COVID-19 appears to have caused statewide overdose death spike in April-May-June
Overdose deaths exceeded 4,000 in 2019, new data show
Source: Harm Reduction Ohio analysis of Ohio Department of Health mortality data
By Dennis Cauchon
President, Harm Reduction Ohio
More than 4,000 Ohio residents died from drug overdoses in 2019, the third time in four years our state has reached this horrific level of death. Even worse: 2020 is on track to be even deadlier.
Overdose deaths have been rising since March 2019, reversing what now appears to have been a short-term decline that occurred in 2018. November 2019 was particularly deadly: 389 deaths, the most ever recorded in Ohio for that month.
A new acceleration in overdose death started a few months ago — in April, May and June of 2020, coinciding with the COVID-19 pandemic. Preliminary mortality data confirm scattered anecdotal reports of increased overdose death during the pandemic and add worrisome detail.
The early mortality data sho the pandemic-related overdose death increase was broad, statewide and cross-cultural. It occurred in all geographic regions of Ohio, touched small cities and rural areas as well as its big cities, and involved all drug preferences except marijuana.
Overdose deaths in Ohio rose 7.1% to 4,028 in 2019, according to a Harm Reduction Ohio analysis of Ohio Department of Health mortality data. In 2020, unless a big improvement occurs in the next few months, this year will be even worse and may come close to the record-breaking level of 4,854 overdose deaths that occurred in 2017 when carfentanil flooded the state’s drug supply.
Harm Reduction Ohio estimates, based on preliminary mortality data, that overdose deaths increased about 29.5% in the first six months of 2020 versus the same period in 2019. The following chart shows how the number of overdose deaths has changed in Ohio since 2013.
Source: Harm Reduction Ohio analysis of Ohio Department of Health mortality data
The percentage change for 2020 reflects the number of overdose deaths recorded in the mortality data as of August 20, 2020, versus the same period a year earlier. If the current pace continues for the rest of the year, overdose deaths in Ohio would exceed 4,500 in 2020 and could approach the historic 4,854 death count of 2017. (The continuation of the current negative trend is no sure thing because overdose death rates in Ohio fluctuate considerably from month-to-month. Things may get better.)
(NOTE: The mortality data used in this article is explained in detail the last section of this report.)
Fentanyl: here, there, everywhere in Ohio
The new data show that the spread of fentanyl and its analogs into the broader drug supply — especially cocaine and meth — continues to expand and is driving overdose death in Ohio. Fentanyl or an analog have been involved in 78.2% of overdose deaths recorded so far in 2020, the highest level ever.
Source: Harm Reduction Ohio analysis of Ohio Department of Health Mortality data
Other key findings:
- Race. For the first time since the 1980s, Ohio’s Black population had a higher overdose death rate in 2019 than for our state’s White population. This trend has continued in the first half of 2020.
- Cocaine. Cocaine-fentanyl deaths rose from 101 in 2014 to 930 in 2019. Fentanyl was involved in 79% of the cocaine-related deaths reported in 2020 versus 2% in 2013. The increased presence of fentanyl in cocaine has driven overdose deaths among Blacks to historically high levels in Ohio. Blacks die of cocaine-fentanyl overdoses at more than twice the rate of Whites in Ohio.
- Methamphetamine. Meth-fentanyl death rose from 12 in 2014 to 599 in 2019. Whites in Ohio die of meth-fentanyl at more than double the rate of Blacks, confirming the conventional view that meth is more popular among Whites while cocaine is more popular among Blacks — an idea also supported by the federal government’s annual drug use survey, which interviews 5,000 Ohioans every year on drug use.
- Heroin. Heroin deaths — including heroin-fentanyl deaths — have plummeted in Ohio, a sign that fentanyl (a compact, inexpensive synthetic opioid) has largely displaced heroin (a bulkier, harder-to-smuggle, harder-to-process substance made from opium poppy plants). Heroin-related deaths fell from a high of 1,444 in 2016 to 520 last year. Of those heroin-related deaths, 82% involved fentanyl in 2019 and so far in 2020, up from just 1.5% in 2013, the year before illicit fentanyl began appearing in Ohio.
Race, drugs and overdose death in Ohio
This next chart looks a little complicated but is worth your time. It shows the racial dynamics of drug preference and overdose death in Ohio. 
Overall, fentanyl kills Blacks and Whites at roughly the same rate. However, underneath this general truth, the picture varies dramatically by race. Fentanyl in cocaine has taken an enormous toll on the lives of Black Ohioans while White Ohioans have paid a great price from fentanyl in meth.
In 2019, 651 Black Ohio residents died of drug overdoses. Of those, 373 (or 57.4%) had cocaine in their systems and three-quarters of those also had consumed fentanyl, knowingly or not. The number of cocaine-fentanyl overdose deaths among Black Ohioans rose from 2 in 2013 to 273 in 2019.
