The COVID-19 pandemic — responsible already for more than 16 million infections and 300,000 deaths in the United States1 —arrives at a time that the nation is still battling another crisis: the rising rates of fatal overdose from opioids and other drugs. Drug-related deaths have skyrocketed in the past few decades to levels that are four times greater than in the 1990s. Unintentional injuries—which include overdose deaths—are now the third leading cause of death in the country. The COVID-19 pandemic has the potential to make the overdose crisis worse. Even before the pandemic began, only a minority of people with opioid use disorder (OUD) received evidencebased treatment with medications, and many people who use drugs struggled to get access to lifesaving harm reduction services like syringe service programs. Early reports show that states are already cutting budgets for these critical substance use services as attention is turned to combatting the COVID-19 pandemic. However, with the recent economic downturn, even more people may be in need of harm reduction, treatment, and other substance use resources than before. Historically high unemployment rates and preventative physical distancing measures have also exacerbated social isolation and despair, known risk factors for substance use disorders.

Many models indicate that COVID-19 will cause increases in suicides, substance use, and overdose deaths. Indeed, preliminary data show increases in both fatal and nonfatal overdoses in many cities and states. There was an increase of 35% in opioid-related overdose in Arizona in March 2020 compared to March 2019. North Carolina is estimating a 15% increase in overdose-related emergency department visits since the beginning of the pandemic.Without additional attention to the preexisting overdose crisis, the loss of life of COVID-19 and its impact on vulnerable populations of people who use drugs will be immense. The COVID-19 and overdose crises both reflect the crucial importance of addressing structural determinants of health. Both crises have had a disproportionate impact on racial and ethnic minority populations due to factors like racism and poverty. Integrating equity in our public health responses to these epidemics will not only have immediate benefits amidst our national crisis but also will transform health outcomes for years to come. The intersecting COVID-19 and overdose crises demand urgent public health action. This paper offers a series of recommendations to policymakers for immediate action in the areas of funding, data and surveillance, harm reduction, and treatment, and for special populations to ensure equitable response to the overdose epidemic in an era of COVID-19.