As COVID-19 kills thousands in Chicago and across Illinois, the opioid epidemic has intensified its own deadly siege away from the spotlight, engulfing one public health crisis inside another.

More than twice as many people have died or are suspected to have died of opioid overdoses in the first five months of the year in Cook County, when compared with the same period last year, according to a ProPublica Illinois analysis of medical examiner’s office death records. There have been at least 924 confirmed or suspected overdose deaths so far in 2020; there were 461 at this time last year. And much like the coronavirus outbreak, the opioid epidemic has disproportionately affected African Americans on Chicago’s West and South Sides.

Statewide, opioid deaths also are outpacing 2019 numbers, largely due to the increase in Cook County.

The deadly surge comes at what was supposed to be a turning point for Illinois. A 2017 state action plan from then-Gov. Bruce Rauner vowed to halt the “explosive growth” of opioid deaths and reduce the projected number of opioid-related deaths this year by a third.

Based on the number of overdose deaths so far in Cook County alone, it’s highly unlikely the state can meet that goal.

While the spike in deaths began several months before the first known case of the coronavirus appeared in Illinois, COVID-19 appears to be exacerbating the crisis.

“This is going to make it so much worse,” said Kathleen Kane-Willis, a researcher with the Chicago Urban League who has studied the opioid epidemic for more than a decade, adding that the true impact of the pandemic on drug overdoses likely won’t be known for some time.

“It’s going to wear on people. It’s going to make them more anxious and depressed,” she said. “Being thrust into poverty is such a stressor, and people do turn to substances to get through that stress.”

The rise in opioid-related deaths in Cook County echoes a pattern seen in other areas of the country, from Milwaukee to Memphis and in Virginia and western New York. The American Medical Association recently sounded an alarm, noting news reports from 28 states on increases in opioid-induced overdoses and issuing a series of recommendations to state governments.

Coroners in at least nine Illinois counties — ranging from Lake County north of Chicago to Peoria County in central Illinois and Madison County near St. Louis — have noted increases, though the number of overdose deaths is far lower than in Cook County. DuPage County Coroner Dr. Richard Jorgensen said he was so startled this month to see 22 overdose deaths in three weeks that he called local rehabilitation clinics and advocates to see if they could explain what was happening.

“They’ve been seeing the same thing — a lot of people calling with problems, having trouble staying sober, having relapses,” said Jorgensen, who worries that more people are using drugs alone because of the state’s stay-at-home order. “If you’re alone, there’s nobody to give you the Narcan,” he said, referring to the drug that can reverse overdoses. “That’s a problem.”

A Complicating Factor

Even before the pandemic hit, state officials, medical experts and drug recovery workers began to notice an increase in overdoses. State officials said they issued an alert in January warning the public about an increase in opioid-related overdoses.

A sustained climb in the number of opioid-related deaths over the previous year began in November, according to a ProPublica Illinois analysis of data from the Cook County Medical Examiner’s Office.

An increase in more dangerous blends of opioids hitting Cook County, including drugs laced with fentanyl and other synthetic additives, is likely partially to blame, several experts and city and state officials said.

“One thing we know for sure: The violent drug cartels and distributors have not stopped trafficking deadly fentanyl,” Robert Bell, the special agent in charge of the Chicago Field Division of the Drug Enforcement Administration, said in a statement. “The recent spike of overdose deaths emphasizes that the opioid and fentanyl epidemic has not paused — in fact, it has intensified in many places.”

In Cook County, fentanyl is listed as one of the primary causes of death in 81% of the confirmed opioid-related fatalities this year, up from 74% last year, according to ProPublica Illinois’ analysis. The majority of the cases involve fentanyl combined with other substances, such as heroin.

