Did the harm from overdose deaths outweigh that from Covid-19 in 2020?

We now have good data on the impacts of the virus and lockdown policies for calendar year 2020 and we can reasonably conclude that lockdown policies probably caused more harm than good in the U.S; looking only at overdose deaths and homicides we see that the harm from lockdowns was probably higher than any direct harm from the virus, and there are many other negative impacts, in terms of increased mortality and otherwise

[This is a short version of an academic paper I’m wrapping up with some co-authors; I’ve included here just the part that looks at “years of life lost” for COVID-19 and for overdose and homicide deaths; showing that the years of life lost for the latter two categories is comparable or even higher than for COVID-19]

Overdose deaths soared to new records in 2020, reaching at least 93,000, up from about 70,000 the year before. This was also by the far biggest increase in a single year, at almost 30%. “It’s huge, it’s historic,” was the New York Times headline on July 14, 2021, when the full 2020 overdose deaths tally became public for the first time.

Figure 1. New York Times graphic showing sharp rise in overdose deaths in 2020, correlating closely with lockdowns.

We can also map the monthly increases in overdose deaths and see that they correlated well with the stringency of lockdown measures in the U.S., reaching a peak in April and May as lockdown stringency peaked, declining over the summer and then peaking again as winter lockdowns arrived.

Figure 2. New York Times graphic showing monthly change in 2020 compared to 2019 overdose deaths.

Here’s a chart showing the stringency of U.S. lockdown measures. Rotate the two charts in your mind to match each other and you can easily see they correlate quite well.

Figure 3. Ourworldindata.org lockdown stringency index for the U.S.

We can now use standard epidemiological tools to compare impacts from the virus itself and policies enacted in response to the virus. “Excess deaths” analysis, which looks at the number of deaths higher or lower than in previous years, is just one of many available tools for assessing impact from disease outbreaks.

Years of Life Lost (YLL) is a more granular mortality impact measure[1] that considers age and comorbidities in relation to mortality. In contrast, excess deaths analysis does not consider age or comorbidities.

The average age at death of U.S. COVID-19 victims is ~76 and the average comorbidities is ~4.0,[2] according to CDC data. About 40 percent of all U.S. COVID-19-related deaths occurred in nursing homes,[3] and an even higher proportion occurred in long-term care homes more generally (1.3 million people lived in skilled nursing homes and another 1.7 million in other assisted living long-term care[4]).

I found, as a preliminary estimate, based on these data, that the average YLL for COVID-19-related deaths in the U.S. for 2020 was ~5.3 years, based on a modification of Briggs et al. 2020.[5] In other words, the average COVID-19 victim had an additional 5.3 years to live, given their age and health profile.

This 5.3 years of life left in the average COVID-19 victim is unsurprising because of the advanced age and frailty of most COVID-19 victims.

This YLL calculation does not, however, factor in the 40 percent nursing home deaths ratio, which would further reduce the YLL for COVID-19 deaths. Co-morbidities are not all equal in severity and given the short survival time for most nursing home residents (five month mean survival time, as a recent paper found), it is clear that the co-morbidities suffered by nursing home residents are significantly more severe than those in non-nursing home residents.

CDC’s COVID-19-related deaths figure for 2020 was 357,246.[6] Multiplying these figures (357,246 deaths x 5.3 years) yields ~1.89 million Years of Life Lost (YLL) for 2020 for direct mortality impacts of the virus in calendar year 2020. This figure assumes that CDC’s count of COVID-19-related deaths is an accurate count of deaths attributable to COVID-19 rather than being only in association with the virus, as it is in fact calculated (more on this later).

To gauge the significance of COVID-19 years of life lost, policymakers should compare this figure to indirect impacts of the virus and virus-related policies. For example, I calculate, based on an average age of death of ~43 years for overdose deaths[7], an average 36.8 YLL for overdose deaths (those living to 43 years old have an average of 36.8 additional years to live, based on the Social Security Administration actuarial life table; SSA 2020[8]). Average age at death for 2019 homicide deaths is even younger, at ~30.[9] Average YLL for these homicide deaths is significantly higher than overdose deaths, at 49.8.

That is, additional years of expected life for overdose deaths was about 37, and about 50 for the average homicide death. These compare very unfavorably to the 5.3 years for the average COVID-19 death. So the impact in terms of years of life lost is 7–10 times higher for every overdose or homicide death than it is for every COVID-19 death.

Figure 4 shows a sharp increase from 70,357 overdose deaths in the 12 months preceding November 2019, compared to the preliminary and incomplete figure of ~93,000 overdose deaths in the 12 months preceding December 2020. Based on these trends, we estimate conservatively 20,000 excess overdose deaths for the full year 2020. There were also an approximate 10,000 excess homicides for 2020 (figure 2), for a total of ~30,000 excess overdoses and homicides that correlate with the pandemic in 2020.

