After years of steady parallelization, two of the worst public health trends in America split during the coronavirus pandemic.
According to newly released federal data, drug overdose deaths rose 30 percent to 92,500 last year, a sudden surge after years of gradual growth as the opioid epidemic hit. In fact, however, suicides fell slightly, from 47,500 in 2019 to 44,800 in 2020.
These two trends have been closely followed over the past decade, so there is an umbrella term in science that encompasses both (among other things): Desperate deaths. Much of the recent stagnation in life expectancy in the US can be explained by these premature deaths, which are particularly focused on young men, and scientists have theories about the economic and social conditions that are driving these trends.
That was the situation before Covid-19. So what happened during the pandemic?
This is the question I asked a handful of public health experts. They told me that while it is almost certainly too early, we can still make some educated guesses.
Why drug overdoses have soared during the pandemic
The surge in drug overdose deaths surprised even people who follow this data closely. Dr. Nora Volkow, director of the National Institute on Drug Abuse, told me the increase in 2020 was a historical deviation based on previous trends. From 2018 to 2019, for example, deaths from overdose increased comparatively slightly by 5 percent. Something was clearly different in 2020.
"We have never seen that before, an increase of 30 percent," said Volkow. “It's very different. It's a break in the trend. "
In some cases, trends that were already underway before Covid-19 worsened. Fentanyl, a more dangerous opioid that is often trimmed with heroin, has spread west of the Mississippi in recent years.
Volkow told me she wondered if drug supplies would be restricted during the pandemic due to travel and other restrictions. But instead, the offer seems to have grown – and become more dangerous. Preliminary data suggests that while deaths from heroin overdose decreased in 2020, deaths with fentanyl increased exponentially, she said. They are driving the rise in all deaths from overdose.
Instead, the pandemic has likely exacerbated the surge in overdoses. The sheer magnitude of the increase is hard to ignore. Moments of stress and social isolation tend to lead to more drug use, Volkow told me. It would make sense for people to be on the lookout for narcotics during the immense social upheaval in 2020. And with a more dangerous product on the market, an increase in overdose deaths would also be expected.
"Fentanyl is common across the country, like the Covid pandemic," said Volkow. "You can say they performed side by side."
In addition, as University of Chicago economist Casey Mulligan wrote in a working paper on the pandemic and deaths from despair, more people are likely to overdose in isolation during the pandemic. No one else was around to administer an overdose drug or call paramedics, which could have resulted in deaths that otherwise would not have occurred.
The Complicated Story Behind The Decline In Suicides During Covid
But if isolation drove up drug use, and with it overdose deaths, how do we explain the decline in suicides, which we could possibly expect to increase at a time of great social anxiety?
A popular, albeit unproven, theory is that the economic relief passed by Congress may have helped alleviate suicidal thoughts during the pandemic. In countries that have generous social safety nets in place, suicide rates have decreased over decades, and increases in personal income have been linked to fewer suicides.
According to this theory, it is possible that last year's stimulus measures contributed to more overdose deaths but fewer suicides. Mulligan points out in his paper on overdosing that personal income has increased but other consumption opportunities have disappeared due to Covid restrictions, although he was also careful to say that a causal link was beyond the purview of his paper.
Volkow gave several reasons to be skeptical of this reading and linked them to the fentanyl problem. People who use opioids generally look for heroin because they know it's not as dangerous as fentanyl – but uncut heroin is also more expensive to buy. If the rise in income contributed to the rise in drug use, we might have expected people to try to buy uncontaminated heroin. Instead, fentanyl-related deaths rose in 2020.
However, the impact of Covid-19 on the suicide rate in America may not yet be fully apparent. There is social science research on previous disasters that shows that while suicides during and immediately after an emergency may slow down, they increase in the months and years that follow.
British researchers reviewed the literature on previous epidemics and suicide rates and found this phenomenon: "There is some evidence that the suicide rate declines in the short term immediately after a disaster." The scholars I have spoken to seem to accept this theory, though the empirical basis for this is somewhat limited.
"The thought was that depression was an internalizing disorder and that getting out of your mind and worrying about other people was a bit protective," said Dr. Paul Earley, past president of the American Society of Addiction Medicine, via email.
But the consistent finding of all the studies the UK researchers reviewed was that suicides eventually increased after a large-scale disaster. Volkow cited the example of Hurricane Katrina: initial research showed that suicidal ideation had indeed decreased in the affected areas immediately after the storm, but later studies found that these attitudes were even more widespread a few years later. Researchers theorized that the continued post-disaster stress, as it took communities so long to recover, may have contributed to an increase in suicidal thoughts and planning.
So the fear would be that the US will see a delayed but significant spike in suicides even as the pandemic subsides.
"People are very concerned that there could be an increase in suicides once the situation has stabilized," said Volkow. “A lot of attention is paid to it at such a major event. Everyone is focused. This can create a sense of support. Once it's out of the main news it goes away. You can feel the neglect, the hopelessness and the helplessness. "
The decline in suicides could also mask worrying trends for America's marginalized communities. A study of suicides in Maryland last year concluded that the suicide rate among blacks doubled during the pandemic, while the suicide rate among whites fell by half. An analysis of 2020 Connecticut suicides found a similar trend.
Surveys by the Kaiser Family Foundation have found that a higher proportion of Black and Hispanic Americans will report symptoms of anxiety or depression during the pandemic. People who are classified as indispensable workers, i.e. disproportionately colored, stated more than twice as often that they had seriously thought about suicide in the last 30 days than non-vital workers.
We'll also have to wait to see the numbers of intentional and unintentional overdoses, which can further complicate the picture. Volkow pointed out that women are more likely than men to deliberately overdose. However, collecting and analyzing this data takes time. As Mulligan noted, an overdose is chemical analysis – was a lethal amount of a drug present at the time of death? – while the decision to die as suicide is rather subjective.
The difficulty of distinguishing suicide from drug overdose is one of the reasons the collective term "deaths of desperation" is so popular. Taken together, there is ultimately no good news in this new data.
What is clear is that in the past year, in addition to all of the deaths directly from Covid-19 itself, many more Americans died in ways that would indicate deep social and existential despair. If the suicide rate increases in the coming months and years, as previous experience suggests, the toll of the pandemic will only increase.