Overdoses killed 1,214 Philadelphians in 2020, marking the city’s second-highest drug death toll on record, and one likely worsened by COVID-19 lockdowns, city officials said.

Just as they were by the coronavirus deaths, Black Philadelphians were hit hardest by overdose deaths, an alarming demographic shift in drug fatalities that began before the pandemic and worsened in 2020.

Overall, overdose deaths increased by 9% from the year before. But fatal overdoses soared by 29% among Black Philadelphians, even as they decreased by 10% among white Philadelphians. The death rate among Hispanic Philadelphians remained about the same from 2019 to 2020, though it had increased in prior years.

“This is really devastating. And, sadly and infuriatingly, it was very preventable. Black drug policy and harm reduction advocates have been ringing the alarm on the overdose crisis,” said Kassandra Frederique, executive director of the Drug Policy Alliance. The national organization advocates for reducing criminalization in drug policy and expanding harm-reduction measures.

“The overdose crisis, as is the drug war, is a racial justice issue as well as a health justice issue,” she said. “It’s not because we are Black that we are experiencing COVID-19 more deeply, experiencing the overdose crisis more deeply. It is because the structures in place make it less safe to be Black people in this country.”

Philadelphia’s death toll is in line with trends across the country showing that more Black and Hispanic people are dying of overdoses, she said.

Fentanyl remained the major drug killer in Philadelphia. The powerful synthetic opioid began making its way into the city’s heroin supply in the mid-2010s and was present in 84% of the city’s drug deaths last year.

Deaths involving heroin and cocaine decreased, while deaths involving fentanyl and pharmaceutical opioids increased. Fentanyl was present in 94% of all opioid-related deaths and in 77% of stimulant-related deaths.

Deaths involving both stimulants and opioids, which have the opposite effect, have been on the rise for several years. But toxicology reports cannot determine whether overdose victims are using stimulants and opioids together intentionally, whether dealers are knowingly selling stimulants cut with opioids; or whether stimulants are being contaminated with fentanyl during the drug packaging process.

The social distancing and lockdown policies imposed to control the COVID-19 pandemic likely influenced the rise in overdose deaths in 2020, said Jewell Johnson, a city substance use epidemiologist.

For years, the majority of the city’s fatal overdoses have taken place in private homes. The lockdown only made that trend worse, city officials believe.

“We know for a fact that a lot of our fatal overdoses happened in the home,” Johnson said. “People live alone and they’re not being checked on by family or friends, and the odds of fatally overdosing does increase. I think that’s the main difference in terms of fatalities from 2019 to fatalities for 2020.”

Johnson also noted that pandemic-related unemployment among Black Philadelphians may be linked to the high overdose death toll in 2020.

Throughout 2019 and into the early months of 2020, the unemployment rate among Black overdose victims hovered around 30%. But in the second quarter of 2020 -- as lockdowns began and millions around the country suddenly were out of work -- the rate among Black overdose victims jumped to 48%, and stayed high for the rest of the year. (Nationwide, the unemployment rate among Black Americans was second only to Hispanic Americans at the height of the pandemic, and remains the highest in the country, three percentage points higher than the national average.)

“The unemployment issue, through COVID, is that people are at loose ends, they’re depressed and upset, and they’re getting into substances more,” said Barbara Schindler, a physician and professor of psychiatry and pediatrics at Drexel’s College of Medicine. She noted patients with untreated mental health issues can turn to substance use to self-medicate -- and added that many people of color have a harder time accessing necessary mental health treatment as it is.

Jim Garrow, a spokesperson for the Philadelphia health department, said city officials believed that lockdown orders would likely affect overdose deaths, and tried to mitigate that toll, continuing to send harm-reduction teams to Kensington, which still sees the highest number of overdose deaths in the city. Training sessions in using Narcan, the overdose-reversal drug, were offered online in the first months of the pandemic.

“Implementing public health measures that the city believes saved lives exacerbated other things that made it worse,” he said. “When faced with two evils, what is the top concern? What is the one that could most negatively affect large portions of the city? How can we target it to make sure the damage we’re doing is minimized? It’s something we’re actively looking into. There’s no playbook for this.”

The city did not anticipate some geographic shifts in overdose deaths that emerged during the pandemic. Fatal overdoses rose in West Philadelphia, North Philadelphia, and Southwest Philadelphia communities, away from typical overdose hot spots like Kensington and South Philadelphia.

“We do have some of our harm-reduction team in South Philly,” Johnson said, “but, we didn’t anticipate these specific zip codes [in West, North, and Southwest Philadelphia] having such large increases in fatal overdoses.”

Jeanmarie Perrone, a physician and professor of emergency medicine at the Hospital of the University of Pennsylvania, says she has been treating a new population of patients in her West Philadelphia emergency department: people newer to opioid use, mostly buying opioid painkillers on the street.

Many of those pills are actually illicit fentanyl pressed into the shape of a prescription painkiller. Many of Perrone’s patients are not prepared for their potency.

“They don’t have Narcan. They are not prepared for that kind of overdose,” she said. And many are hiding their drug use: “A lot of the patients we treat -- they work, they have jobs, families, kids, and their dosing has escalated to the point they can’t afford it.”

She said it’s crucial to educate patients and families in neighborhoods where opioids have historically been less prevalent but now are killing people in increasing numbers. At times, Perrone said, she feels as she did a decade or so ago when the city was first beginning to hand out Narcan in Kensington.

“We need to partner with faith-based groups, or other community organizations, who can get the message out that this is a disease that’s treatable,” she said.

Garrow said the health department has been encouraged by some federal efforts to mitigate the effects of the lockdowns. One example: relaxing rules around prescribing buprenorphine, a popular opioid addiction treatment drug more heavily monitored by the federal government before the pandemic. He said he hoped the easing of those rules would get more doctors prescribing buprenorphine -- and more Philadelphians into treatment.

And with COVID-19 vaccines more readily available and the city poised to fully reopen, Johnson said she “would hope that the [overdose] trends decline.”

“But only time will tell, unfortunately,” she said.