Figure 4. Preliminary drug overdose death trends in the U.S., through Nov. 2020 (Source: NVSS 2021).

Figure 5. U.S. homicide deaths in 2020 compared to previous years.[10]

Using this ~30,000 excess overdoses and homicides in 2020[11] yields ~1.3 million total YLL for just these two categories of non-COVID-19 excess deaths.

Comparing these two YLL figures (COVID-19 YLL and YLL for excess overdoses and homicides) we see that the mortality impact from just these two categories of non-COVID-19-related causes of death was in a similar range to COVID-19-related mortality impacts.

Figure 6. Preliminary comparison of Years of Life Lost for direct mortality impacts of COVID-19 for 2020, versus indirect impacts of pandemic policies, including only excess overdose deaths and homicides.

We may also compare YLL from COVID-19 to YLL from all overdoses, or all homicides, as a comparison to the harm from these socially undesirable causes of death. Figure 7 shows the YLL for the 93,000 overdoses in 2020 compared to YLL from all COVID-19 deaths (357,000). The YLL for overdoses is almost twice that from COVID-19.

Figure 7. Overdose deaths YLL compared to YLL from COVID-19 deaths. The years of life lost from all overdose deaths are substantially higher than from all COVID-19-related deaths.

Due to the likelihood that non-COVID-19 YLL was significantly higher than COVID-19 YLL, during 2020 and probably in 2021 also, it is highly important for policymakers to consider YLL figures alongside, or possibly instead of, excess deaths figures, due primarily to the higher granularity of the YLL measure.

If policy makers, for example, were aware of the significantly larger YLL impact that occurred due to indirect impacts of the pandemic such as lockdown measures and related policies, one would hope that there were would have been less eagerness to impose lockdowns and, instead, to search for a more appropriate balance between preventing COVID-19 infection and deaths, on the one hand, and not causing substantially more harm through the imposition of unnecessary and damaging policies, on the other hand.

In sum, it is clear at this point that the harm caused by lockdowns is significantly greater than any harm prevented by lockdowns, and this conclusion follows even from looking at just two non-COVID-19 cause of death categories: overdoses and homicides. When we tally all non-COVID-19 causes of death for 2020, and their associated years of life lost, we will have multiple times the YLL for COVID-19 deaths alone. By this logic, even if lockdowns did in fact cause lower COVID-19 deaths, it is very unlikely that the net benefits from reduced COVID-19 deaths would have outweighed the net harms from other causes of death that were exacerbated by lockdowns.

[1] See, e.g. Gardner JW, Sanborn JS. Years of potential life lost (YPLL) — what does it measure? Epidemiology. 1990 Jul;1(4):322–9. doi: 10.1097/00001648–199007000–00012. PMID: 2083312; Quast, T., et al. 2021. Years of life lost associated with COVID-19 deaths in the USA during the first year of the pandemic.

[2] Online at: https://www.cdc.gov/nchs/nvss/vsrr/covid_weekly/index.htm.

[3] Ioannidis, et al. 2021. Second versus first wave of COVID-19 deaths: Shifts in age distribution and in nursing home fatalities.

[4] Dooling, K. 2020. CDC presentation, p. 8. Online at: https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2020-12/COVID-02-Dooling.pdf.

[5] Briggs, A. et al. 2020. “Estimating (quality‐adjusted) life‐year losses associated with deaths: With application to COVID‐19” Our calculations are based on use of updated data and assumptions in the Briggs et al. 2020 spreadsheet model. That paper included data only through July of 2020, but did also provide a spreadsheet for others to modify based on new data.

[6] CDC/NCHS Weekly Provisional Counts of Deaths By State and Select Causes, June 2, 2021. https://data.cdc.gov/NCHS/Weekly-Provisional-Counts-of-Deaths-by-State-and-S/muzy-jte6.

[7] American Addiction Centers 2019. Online at: https://www.projectknow.com/discover/cutting-it-short/. We assume, for this preliminary analysis, that the average age of overdose death is a good proxy for homicides and suicides also, partly because the excess deaths for overdoses are considerably higher than the other two categories, and also because it is likely that homicide and suicide deaths may be younger on average than overdose deaths.

[8] Social Security Administration actuarial life table, 2020. Online at: https://www.ssa.gov/oact/STATS/table4c6.html.

[9] Statista.com, for 2019 homicides, online at https://www.statista.com/statistics/251878/murder-victims-in-the-us-by-age/.

[10] Ahmad FB, Cisewski JA. Quarterly provisional estimates for selected indicators of mortality, 2018-Quarter 4, 2020. National Center for Health Statistics. National Vital Statistics System, Vital Statistics Rapid Release Program. 2021. Online at: https://www.cdc.gov/nchs/nvss/vsrr/mortality-dashboard.htm#.

[11] NVSS Provisional drug overdose death counts. Online at: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.

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