Medicaid expansion and drug overdose mortality during the COVID-19 pandemic in the United States

Drug Alcohol Depend. 2022 Mar 1;232:109340. doi: 10.1016/j.drugalcdep.2022.109340. Epub 2022 Feb 2.


Background: The COVID-19 pandemic caused disruptions in the delivery of health services, which may have adversely affected access to substance use disorder (SUD) treatment services. Medicaid expansion has been previously associated with increased access to SUD services for low-income adults. Thus, the pandemic may have differentially impacted overdose mortality depending on expansion status. This study examined trends in overdose mortality nationally and by state Medicaid expansion status from 2013 to 2020.

Methods: State-level data on overdose mortality were obtained from the Centers for Disease Control and Prevention's WONDER database for 2013-2020 (N = 408 state-years). The primary outcomes were drug and opioid overdose deaths per 100,000 residents. The primary exposure was Medicaid expansion status as of January 1st, 2020. Difference-in-difference (DID) models were used to compare changes in outcomes between expansion and non-expansion states after the onset of the COVID-19 pandemic.

Results: The U.S. experienced 91,799 drug overdose deaths in 2020, a 29.9% relative increase from 2019. Expansion states experienced an adjusted increase of 7.0 drug overdose deaths per 100,000 residents (95% CI 3.3, 10.7) and non-expansion states experienced an increase of 4.3 deaths (95% CI 1.5, 8.2) from 2019 to 2020. Similar trends were observed in opioid overdose deaths. In DID models, Medicaid expansion was not associated with changes in drug (0.9 deaths, 95% CI -2.0, 3.7) or opioid overdose deaths (0.8 deaths, 95% CI -1.8, 3.5).

Conclusions: The increase in drug or opioid overdose deaths experienced during the first year of the COVID-19 pandemic was similar in states with and without Medicaid expansion.

Keywords: COVID-19; Medicaid; Opioid use disorder; Overdose mortality; Substance use disorder.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Analgesics, Opioid / therapeutic use
  • COVID-19*
  • Drug Overdose* / epidemiology
  • Humans
  • Medicaid
  • Pandemics
  • SARS-CoV-2
  • United States / epidemiology


  • Analgesics, Opioid