New data from the Rhode Island Department of Health (RIDOH)'s Office of the State Medical Examiners (OSME) indicate a sharp increase in accidental drug overdose deaths during the first seven months of 2020. (It can take up to 90 days for the OSME to confirm a decedent's cause and manner of death.)

There have been 233 accidental drug overdose deaths between January and July 2020, compared to 185 during the same period last year. Between these two periods, all drug fatal overdoses increased by 26% and opioid-involved fatal overdoses increased by 33%. During July, more Rhode Islanders died of drug overdoses than any month since the State started tracking fatal overdose data. Similar trends are being seen nationally.

The stressors and isolation of the COVID-19 pandemic are believed to be factors in this increase, resulting in what researchers call a syndemic, which is the amplified result of two or more diseases that exist simultaneously in a community. However, Rhode Island's increase in overdose deaths started before the state's first COVID-19 case. Other factors that are likely contributing to the increase are polysubstance use (the use of more than one drug at the same time), counterfeit pills, and the presence of illegally made fentanyl in drugs like cocaine, counterfeit pills, methamphetamine, and other substances.

Counterfeit pills, which often look like prescription medications, are in greater supply throughout the United States, particularly oxycodone (an opioid) and benzodiazepines (a sedating drug). These pills vary in purity and potency and can contain unknown amounts of fentanyl. It is impossible for an end user to know what drugs might be present in counterfeit pills. These counterfeit pills are even more lethal when crushed and snorted. One pill can cause a fatal overdose.

"What underlies the diseases of substance use disorder and COVID-19 are factors in our communities that affect people's abilities to be healthy and safe, such as housing, employment, education, and discrimination," said Director of Health Nicole Alexander-Scott, MD, MPH. "While getting prevention and treatment resources into the community to prevent overdoses immediately, we need to continue working to address these larger structural issues. Every single overdose is preventable. There is help and there is hope for everyone who is living with the disease of substance use disorder."

"The increased potency of drugs combined with the challenges of COVID-19 have stressed an already fragile system," said Kathryn Power, M.Ed., Director of the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities & Hospitals (BHDDH). "These challenges might have led people who were in recovery to relapse. In other cases, people who use drugs occasionally, like cocaine, might have succumbed to an overdose by not knowing fentanyl was present."

Director Power and Dr. Alexander-Scott are the co-chairs of Governor Gina M. Raimondo's Overdose Prevention and Intervention Task Force.

"The collision between the COVID-19 and opioid epidemic has really highlighted how crucial social determinants of health- safe housing, good employment, access to mental health support- are to sustaining long-term recovery," said Dr. Jon Soske of Rhode Island Communities for Addiction Recovery (RICARES). "So many people have relapsed after evictions, layoffs, and traumatic losses- and these have hit racialized communities hardest. Addressing these issues at a systemic level is crucial going forward."?

Additional data points

- Accidental drug overdose deaths decreased by 8.3% between 2016 and 2019, dropping from 336 to 308. - Rhode Island is on track to exceed 2016's total by at least 25%. - During the first seven months of 2020, non-fatal overdoses fluctuated by month. During April and May, the numbers of non-fatal overdoses that EMS responded to in Rhode Island were lower. - All Rhode Island cities and towns are being affected. Particular overdose hotspots include Providence, Pawtucket, Warwick, and Woonsocket. Fatal overdoses doubled among Warwick and Providence residents during the first six months of 2020. In North Kingstown and Scituate, the total number of fatal overdoses during the first six months of 2020 exceeded the towns' total numbers for all of 2019. - While the rate of fatal overdoses among White Rhode Islanders declined between 2016 and 2019, that rate increased in the first seven months of 2020. Overdose rates generally increased among African American and Hispanic Rhode Islanders from 2016 to 2019 and continued to increase during the first seven months of 2020. - Overdose death data by month and year are available online.

Current action steps

In response to these trends, RIDOH and BHDDH hosted an emergency, online Community Overdose Engagement (CODE) meeting in July with more than 150 state and community stakeholders. Actions steps coming out of that meeting that are either in the implementation or planning phase are:

- Increased street outreach activities in overdose hotspots across the state. Certified peer recovery support specialists from community-based organizations like AIDS Care Ocean State, Community Care Alliance, East Bay Recovery Center, Parent Support Network, and Project Weber/RENEW distribute naloxone, sterile syringes, and fentanyl test strips and provide wrap-around services and basic needs to individuals who use drugs. - Increased housing support for vulnerable populations in Woonsocket and Providence. Through the West Elmwood 02907 CODE project, Amos House maintains additional beds within its temporary housing assistance program. Project Weber/RENEW in Providence offers recovery housing grants for clients, and Sojourner House in Woonsocket will provide a drop-in housing clinic for emergency services. - Strategic placement of Substance Abuse and Misuse Teams (SMART) at Rhode Island Hospital's and Landmark Hospital's emergency departments. Trained staff are ready to connect patients who have recently experienced an overdose to local treatment and recovery support services. - Collaboration with a community-led work group and expert advisors across state agencies to explore the development of an overdose prevention center. Health services such as STI testing, addiction treatment, housing supports, and basic services (i.e., showers, food, and clothing) would be available at such a center. This would also be a place where people could use pre-obtained substances while being peer or medically supervised. Sterile equipment and immediate overdose response resources would be available to reduce overdose and infectious disease risk.

Next steps

- On October 30, the City of Providence Healthy Communities Office, West Elmwood Housing Development Corporation, Amos House, Rhode Island Public Health Institute, Systems Change Strategies, and Project Weber/RENEW will host a virtual event. They will release key findings from a community needs assessment and identify action steps. Members of the public can sign up at bit.ly/PVDCODE

- The Rhode Island Executive Office of Health and Human Services (EOHHS) is conducting an Evidence Update and Strategic Programmatic Review of Governor Raimondo's Overdose Prevention and Intervention Task Force 2019-2021 Strategic Plan.

Resources for people who need help

If you or someone you care about is living with a substance use disorder, there is 24/7 treatment and mental health support available over the phone or in-person.

- BH Link, Rhode Island's 24/7 behavioral health hotline, 401-414-LINK (5465), connects callers to trained professionals who can provide confidential counseling, referrals, and support services. People can go to BH Link's drop-in center in-person to get connected to support at 975 Waterman Ave. in East Providence.

- The Buprenorphine Hotline, 401-606-5456, provides telehealth services for experiencing opioid withdrawal. Callers can learn about Medication Assisted Treatment (MAT) options and make a plan for continued treatment and recovery support through a Rhode Island Center of Excellence. Rhode Island Centers of Excellences are specialty centers that use evidence-based practices and provide treatment and the coordination of care to individuals with moderate to severe opioid use disorder.

- Fire stations in Providence, Newport, and Woonsocket are "Safe Stations." They are open every day to help people in crisis get connected to a peer recovery support specialist and treatment and recovery support services.

How you can save a life

- Learn the signs of an overdose, such as slow, shallow breaths; gurgling noises; breathing that has stopped; very pale skin; and, blue-gray lips and fingernails.

- Call 9-1-1 first if someone is overdosing. The Rhode Island Good Samaritan Law protects people who call for help when a person is experiencing an overdose.

- Carry the overdose reversal medicine naloxone (sometimes called Narcan) and know how to use it. Naloxone is available at pharmacies without a prescription. You can also get naloxone from a community-based organization like AIDS Care Ocean State, East Bay Recovery Center, Parent Support Network, Project Weber/RENEW, URI Community First Responders and RICARES.