Emergency departments across the United States experienced a dramatic 29% year-over-year increase in opioid overdose visits amid the COVID-19 pandemic, with overall drug overdose emergency department admissions rising up to 45% compared to 2019 levels from mid-April 2020 onward according to research published in JAMA Psychiatry. The study analyzed data from the Centers for Disease Control and Prevention’s National Syndromic Surveillance Program examining emergency department admissions between December 2018 and November 2020, revealing that behavioral health-related visits increased substantially during the March through October 2020 period despite overall emergency department utilization declining following the national emergency declaration. These findings underscore the devastating toll that pandemic-related social isolation, economic instability, treatment disruption, and healthcare system strain have exacted on Americans struggling with mental health conditions and substance use disorders, while highlighting the urgent need for enhanced prevention messaging, screening, intervention, and longitudinal surveillance tracking COVID-19’s long-term behavioral health impacts.
The research encompassed approximately 70% of the nation’s emergency department visits, drawing data from more than 3,500 emergency departments across 48 states and Washington, D.C., providing robust national representation enabling confident conclusions about pandemic-related behavioral health emergency department utilization trends. Researchers classified behavioral health admissions into six distinct categories including mental health conditions, opioid overdoses, overdoses from other substances, suicide attempts, domestic violence outcomes, and child abuse and neglect, enabling granular analysis of how different behavioral health presentations evolved throughout the pandemic’s progression.
Overdose Emergency Department Visits Show Alarming Acceleration
Of nearly 190 million total emergency department visits captured in the National Syndromic Surveillance Program data, behavioral health-related admissions increased during the mid-March through October 2020 period compared to the corresponding 2019 timeframe, with overdose visits demonstrating particularly large weekly increases. The 29% year-over-year rise in opioid overdose emergency department presentations represents a substantial acceleration of already-concerning pre-pandemic trends, suggesting that pandemic conditions dramatically exacerbated the ongoing opioid crisis through multiple interconnected mechanisms affecting both drug supply characteristics and individual risk factors.
The 45% increase in overall drug overdose emergency department admissions from mid-April onward indicates that the overdose surge extended beyond opioids to encompass stimulants, benzodiazepines, and other substances, reflecting broader patterns of increased substance use, risky consumption behaviors, and overdose vulnerability during the pandemic. This multi-substance overdose increase suggests that pandemic-related stress, isolation, economic hardship, and routine disruption affected individuals with diverse substance use patterns rather than specifically impacting only those using opioids.
The timing of overdose increases beginning in mid-April corresponds to the period when initial lockdown orders were broadly implemented, unemployment surged, social support systems were disrupted, and treatment access became severely constrained as facilities closed or reduced capacity. This temporal pattern suggests that pandemic-related social and economic disruptions played significant roles in driving overdose increases beyond any direct effects of COVID-19 infection or healthcare system strain.
Divergent Trends Between Overall and Behavioral Health Emergency Utilization
Following the March 13, 2020 national emergency declaration, overall emergency department visits decreased substantially as Americans avoided emergency departments due to infection concerns, public health messaging encouraging people to stay home, elective procedure cancellations, and pandemic-related behavior changes reducing certain injury types like motor vehicle accidents. However, behavioral health-related emergency department visits increased during this same period, creating a striking divergence where emergency departments saw fewer total patients but higher proportions presenting with mental health crises, overdoses, suicide attempts, and violence-related injuries.
This pattern indicates that behavioral health emergencies intensified to degrees that overcame the powerful forces deterring emergency department utilization, with individuals experiencing psychiatric crises, overdoses, or violence-related injuries requiring emergency care despite widespread reluctance to seek hospital treatment during the pandemic. The fact that behavioral health visits increased while overall emergency utilization declined suggests that observed trends substantially understate the true magnitude of behavioral health deterioration, as many individuals who would have sought emergency care under normal circumstances likely suffered without treatment due to pandemic-related barriers and hesitancy.
Emergency departments serve as safety nets for behavioral health crises when community treatment systems lack capacity, accessibility, or immediate availability, with emergency visits often representing treatment system failures rather than optimal care pathways. The increasing behavioral health emergency department utilization amid pandemic-related community treatment disruption illustrates how inadequate outpatient and crisis response infrastructure forces individuals experiencing psychiatric emergencies and overdoses into emergency settings ill-equipped to provide specialized behavioral health intervention beyond medical stabilization and crisis containment.
Multiple Mechanisms Drive Pandemic-Related Overdose Increases
The dramatic overdose increase reflects convergence of multiple factors that independently elevated overdose risk while interacting synergistically to create exceptionally dangerous conditions for individuals with substance use disorders. Social isolation resulting from lockdowns, remote work, and social distancing eliminated the protective presence of others who might intervene during overdoses, summon emergency assistance, or administer naloxone, with many pandemic overdoses occurring when individuals used substances alone rather than in social contexts where witnesses could provide lifesaving intervention.
Economic instability and unemployment increased psychological distress while reducing financial resources available for treatment, housing, food, and other basic needs, with substance use potentially increasing as a maladaptive coping mechanism while economic hardship simultaneously limited access to harm reduction supplies, drug checking services, and treatment programs. The relationship between economic stress and substance use operates bidirectionally, with financial problems contributing to increased consumption while substance use impairs employment stability and economic functioning.