In 2019, 3,331 White Ohio residents died of drug overdoses. Meth was involved in 776 of those overdose deaths. up from from 54 in 2013. Three-fourths of Whites who died with meth in their systems also had consumed fentanyl, knowingly or not.
In 2013, nobody in Ohio died of a meth-fentanyl combination. In 2019, 599 Ohio residents died of meth-fentanyl, including 569 Whites and 28 Blacks.
This isn’t incremental change. It is a revolution in the nature of overdose death in Ohio.
What’s happening now, during COVID?
Through August 24, a total of 2,071 overdose deaths have been recorded for 2020 in Ohio’s mortality database, a 29.5% increase from what had been reported at this time a year ago. That provides a rough estimate of the total number of overdose deaths have changed in the first half of 2020 vs. the first half of 2019.
This comparison is not a perfect measure because there is some variation in how many deaths are reported into the database and from what regions. But, overall, mortality records are coded and added to the dataset at a fairly steady pace, week after week, making year-to-year comparisons a timely and fairly accurate measure.
The Ohio Department of Health mortality database includes all deaths in Ohio. Harm Reduction Ohio analyzes deaths determined to have been caused by unintentional drug poisonings (i.e., overdose).
What’s frightening about the 2020 data reported so far is that an unusually large jump in overdose deaths occurred in April, May and June, when social isolation and economic stress increased in response to COVID-19. A link between COVID-19 and increased overdose death seems likely.
Several counties have reported overdoses increases during this period, but, until now, it was unclear if these overdose clusters were statistical variations or had been offset by declines elsewhere.
The number and pattern of the 2,071 overdose deaths record so far in the state’s 2020 mortality data — plus the 4,030 documented overdose deaths in 2019 — confirm that an acceleration of overdose death underway and that is large in size, geographically widespread and cuts through multiple demographic groups (racial, rural vs. urban, etc.).
Geography of overdose death
Where has overdose death grown most significantly?
- Eight counties have reported overdose deaths in the first half of 2020 that exceed deaths reported in all of 2019. Those counties are: Ashland, Coshocton, Fairfield, Fulton, Mercer, Morgan, Vinton, Wyandot. Three of these counties — Coshocton, Morgan, Vinton — have reported overdose deaths in the first half of this year that exceed what they’ve had in any year, ever, even during the 2017 death spike caused by carfentanil.
- Fourteen counties set overdose death records in 2019, mostly caused by a late-in-the-year acceleration of death that continues in 2020. These counties set or tied their overdose record highs in 2019: Defiance, Franklin, Gallia, Highland, Lucas, Marion, Morrow, Pickaway, Pike, Scioto, Stark, Union and Wood.
- Scioto County — home of Portsmouth, located on the Ohio River — had the state’s highest overdose death rate in 2018 and 2019 — and is on track to have the state’s highest rate again in 2020. The mortality data reports 41 overdose deaths so far in Scioto County. If this pace continues, it would exceed the 81 overdose deaths reported in 2019 when the county had the highest overdose death rate of any Ohio county anywhere in any year.
There is some good news. Overdose death rates have fallen sharply in a few places, notably in a 50-mile circle around Dayton, which once led the state (and the nation) in overdose death rates.
Montgomery County (home to Dayton) had 266 overdose deaths in 2019, down from 275 in 2018 and 521 in 2017. Neighboring Clark County (Springfield) has seen overdose deaths fall from 96 in 2017 to 56 last year. In Hamilton County (Cincinnati), overdose deaths fell to 353 in 2019, lower than in 2017 or 2018.
However, these positive trends appear to have slowed or reversed entirely in the second half of 2019 and the first half of 2020.
All of Ohio’s ten largest counties — except perhaps Cuyahoga (Cleveland) — are currently on track to report increased overdose death this year. Franklin County (Columbus) is particularly worrisome. Last year, it recorded 547 overdose deaths, an increase from 476 the year before and displaced Cuyahoga as the county reporting the most overdose deaths in Ohio.
Conclusion: Lessons learned?
In summary, overdose deaths began climbing again in March 2019, accelerated in the second half of 2019 and then surged again, on top of that, in the spring of 2020. It seems likely the April-May-June surge was related to the COVID-19 pandemic. The increase in overdose deaths has been experienced throughout Ohio, in big cities, small cities and rural areas.
The spread of fentanyl and fentanyl analogs into the broader drug supply is driving increased overdose death in Ohio. White Ohio residents are dying disproportionately from meth-fentanyl, and Black Ohio residents are dying disproportionately from cocaine-fentanyl.
The net effect is Ohio faces an overdose crisis that is not really about opioid use, although we continue to treat it this way. Ohio has an increasingly dangerous drug supply that is killing people who use all prohibited drugs except marijuana.
