toxins, making dosing a ‘deadly guessing game’)
More sophisticated criminal drug rings who distribute toxic/contaminated drug products via:
- illegal online pharmacies (unapproved sales platforms)
- schools
- music festivals
- other venues
New medicines being used for non-medical purposes (such as led to the opioid crisis)
NMU use of medications for social anxiety or depression
Covid-19 anxiety and depression relating to bereavements, social isolation, financial pressures, and other losses

Opioid Overdose Statistics

How many have died so far from the Opioid Crisis in the United States?

According to the CDC and other overdose-awareness experts, deaths from opioid-related overdoses have increased by 200% since the year 2000.
The CDC reported that over 841,000 Americans have died from opioid-related deaths since the year 2000.

The ‘opioid epidemic’ is now well-recognised as a major public health concern, with numerous lawsuits against manufacturers and their marketing teams including McKinsey.

Read on to discover how the Covid-19 pandemic is impacting substance use and overdose rates.

How have drug use patterns changed during the pandemic?

An introduction to the rise in opioid-based prescriptions and overdose statistics: the impact of Covid-19 on substance use and drug-induced fatalities.

Has there been a significant increase in drug use – including alcohol – since the Covid-19 pandemic began?

The likely answer is YES.
But just how much it has changed — is yet to be determined.

“We are still in the midst of the pandemic, with our post-pandemic years somewhere in our future.

However, healthcare professionals are reporting changes in their clients’ substance use behaviours in response to pandemic-related stressors.

Australia substance use statistics and the Covid-19 pandemic

We are hearing numerous reports on increased substance use rates related – directly and indirectly, linked with Covid-19 pandemic changes to society – and hence, to our individual mental health states.
But the full impact of the Covid-19 pandemic – including the many bereavements, other losses, and changes to our social structures — will be an ongoing research concern.

“It may be decades (not years) before we recognise the full impact of the Covid-19 pandemic on our intake of substances and other mental health concerns.

Pandemic mental health outcomes and substance use research

Due to the increased rates of substance use and drug-induced deaths (drug overdoses) directly and indirectly related to the impacts of the Covid-19 pandemic:

“Research into overdose awareness and overdose prevention programs must be given priority funding in the wake of the pandemic.

Adequate research funding for groups such as the Penington Institute will be needed to adequately explore the impact of the pandemic on substance use trends and mental health outcomes.

Click here to support overdose prevention research by the Penington Institute.

Future research into substance use will need to cover the full variety of substances individuals are turning towards (in higher numbers), in what might be an attempt to “soften the blow” (or boredom) of living with an entirely altered socio-economic landscape.

This includes not only illicit drugs, legal drugs such as alcohol, and prescription medicines being used for non-medical purposes (NMU) or in above-recommended dose amounts — but also food substances. That is, the excess calories from comfort foods or binge eating while watching Netflix – or the opposite, forgetting to eat at all (or not being able to afford food) — or a combination of all of the above.

It might feel as if we’ve been living with the pandemic for many years. But relatively speaking, it is early days. The impact of the Covid-19 pandemic on substance use, mental health outcomes, unintentional drug overdoses, and intentional self-harm behaviours including suicides, is yet to be fully assessed.

How much more are people drinking?

Changes in alcohol consumption related to Covid-19

Data on alcohol consumption rate changes and other drug use changes in response to the Covid-19 pandemic is relatively limited at present.

We are aware, however, of the following estimates.

Alcohol consumption increased for approximately 20% of Australians who use alcohol (self-reported data).
There has also been a suspected increase in the number of people ‘mixing’ alcohol with other drugs.

Drug-related ‘substance substitutions’ are also not uncommon when substance supply chains are interrupted by the pandemic and/or drug arrests.

This can lead to individuals using toxic substances they have limited experience with in terms of ‘dosing’ (intake levels).
This can result in potentially fatal drug mixing behaviours/overdose fatalities.

“According to the Penington Institute, approximately 1 in 7 Australians presenting to an Emergency Room for overdose treatment, is likely to die from another overdose toxicity event within 12 months post-visit to the ER.