Still, the sheer number of opioid-related fatalities in Cook County this year has left some experts disheartened. As of Friday, the medical examiner’s office had confirmed nearly 500 deaths involving opioids. An additional 614 deaths are still under investigation, typically pending toxicology results. Of those, some 70% to 80% are expected to come back positive for opioids, according to the county’s chief medical examiner, Dr. Ponni Arunkumar. (Pathologists often ask for toxicology screenings when there is evidence of an overdose, such as white powder near the body or a needle in the arm, a spokeswoman for the medical examiner’s office said.)

That projection would put the year’s total at at least 924, more than double the number in the first five months of 2019.

“Oh, goodness. That’s insane,” said Dr. Steven Aks, an emergency room physician at John H. Stroger Jr. Hospital of Cook County and chief of toxicology for Cook County Health, when told about the increase. “This is something that we were very nervous about when the pandemic hit.”

In addition to the rise in deaths, state officials say there have been increases in nonfatal overdoses involving opioids in the first four months of this year. In February, the numbers jumped by more two-thirds, to 2,047 when compared with the average over the previous three Februaries. In Chicago, emergency calls related to overdoses were up by more than a third from January through mid-April this year compared with the same period in 2019, according to an analysis of police and fire department call data.

Dani Kirby, director of the division of substance use prevention and recovery for the state’s Department of Human Services, said in a statement that COVID-19 has complicated both the state’s response to the overdose crisis and the lives of those who use drugs.

“The stress of unemployment, isolation, and general uncertainty are all risk factors for a return to substance use or an escalation of existing patterns of use,” Kirby said. “There is an additional concern that, due to the risk of exposure to COVID-19, people may be more reluctant to call 911 or go to a hospital when an overdose occurs.”

Some overdose prevention strategies “directly contradict” strategies that are meant to prevent the spread of COVID-19, she added.

“We know that human connection is a fundamental element of service delivery — whether a program is linking someone to harm reduction supplies (clean syringes, naloxone, safer smoking supplies, etc) or providing treatment and recovery services — and COVID-19 makes it more difficult for people to access these services,” Kirby said in the statement. Naloxone is an overdose-reversal drug.

Matthew Richards, deputy commissioner of behavioral health for the Chicago Department of Public Health, echoed those challenges. “Sometimes persons that are at highest risk for overdoses, part of the effort is really meeting people where they are in community with peer services or community health educators and building rapport,” he said. “What that looks like right now in terms of social distancing and whatnot is really complicated.”

Some Chicago-based programs that serve people who use drugs have had to scale back or shutter services in the wake of the pandemic, in part to protect older workers who may be more vulnerable to the coronavirus. Officials at other programs, on the other hand, said they have been able to meet an increase in demands for some services, such as naloxone, or medical outreach.

The pandemic has also meant that many people who rely on panhandling to make money and buy drugs are unable to do so now, because so many downtown office workers are now working from home, said Andrew Wojda, who works on a street medicine outreach team for The Night Ministry, a Chicago-based organization that works with the homeless.

This decreases their drug tolerance, making them more vulnerable to an overdose when they use again. “When they do get some cash, then they’re going back to using however much they were using a few days ago,” Wojda said. “But within three days, their tolerance can go down. It doesn’t really take much time at all for that to start being a much riskier game they’re playing.”

A Statewide Problem

Researchers and advocates said they are worried about the spread of the coronavirus among drug users and whether deaths involving both opioids and COVID-19 are being adequately tracked. Drug users often have comorbidities — underlying medical conditions — that make them more vulnerable to contracting the coronavirus. It might be hard to distinguish virus-like symptoms from those of withdrawal, researchers said.

So far only four people whose deaths were related to opioids also tested positive for the coronavirus, according to data from the Cook County Medical Examiner’s Office. The office said it has not found a direct correlation between opioids and the coronavirus.

A spokeswoman for the office said they do not test every body for COVID-19. Instead, the body is tested if the person is suspected to have contracted the virus but was not tested at a hospital or if the office’s investigators find out the person displayed symptoms or was exposed to someone who had contracted the virus.