Overdose death is growing not as a result of increased drug use, much less increased opioid use. The problem is an impure, unpredictable, unknowable drug supply in which a synthetic opioid, originally intended as a compact, cost-effective replacement for prescription opioids and heroin, has become an all-purpose adulterant for all prohibited drugs.
The real lesson is that drug prohibition pushes this large consumer market for drugs toward smaller, easy-to-hide, potent alternatives. Chinese labs didn’t create fentanyl in Ohio. The drug war did. This may not have been the intent of drug war, but it is an unavoidable, unpreventable, inevitable consequence of it. Fentanyl is the marketplace’s rationale response to drug prohibition. This is how contraband markets work — always. It is the opposite of how legal and regulated markets work.
What causing overdose death in Ohio? Let’s be honest: drug prohibition is the cause. Prohibition kills. Always has, always will, is doing so right now.
By the numbers: How this analysis was done
Harm Reduction Ohio analyzes the Ohio Department of Health mortality database on a regular basis to track the number of overdose deaths in Ohio in a timely manner. This dataset lets us examine locations, demographics and drugs involved as in the year progresses.
The state’s mortality database is complicated to use for beginners but ultimately can be understood by anyone willing to spends time to learn it. The database can be found here. The data is updated weekly, every Monday morning, to include newly coded death certificates. About 40% of Ohio deaths are entered into the dataset within two months, 75% within three months, 95% within four months and 99% within six months.
Click to access Ohio’s mortality database
The mortality dataset for the previous year is usually finalized in the summer, then analyzed by government health authorities who report official numbers and rates of overdose death at the end of the year.
For a timely understanding of overdose death, Harm Reduction Ohio analyzes mortality data on an ongoing basis throughout the year. This lets us watch trends as they develop and report them earlier than others. With this data, we see can report big changes within one, two or three months of them occurring.
Why timely analysis of mortality data matters
Source: Harm Reduction Ohio analysis of Ohio Department of Health mortality data
Harm Reduction Ohio has used the state mortality data for the last three years to accurately document all major changes and trends in overdose patterns before they were recognized elsewhere. Most recently, Harm Reduction Ohio reported in February 2020 that overdose deaths rose above 4,000 in 2019. (See “Special Report: Ohio overdose deaths on rise again, exceed 4,000 in 2019.”) The final number in the dataset now is 4,030 overdose deaths, a 7.1% increase from 2018.
By contrast, in February 2020, the most recent overdose death number provided by the state was for 2018, a year in which overdose deaths declined. The latest official report, issued in November 2019, was accurate but old. It led journalists, elected officials, policymakers and others to operate on the outdated and erroneous belief that Ohio was making progress in reducing overdose death.
Slow reporting of overdose data data is a serious problem because overdose patterns in Ohio change quickly and dramatically. Reports and policies based on overdose data that is one to two years old has limited value.
Why is timeliness so crucial?
In the last 10 years, Ohio has been through four distinct overdose eras, each requiring a different policy response. A new era is sometimes over before official overdose document it or policies are proposed. The four overdose eras are (1) the expansion of prescription opioids, (2) the switch to heroin that following the prescription drug crackdown, (3) fentanyl and its analogs supplementing, then replacing heroin, and (4) the spread of fentanyl into the larger drug supply, especially the stimulants cocaine and meth.
Harm Reduction Ohio used this state’s mortality dataset (updated weekly) to report in December 2018 that overdose deaths had fallen in 2018, challenging the then-outdated belief that overdose death was as high as ever in Ohio. (See “Why have overdose deaths fallen in Ohio? One reason: Carfentanil has vanished.”)
The state had released its official overdose report on 2017 deaths in October 2018, leading to a no longer accurate impression that overdose deaths were still rising.
Overdose eras in Ohio
For those not familiar with overdose death patterns in Ohio, each of the overdose eras noted above led to higher and sustained levels of overdose death. The prescription drug era caused what, at the time, seemed like a large increase in overdose death. In retrospect, it was a modest increase compared to the deadly, if unintended, effects that would follow a crackdown on prescription drugs.
Consumers switched from prescription opioids (of known quantity and quality) to heroin (an illicit opioid of uncertain contents and dosage). This switch from prescription opioids to heroin sent overdose deaths to an unprecedented level.
In 2014, fentanyl entered the Ohio heroin supply as a cheap potency boost. Fentanyl is a small, cheap, easy-to-make, easy-to-hide opioid that can be imported by mail from China, Eastern Europe or Central America. Fentanyl is ideal contraband in drug markets. Fentanyl and its analogs — some weaker than fentanyl, some stronger — expanded its presence in the heroin supply over the next two years. The expansion of fentanyl in Ohio’s heroin/opioid supply sent overdose deaths to an even higher level.
