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Review 2: "Estimating The Uncertain Effect of the COVID Pandemic on Drug Overdoses"

A Denham (Harvard Medical School) | 📒📒📒 ◻️◻️

Published onMay 27, 2023
Review 2: "Estimating The Uncertain Effect of the COVID Pandemic on Drug Overdoses"
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key-enterThis Pub is a Review of
Estimating The Uncertain Effect of the COVID Pandemic on Drug Overdoses
Estimating The Uncertain Effect of the COVID Pandemic on Drug Overdoses

ABSTRACT Objective U.S. drug-related overdose deaths and Emergency Department (ED) visits rose in 2020 and again in 2021. Multiple studies and the news media attributed this rise primarily to increased drug use resulting from the societal disruptions related to the coronavirus (COVID-19) pandemic. A competing explanation is that higher overdose deaths and ED visits may instead have been a continuation of pre-pandemic trends in synthetic-opioid deaths. We assess the evidence on whether increases in overdose deaths and ED visits are likely to be causally related to the COVID-19 pandemic, increased synthetic-opioid use, or some of both.Methods We use national data from the Centers for Disease Control and Prevention (CDC) on rolling 12-month drug-related deaths (2015-2021); CDC data on monthly ED visits (2019-September 2020); and ED visit data across 21states from a national ED group (January 2016-June 2022). We study drug overdose deaths per 100,000 persons during the pandemic period, and ED visits for drug overdoses, compared to predicted levels based on pre-pandemic trends.Results Mortality National overdose mortality increased from 21/100,000 in 2019 to 26/100,000 in 2020 and 30/100,000 in 2021. The 2020 increase is well-predicted by models that extrapolate pre-pandemic trends for rolling 12-month mortality to the pandemic period, consistent with higher mortality reflecting continuation of those trends. Placebo analyses (which assume the pandemic started earlier or later than March 2020) do not provide evidence for a change in trend in or soon after March 2020. State-level analyses of actual-minus-predicted mortality, relative to pre-pandemic trends, show no consistent pattern. The state-level results support state heterogeneity in overdose mortality trends, and do not support the pandemic being a major driver of overdose mortality.ED visits ED overdose visits rose during our sample period, reflecting a worsening opioid epidemic, but rose at similar rates during the pre-pandemic and pandemic periods.Conclusion The causes of rising overdose mortality in 2020 and 2021 cannot be definitely determined, but the observed increases can be largely explained by a continuation of pre-pandemic trends in synthetic-opioid deaths, principally fentanyl. In contrast to prior studies, we do not find support for the pandemic having been a principal driver of rising mortality. Policymakers need to directly address the synthetic opioid epidemic, and not expect a respite as the pandemic recedes.

The preprint titled “Estimating the Uncertain Effect of the COVID Pandemic on Drug Overdoses” analyzes national and state-level CDC drug overdose mortality data and unique sources of emergency department (ED) visit data to evaluate the claim that drug overdoses rose in 2020- 2021 due to the COVID-19 pandemic. The authors construct a counterfactual of expected overdose deaths during the pandemic period, using observed pre-pandemic trends, and compare it to the observed trends during the first pandemic year. The authors do not find support for the pandemic driving drug overdose mortality increases and conclude that these increases are likely explained by a continuation of pre-pandemic trends in synthetic opioid deaths. Overall, the results are potentially informative.

The strengths of this work include using more comprehensive data over a longer time period than the existing research on the topic, rigorous methodology, and well-structured and clear writing. The authors do an outstanding job positioning their research paper within the current literature and contextualize their research question and methodological approach well.

There are several potential limitations and suggestions for the authors to consider as they prepare to publish their manuscript. First, a more detailed explanation of how model fit was assessed and why the particular polynomial was chosen would be beneficial. The current model predicts a dramatic increase in overdose mortality in 2020, which can be hard to believe (especially the 2015 model for all overdoses). Would a different polynomial predict a lower slope for 2020?

Second, I wonder how the authors might interpret the positive difference between the actual and predicted mortality between April and November 2020 (Figure 1, Panels B and C)? Could this indicate a pandemic effect? This should be discussed.

Third, I believe that the outlying states may be informative and thus should not be omitted from Figure 2. Additionally, a U.S. map with states color-coded according to actual-minus-predicted may be a better visualization. Although the authors did not visually identify a pattern, state heterogeneity may be meaningful in that the pandemic may have played a greater role in some states than others. If the same polynomial model was fit on each state, perhaps model fit could be inappropriate in some states and state-specific models might be beneficial.

Fourth, the conclusion at the end of the Discussion claiming that the data is unlikely to support a more definitive message than in the preprint may be an overstatement. The authors could instead discuss how future research, for example using the CDC multiple-cause-of-death data, could extend their work and potentially elucidate the role of the pandemic in drug overdose mortality.

Additionally, I would recommend adding to the limitations that counts of synthetic opioids may be measured with error given that the percentage of unclassified drug overdoses decreases over time.

In conclusion, the preprint provides an important analysis that challenges the prevailing narrative that the COVID-19 pandemic has played a major role in the growth of drug overdose mortality. The findings should draw public health professionals’ and academics’ attention to the need to continue addressing the opioid epidemic, particularly synthetic opioid use and overdoses, through targeted policies and interventions, rather than hope that drug overdoses will naturally decline as the pandemic wanes.

Bryce Wo:

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