In suburban Lake County, where the coroner, Dr. Howard Cooper, said all bodies are tested for COVID-19 as a safety measure and to let families know if their loved one had the disease, only one of the 43 confirmed or suspected overdose deaths so far this year has also tested positive for the coronavirus. The county also has experienced a rise in fatal overdoses, which Cooper said totaled 23 this time last year.

Even in counties that haven’t seen a rise or are seeing modest increases of one or two deaths, coroners remain concerned. With 14 confirmed or suspected overdose deaths this year, Kane County is up by only two compared with the same time last year, but COVID-19 may upend things, said Coroner Rob Russell.

“Maybe we haven’t seen it yet,” he added. “Maybe it’s coming.”

In Peoria County, Coroner Jamie Harwood said it has been tough to witness a rise in overdoses because it represents a reverse of hard-won progress. From January to April of 2018, the county saw 31 overdose deaths. In 2019, that number dropped to six, which he attributes to increased naloxone distribution, offering fentanyl test strips and providing clean needles for exchange. But now, with this latest spike, the county is almost double 2019’s numbers for the same time with 11 overdose deaths this year.

“It’s really hard to see it go up because you know that there’s a kid left without a parent, a mom left without a daughter or a son,” Harwood said.

A Hopeful Goal

This was the year that opioid-related deaths were supposed to drop significantly in Illinois. A 2017 state action plan developed under Rauner outlined steps to reduce the estimated death toll by one-third, from a projected 2,700 to about 1,800 in 2020.

Statewide opioid-related deaths had been on the decline, from 2,202 in 2017 to 2,167 in 2018. It was the first decrease in overdose deaths among Illinois residents in five years. The numbers fell again last year to 2,107, state officials said.

The drop in 2018 was largely due to a decrease in opioid-related deaths for white residents. But those deaths rose for African Americans, who saw a 9% increase, and to a lesser extent for Latino residents, who saw a 4% increase, state figures show, resulting in what a 2019 state report called a “persistent disparity.”

The data on the most recent deaths in Cook County magnify the disparities. African Americans make up more than half the confirmed opioid-related deaths so far this year, even though they make up less than a quarter of county residents.

This trend is also happening nationally: One recent study showed that whites were the only group that saw a decline in drug-induced deaths in 2018.

Kane-Willis, who co-authored a 2017 report on the impact of the opioid epidemic on African Americans and is preparing to publish a follow-up paper, said black drug users have higher overdose mortality rates for many of the same reasons they’re more likely to die from COVID-19: poverty, less access to effective medical treatment and more health problems.

A spokeswoman for Gov. J.B. Pritzker’s office said the administration is “continuing to work toward” the action plan’s goals and highlighted initiatives this year to combat the overdose crisis with an emphasis on social and racial equity.

In January, Pritzker issued an executive order to promote equitable prevention and treatment access, as well as earmarking $4.1 million to expand opioid-related services across the state. Some of that money is going to a state Rapid Deployment Project that teams with local health departments to target specific communities that have seen spikes in overdoses, officials said.

In response to the coronavirus pandemic, Illinois has eased up regulations to allow patients to take home longer-lasting supplies of methadone, residential facilities are taking extra measures to protect residents and staff, and community organizations are ensuring patients have better access to naloxone, Kirby said.

The city of Chicago, meanwhile, said it’s studying data on overdoses to identify demographic and geographic patterns and determine which neighborhoods need the most resources, including naloxone, syringe exchanges and community health education, Richards said. The city has already increased funding for naloxone distribution, he said, and in June plans to start issuing monthly reports showing year-to-date trends.

The goal, he said, is to create a robust response to the epidemic.

“I don’t want to underestimate the challenge, but I also don’t want to underestimate the power of using data to fund things that work,” he said. “Our goal is to get the biggest impacts that we can possibly get. We’re talking about saving lives.”

Ash Ngu and Haru Coryne contributed reporting.

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