Research into overdose prevention/overdose interventions is warranted

Overdose prevention research and funding supports for substance use harms are direly needed.
Funding could mean that an ER visit in relation to overdose care becomes a transformative opportunity for life-saving interventions and mental health education.
Rather than a one-stop, acute-care visit for an overdose toxicity event, where the ER patient later dies of a similar yet more toxic event (or a similar toxicity event without access to an ambulance and medical care).

Alcohol use in Australia related to the pandemic (Covid-19)

Snapshot of alcohol use/alcohol expenditures during the pandemic (Australia example):

Weekly alcohol expenditures at bottle shops/liquor stores increased from 4% to 24% on a weekly basis (compared to the preceding year’s expenditures on alcohol).
Alcohol service venues (bars, clubs, sporting grounds, restaurants, casinos) were frequently closed OR restricted in patron numbers.
These venues reported fluctuating revenues for alcohol services in the same period of time – or decreased income from venue-consumed alcohol sales compared to the preceding year(s), primarily due to patron limits, less socialisation during the pandemic, Covid-19 outbreaks, and state-wide lockdowns.
There was also a self-reported decrease in alcohol consumption by 27% of survey respondents compared to the 20% who self-reported increasing their alcohol consumption rates.

Source: Australian Institute of Health and Welfare (AIHW) 2021

Alcohol sales increases and the global pandemic

Do higher alcohol sales figures equate to higher consumption rates during the pandemic?

Not necessarily, but likely.

Current alcohol sales figures may not, however, equate to current consumption levels.
It must be remembered that the uncertainty of a pandemic has lead to ‘panic buying’ and ‘stockpiling’ of certain goods.
Additionally, there may be a general balancing out of total alcohol intake across the country.

In other words, decreases in alcohol consumption in public venues (pubs, etc) may negate or ‘balance out’ the self-reported increases in consumption and the notable rise in sales.

Even with venues being closed, and sporting events becoming ‘non-attendance’ events watched on television instead of in pubs serving alcohol – self-reported alcohol consumption data indicates at least 1 in 5 Australians are drinking more alcohol since the pandemic began. And, as noted earlier, we remain in the earliest of days of this pandemic.

The full effects of Covid-19 changes to society – including mental health outcomes and substance use harms — are yet to be reported. The impacts of a pandemic on our social structures, our physical beings and our mental health, may continue to cumulate for several years. Resiliency education is going to be needed across the world.

The impact of Covid-19 changes on overdose rates

For individuals engaging in increased substance use, including alcohol, these changes may lead to higher rates of drug-related deaths including drug-induced deaths (overdose fatalities).

It appears that people ARE trying to find ways to cope with the uncertainties, changes, and losses of the Covid-19 pandemic.
As with other traumatic events, some individuals turn to substance use (or increased usage of alcohol and other drugs) in an attempt to self-soothe/self-medicate.
Others increase their use of alcohol and other drugs out of loneliness and boredom.
And some people simply lose inhibitions when they feel the ‘world is looking bleak’, meaning they may try substances (or routes of administration) — or mixes of substances — they hadn’t tried before.

“Any significant change in our lifestyles that results in an increased level of drug-use including alcohol, or increased numbers of people engaging in drug-use/alcohol consumption, raises the risks of overdose fatalities. The pandemic is already having a major effect on drug-related harms and overdose fatalities according to preliminary data. Further research funding, more mental health care funding, is required.

What the data currently shows – concern, but also uncertainty

Challenges of estimating alcohol/drug use variations during Covid-19

Changes in legal drug use (alcohol and prescription medications) can be partially estimated:

by comparing sales figures to prior years
by performing long-term sales trends analysis
by estimating and adjusting for the percentage of expenditures related to panic buying and ‘stockpiling’
by comparing Emergency Room poisoning cases and overdose fatalities related to these products

Preliminary studies also suggest the following risk factors for overdose deaths:

increases in illicit drug-taking
individuals substituting alcohol and prescription drugs for illicit drug products (or vice versa) when supply chains become disrupted due to the pandemic, and/or related to drug-supply chain disruptions (drug busts, travel restrictions) OR to a lack of prescription medications relating to Covid-19 pharmaceutical supply chain issues

Overall, it is difficult to accurately estimate changes in illicit drug use and substance mixing.

