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Alongside the emergence of COVID-19 in the United States, several reports highlighted increasing rates of opioid overdose from preliminary data. Yet, little is known about how state-level opioid overdose death trends and decedent characteristics have evolved using official death records. We requested vital statistics data from 2018–2020 from all 50 states and the District of Columbia, receiving data from 14 states. Accounting for COVID-19, we excluded states without data past March 2020, leaving 11 states for analysis. We defined state-specific analysis periods from March 13 until the latest reliable date in each state’s data, then conducted retrospective year-over-year analyses comparing opioid-related overdose death rates, the presence of specific opioids and other psychoactive substances, and decedents’ sex, race, and age from 2020 to 2019 and 2019 to 2018 within each state’s analysis period. We assessed whether significant changes in 2020 vs. 2019 in opioid overdose deaths were new or continuing trends using joinpoint regression. We found significant increases in opioid-related overdose death rates in Alaska (55.3%), Colorado (80.2%), Indiana (40.1%), Nevada (50.0%), North Carolina (30.5%), Rhode Island (29.6%), and Virginia (66.4%) – all continuing previous trends. Increases in synthetic opioid-involved overdose deaths were new in Alaska (136.5%), Indiana (27.6%), and Virginia (16.5%), whilst continuing in Colorado (44.4%), Connecticut (3.6%), Nevada (75.0%), and North Carolina (14.6%). We found new increases in male decedents in Indiana (12.0%), and continuing increases in Colorado (15.2%). We also found continuing increases in Black non-Hispanic decedents in Massachusetts (43.9%) and Virginia (33.7%). This research analyzes vital statistics data from 11 states, highlighting new trends in opioid overdose deaths and decedent characteristics across 10 of these states. These findings can inform state-specific public health interventions and highlight the need for timely and comprehensive fatal opioid overdose data, especially amidst concurrent crises such as COVID-19. Key messages:Our results highlight shifts in opioid overdose trends during the COVID-19 pandemic that cannot otherwise be extracted from aggregated or provisional opioid overdose death data such as those published by the Centres for Disease Control and Prevention.Fentanyl and other synthetic opioids continue to drive increases in fatal overdoses, making it difficult to separate these trends from any possible COVID-19-related factors.Black non-Hispanic people are making up an increasing proportion of opioid overdose deaths in some states.State-specific limitations and variations in data-reporting for vital statistics make it challenging to acquire and analyse up-to-date data on opioid-related overdose deaths. More timely and comprehensive data are needed to generate broader insights on the nature of the intersecting opioid and COVID-19 crises Our results highlight shifts in opioid overdose trends during the COVID-19 pandemic that cannot otherwise be extracted from aggregated or provisional opioid overdose death data such as those published by the Centres for Disease Control and Prevention. Fentanyl and other synthetic opioids continue to drive increases in fatal overdoses, making it difficult to separate these trends from any possible COVID-19-related factors. Black non-Hispanic people are making up an increasing proportion of opioid overdose deaths in some states. State-specific limitations and variations in data-reporting for vital statistics make it challenging to acquire and analyse up-to-date data on opioid-related overdose deaths. More timely and comprehensive data are needed to generate broader insights on the nature of the intersecting opioid and COVID-19 crises

BackgroundSince COVID-19 erupted in the United States, little is known about how state-level opioid overdose trends and decedent characteristics have varied throughout the country.ObjectiveInvestigate changes in annual overdose death rates, substances involved, and decedent demographics in opioid overdose deaths across nine states; assess whether 2019-2020 trends were emerging (i.e., change from 2019-2020 was non-existent from 2018-2019) or continuing (i.e., change from 2019-2020 existed from 2018-2019).DesignCross-sectional study using vital statistics data to conduct a retrospective analysis comparing 2020 to 2019 and 2019 to 2018 across nine states.SettingAlaska, Colorado, Connecticut, Indiana, Massachusetts, North Carolina, Rhode Island, Utah, and Wyoming.ParticipantsOpioid-related overdose deaths in 2018, 2019, and 2020.MeasurementsAnnual overdose death rate, proportion of overdose deaths involving specific substances, and decedent demographics (age, sex, race, and ethnicity).ResultsWe find emerging increases in annual opioid-related overdose death rates in Alaska (55.3% [P=0.020]), Colorado (80.2% [P<0.001]), Indiana (40.1% [P=0.038]), North Carolina (30.5% [P<0.001]), and Rhode Island (29.6% [P=0.011]). Decreased heroin-involved overdose deaths were emerging in Alaska (−49.5% [P=0.001]) and Indiana (−58.8% [P<0.001]), and continuing in Colorado (−33.3% [P<0.001]), Connecticut (−48.2% [P<0.001]), Massachusetts (39.9% [P<0.001]), and North Carolina (−34.8% [P<0.001]). Increases in synthetic opioid presence were emerging in Alaska (136.5% [P=0.019]) and Indiana (27.6% [P<0.001]), and continuing in Colorado (44.4% [P<0.001]), Connecticut (3.6% [P<0.05]), and North Carolina (14.6% [P<0.001]). We find emerging increases in the proportion of male decedents in Colorado (15.2% [P=0.008]) and Indiana (12.0% [P=0.013]).LimitationsDelays from state-specific death certification processes resulted in varying analysis periods across states.ConclusionThese findings highlight emerging changes in opioid overdose dynamics across different states, which can inform state-specific public health interventions.