The introduction of ultra-power carfentanil in mid-2016 caused a horrific spike in overdose deaths from July 2016 through July 2017. Monthly deaths peaked in January 2017 at 482 deaths. The highest number of overdose deaths reported in any 12-month period was 5,000 (exactly) that occurred in the 12 months ending June 30, 2017.
Then, for reasons that are unclear, carfentanil went away and, by 2018, had nearly vanished in Ohio, albeit temporarily. As carfentanil left Ohio’s drug supply, overdose deaths declined steadily from the carfentanil-driven peak. Overdose death declined significantly from August 2017 through February 2019. The decline of death in calendar year 2018 made the future look promising. Overdose death reached a recent low in Ohio at 281 deaths in April 2018.
The modern overdose era
However, the spread of fentanyl from opioids into the broader drug supply — cocaine, meth, fake pills, etc. — was already underway. As fentanyl and its analogs increasingly became all-purpose adulterants, the nature of overdose death (i.e., who died and why) changed, too. Fentanyl-related overdose death spread to people who were not regular opioid users, especially those who preferred stimulants.
That is the era we are now in. In Ohio, a fentanyl-juiced powder can pass for almost any drug. Even dealers are guessing what’s in substances that has passed through many hands in the supply chain.
Today, all illegal drugs except marijuana carry significant fentanyl risk. (Fentanyl-laced marijuana is a myth. Also, fentanyl has rarely been found LSD or mushrooms, at least in Ohio.)
Does Ohio have a drug use problem?
To further understand this current era of overdose death in Ohio, it’s crucial to know that drug use levels in our state are average. Ohio residents do not use drugs at exceptionally high rates. (See “The myth of Ohio’s ‘drug use problem'” and “Drug Use: Is Ohio really different?” for federal drug use survey data on Ohio compared to other states.)
What Ohioans do is die at exceptionally high rates from drug overdoses. The reason is fentanyl and its analogs (especially carfentanil) came to Ohio early, fast and hard, expanding quickly throughout the heroin supply and, 18 months later, into other drugs.
The pattern of Ohioans importing fentanyl (and especially ultra-dangerous carfentanil) through the mail was more extreme than in any other state in the country. For reasons unknown, fentanyl was an Ohio thing from the start. (Read “Where is fentanyl added to cocaine? Mostly in Ohio. Result: 3,000 dead” to understand how heroin, cocaine and meth come to Ohio in pure, unadulterated form and get boosted with fentanyl in Ohio.)
Overdose death: It’s all about the drug supply
Source: Harm Reduction Ohio analysis of state crime lab data
In short, the mountainous rise (and fall) that occurred in Ohio overdose deaths in 2016, 2017 and 2018 was almost entirely a function of the amount of carfentanil in our state’s drug supply. You can see how an increase in carfentanil in late 2019 likely caused overdose deaths to rise in Ohio.
Since 2016, every significant jump in overdose death in Ohio — both at the local level and state level — has been tied to the increased presence of carfentanil. Likewise, every significant decline has been tied to carfentanil’s receding in the drug supply. Carfentanil is an ideal drug to smuggle because it is active in minuscule amounts. But carfentanil’s potency in nearly invisible specks makes it impossible for a drug dealer or amateur chemist — or even a professional chemist! — to dilute it and package it in a way that is not extraordinarily dangerous.
How to save many lives quickly: Drug checking
In short, the content of the drug supply — not drug use — is what drives overdose death. Drug checking — i.e., testing drug contents and purity before people consume substances, rather testing a decedents blood after the person is dead — is the only policy that can significantly reduce overdose deaths during the drug war’s fentanyl era.
Harm Reduction Ohio’s analysis of state drug seizure data confirmed the epidemiological relationship between changes in the drug supply and changes in overdose deaths in a series of article on this web site. (We used Ohio’s mortality data and crime lab results from tens of thousands of chemical tests done at Ohio’s state crime labs to scientifically document the relationship.) Similar analyses of this Ohio data has been published in two scientific journal publications. (Search “carfentanil” on this web site for many stories on the topic or read the Journal of the American Medical Association article, co-authored by me.)
Harm Reduction Ohio analyzes and reports data and trends faster than others because overdose deaths change quickly, constantly and unpredictably. (I am also a journalist by training.) Relevant data needs to be monitored constantly — like the stock market or baseball standings or any data set that constantly changes.
The mortality data in this article is the same data as all researchers have. My innovation is using the information promptly. Harm Reduction Ohio is dedicated to providing an accurate, actionable and contemporaneous understanding of what’s happening in Ohio now. We operate the state’s largest naloxone distribution program — 15,000+ free kits of the overdose-reversing drug this year alone — because we want to save lives today.
Mortality data can do more than record a tragic history lesson. Let’s commit ourselves to understanding what’s happening today, not yesterday or two years or ten years ago. Let’s save some lives today. Knowledge is power. Let’s use it.
— Dennis Cauchon, President, Harm Reduction Ohio