But there’s no doubt that the pandemic has had — and will continue to have — an impact on substance use behaviours. These changes subsequently increase the risks of accidental and intentional overdoses.

Statistics suggest an alarming increase in alcohol/drug consumption habits and overdose risks since the Covid-19 pandemic began.

But it isn’t only substance use (or substance-use addictions) that are on the rise.

There appears to be an increase in food consumption or “food addictions” as a means of coping with stress and boredom.
Excess food consumption is coinciding with reduced opportunities to exercise (due to lockdowns and gym closures).

Unless we act – and unless we have appropriate levels of funding — the pandemic will add to our existing obesity epidemic, as well as to our overdose risks and other health harms.

In summary, we all need to do our part to raise awareness – including by participating in International Drug Overdose Awareness activities and related supports, and supporting the Penington Institute if you can.

Get involved with ‘drug overdose awareness day’ by contacting the Penington Institute.

International Drug Overdose Awareness Day is scheduled for Tuesday, August 31, 2021 (31 August 2021).
Led by the Penington Institute, Overdose Awareness Day helps increase community awareness of the potential risks of polydrug use, non-medical use of prescription medications, and other risks linked with drug-induced deaths/overdose toxicity levels from non-medical use of prescriptions, illicit drugs, alcohol and illicit medications.

Please click here to donate to the Penington Institute and click here to organise an overdose awareness campaign or fundraising event.

Snapshot of the impact of the Covid-19 pandemic on mental health outcomes and substance use risks.

Why, exactly, are overdose risks rising since the pandemic started?

The pandemic has led to unprecedented increases in lifestyle changes and related stressors.

There has been an increase in the use of alcohol and anxiolytics (anti-anxiety and anti-panic drugs medications) along with ‘drug mixing’ behaviours.
There have been unrecognised levels of trauma, grief, and PTSD linked to the wide-ranging impact of pandemic-related changes – including complicated bereavement scenarios, travel restrictions, loss of employment, increasing levels of debt, other financial burdens, geographical displacement, homelessness, and various forms of social isolation.
Stressors also include home-schooling demands, relationship stress, and higher risks of violence in the homes.

Industry compliance with Good Manufacturing Practice (GMP) and GxP — including Good Warehousing Practice and Good Distribution Practice — may help reduce overdose risks.

Prevention efforts can be aided by the establishment of effective pharmacovigilance systems, community education, batch tracing (serialisation technologies), and related API diversion prevention measures (to reduce the threat of medicines falling into illegal supply chains).

The pharmaceutical industry in support of overdose prevention efforts

International Drug Overdose Awareness Day

As an industry, we can also do our part to help reduce overdoses by ensuring GMP compliance across the globe.

One of the articles in this 10-part blog series discusses how GMP compliance can prevent product diversions and the importance of packaging and labelling warnings and pharmacist involvement in overdose prevention efforts.

Compliance with Good Distribution Practice (GDP) and Good Documentation Practice, are certainly important for helping reduce product theft, API diversions and illicit supply chains. Regulators and internet companies can work together to prevent illicit drug distribution through unapproved, illegal ‘online pharmacies’ (read the article on counterfeit products in Australia and around the globe).

As an industry, we can also help by increasing community awareness of the dangers of non-medical use (NMU) of pharmaceutical products – and the dangers of mixing drugs (polysubstance use) such as mixing alcohol, opioid medications and certain types of prescriptions – as part of International Drug Overdose Awareness Day on the 31^st of August 2021.

For additional information, read this entire series of blogs being published from 22 August 2021 through 31 August 2021 in support of polydrug-use overdose awareness and Drug Overdose Awareness Day (31 August 2021).

Please support the Penington Institute.

Additional blogs on Overdose Awareness resources and Prevention research being published in late August 2021.