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Impact of the COVID-19 pandemic on opioid overdose and other adverse events in the USA and Canada: a systematic review
  1. Siddartha Simha1,
  2. Yusuf Ahmed2,
  3. Chad M Brummett1,3,
  4. Jennifer F Waljee3,4,
  5. Michael J Englesbe3,4 and
  6. Mark C Bicket1,3
  1. 1 Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
  2. 2 University of Michigan Medical School, Ann Arbor, Michigan, USA
  3. 3 Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan, USA
  4. 4 Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
  1. Correspondence to Dr Mark C Bicket, Anesthesiology, Michigan Medicine, Ann Arbor, Michigan 48109, USA; mbicket{at}


Importance The COVID-19 pandemic impacted healthcare beyond COVID-19 infections. A better understanding of how COVID-19 worsened the opioid crisis has potential to inform future response efforts.

Objective To summarize changes from the COVID-19 pandemic on outcomes regarding opioid use and misuse in the USA and Canada.

Evidence review We searched MEDLINE via PubMed, EMBASE, and CENTRAL for peer-reviewed articles published between March 2020 and December 2021 that examined outcomes relevant to patients with opioid use, misuse, and opioid use disorder by comparing the period before vs after COVID-19 onset in the USA and Canada. Two reviewers independently screened studies, extracted data, assessed methodological quality and bias via Newcastle-Ottawa Scale, and synthesized results.

Findings Among 20 included studies, 13 (65%) analyzed service utilization, 6 (30%) analyzed urine drug testing results, and 2 (10%) analyzed naloxone dispensation. Opioid-related emergency medicine utilization increased in most studies (85%, 11/13) for both service calls (17% to 61%) and emergency department visits (42% to 122%). Urine drug testing positivity results increased in all studies (100%, 6/6) for fentanyl (34% to 138%), most (80%, 4/5) studies for heroin (-12% to 62%), and most (75%, 3/4) studies for oxycodone (0% to 44%). Naloxone dispensation was unchanged and decreased in one study each.

Interpretation Significant increases in surrogate measures of the opioid crisis coincided with the onset of COVID-19. These findings serve as a call to action to redouble prevention, treatment, and harm reduction efforts for the opioid crisis as the pandemic evolves.

PROSPERO registration number CRD42021236464.

  • Opioid-Related Disorders
  • Analgesics, Opioid
  • COVID-19
  • Pain Management

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  • Contributors Contributorship statement: (1) Conception and design: SS, MCB (2) Administrative support: MCB, CMB, MJE, JFW (3) Provision of study materials or patients: SS, YA, MCB (4) Collection and assembly of data: SS, YA, MCB (5) Data analysis and interpretation: SS, YA, MCB (6) Manuscript writing: All authors (7) Final approval of manuscript: All authors (8) Overall guarantor: SS.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests Disclosures: SS and YA have no disclosures. CMB, MJE, JFW and MCB receive funding from the Michigan Department of Health and Human Services and the National Institute on Drug Abuse (R01DA042859). MCB reports past consultation with Axial Healthcare and Alosa Health not related to this work. CMB is a consultant for Heron Therapeutics and the Benter Foundation, served as a one-time consultant for Vertex Pharmaceuticals and Alosa Health, and provides expert medical testimony.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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