The COVID-19 pandemic was associated with sharp increases in fatal and non-fatal drug overdoses, exacerbating the U.S. overdose crisis (Centers for Disease Control and Prevention, 2023; Cartus et al., 2022). Policies enacted to reduce the spread of COVID-19 (e.g., stay-at-home orders) disrupted healthcare access and increased rates of loneliness, anxiety, and depression (Moynihan et al., 2021; Penninx et al., 2022), particularly for patients with chronic pain (Ziadni et al., 2022; Lee et al., 2021). While clinical guidelines recommend non-pharmacologic alternatives to long-term opioid therapy (LTOT) for chronic pain (Dowell et al., 2022), limited access to non-pharmacologic treatment during the pandemic led to an increase in opioid prescribing, duration, and dosage for patients with chronic pain (Lee et al., 2021), all risk factors of overdose (Dowell et al., 2022). During the first year of the pandemic, patients with comorbid chronic pain and opioid use disorder (OUD) experienced disruptions in access to medications for OUD (mOUD), which reduce the risk of opioid overdose and related mortality (Currie et al., 2021; Dowd and Mark, 2022; Joudrey et al., 2021). Following initial disruptions, national policies were enacted to expand access to chronic pain and OUD treatment services (Jones et al., 2022; Koonin et al., 2020; Miller et al., 2021), including telemedicine (Koonin et al., 2020; Miller et al., 2021) and extended buprenorphine prescriptions and methadone take-home doses (Jones et al., 2022).

While policies were intended to maintain healthcare services for adults with chronic pain and reduce the pandemic-related burden of OUD, the effects of the pandemic on opioid overdose among patients with chronic pain is unclear. Therefore, information is needed to inform healthcare policy for patients with chronic pain, a population with high risk of opioid overdose (Kennedy et al., 2022). Leveraging 2019–2020 data of New York State (NYS) Medicaid claims, we examined associations between LTOT and/or OUD with fatal or non-fatal opioid overdose, and whether the pandemic moderated overdose risk among patients with chronic pain.