Treatment disruption as facilities closed, reduced capacity, or transitioned to telehealth models that some patients could not access due to technology limitations, housing instability, or privacy concerns left many individuals without the clinical support, medication-assisted treatment, or peer connections that had previously supported their recovery. Gaps in treatment continuity frequently precipitate relapse, with individuals losing tolerance during abstinence periods becoming vulnerable to fatal overdoses if they resume substance use at previously tolerated doses.
Illicit drug supply contamination with fentanyl and increasingly potent synthetic opioids transformed overdose risk profiles, with users often unknowingly consuming substances containing lethal fentanyl concentrations. The pandemic disrupted international drug trafficking patterns while accelerating the ongoing transition from heroin to synthetic opioids that require no agricultural production or complex supply chains, with fentanyl’s extreme potency enabling profitable trafficking in small volumes while creating extreme overdose danger from dosing errors or unexpectedly potent supplies.
Broader Behavioral Health Emergency Department Trends
Beyond overdoses, the study documented increases across other behavioral health emergency department visit categories including mental health conditions, suicide attempts, domestic violence, and child abuse and neglect, illustrating the pandemic’s comprehensive impact across multiple dimensions of behavioral health and interpersonal violence. Mental health condition emergency visits likely reflected pandemic-related anxiety and depression exacerbations, delayed care for chronic psychiatric conditions, and acute crises among individuals who lost access to outpatient treatment when providers closed or capacity became insufficient to meet surging demand.
Suicide attempt increases aligned with concerning trends in suicidal ideation that multiple surveys documented throughout the pandemic, with social isolation, economic stress, grief from COVID-19 deaths, and pervasive uncertainty about the future creating conditions elevating suicide risk. Emergency department visits represent only the subset of suicide attempts requiring emergency medical care, suggesting that total attempts including those not requiring hospital treatment likely increased even more dramatically than emergency department data indicate.
Domestic violence and child abuse emergency department visits increasing during lockdowns reflected the dangerous combination of families confined together in stressful conditions with reduced access to external support systems, school-based abuse detection, and escape options for victims trapped with perpetrators during stay-at-home orders. These violence increases likely substantially understate true prevalence given that pandemic conditions also reduced opportunities for victims to seek help or for external observers to detect and report abuse.
Implications for Prevention and Intervention
Study authors emphasized that findings underscore the need for continued mental health, suicide, overdose, and violence prevention messaging, screening, and interventions at individual, relationship, community, and societal levels, alongside longitudinal surveillance tracking COVID-19’s long-term behavioral health impacts. This multilevel approach recognizes that effectively addressing pandemic-related behavioral health consequences requires coordinated action across clinical services, public health programs, community organizations, policy reforms, and social determinants interventions rather than expecting any single strategy to adequately respond to complex, interconnected challenges.
Individual-level interventions encompass clinical treatment for substance use disorders and mental health conditions, harm reduction services including naloxone distribution and drug checking, safety planning for individuals at suicide risk, and supportive services addressing housing, employment, and social connection. Relationship-level approaches involve family therapy, couples counseling, parenting support, and violence prevention programs addressing interpersonal dynamics contributing to behavioral health problems and violence.
Community-level strategies include expanding treatment capacity, developing crisis response infrastructure, implementing community-based prevention programs, addressing social determinants through housing and employment initiatives, and building social cohesion counteracting isolation. Societal interventions encompass policy reforms improving insurance coverage and treatment access, reducing stigma through public education campaigns, regulating pharmaceutical opioid prescribing, and addressing structural inequities in healthcare access, economic opportunity, and social support systems.
Long-Term Surveillance and Research Needs
The study authors called for longitudinal surveillance tracking COVID-19’s enduring behavioral health impacts, recognizing that pandemic consequences will likely persist long after acute public health emergency phases conclude. Mental health conditions and substance use disorders triggered or exacerbated during the pandemic may require years of treatment, with some individuals experiencing chronic conditions requiring ongoing support. Economic impacts including unemployment, business failures, and wealth destruction will continue affecting behavioral health long after pandemic-related restrictions end.
Surveillance systems must track not only emergency department utilization but also outpatient treatment engagement, overdose deaths occurring outside emergency settings, suicide completions, violence prevalence, and population-level behavioral health indicators measured through surveys and administrative data. Comprehensive monitoring enables early detection of emerging problems, evaluation of intervention effectiveness, and evidence-informed policy adjustments responding to evolving needs as pandemic recovery progresses.
Research examining mechanisms linking pandemic conditions to behavioral health deterioration, identifying populations at elevated risk, evaluating prevention and treatment approaches, and developing evidence-based interventions will prove essential for optimizing responses to current challenges while building preparedness for future public health emergencies that will inevitably affect behavioral health. The COVID-19 pandemic exposed fundamental vulnerabilities in behavioral health systems that struggled to maintain service continuity and meet escalating needs, demanding substantial investment in infrastructure, workforce, and care delivery innovations ensuring that future crises do not generate comparable devastation.
The 29% increase in opioid overdose emergency department visits amid the pandemic represents a tragic illustration of how public health emergencies exacerbate pre-existing behavioral health crises, demanding comprehensive prevention, treatment, and harm reduction responses that address the multilevel factors driving overdose risk while building resilient systems capable of maintaining essential services during future disruptions.
