About 490,000 Americans have officially died from Covid-19 over the past year. But even that staggering figure fails to capture the pandemic's full toll on American lives and health thus far—or the toll it could continue to collect long after the novel coronavirus comes under control.

For example, providers and experts have expressed concerns that delays in seeking health care have led to excess deaths from heart disease, cancer, and other chronic conditions, and they fear those delays could cause more potentially avoidable deaths in years to come. Further, the pandemic helped to fuel a mental health crisis in America that has claimed many lives.

And at the same time, three concerning trends of substance use have emerged that threaten to drive even more deaths. Here's what those three trends are, and what they mean for patients and providers.

Trend 1: Opioid drug-related overdoses, deaths spiked in 2020

After nearly 30 years in which U.S. drug overdose deaths had steadily increased, the number of Americans who died from a drug-related overdose declined by 4.6% in 2018—a hopeful sign that we were finally emerging from the opioid misuse epidemic.

Unfortunately, that decline didn't last long. Last year, CDC data showed that the number of U.S. overdose fatalities increased by 4.6% in 2019, reaching a new record-high of 70,980 deaths. And recent data suggests overdose deaths grew even more in 2020, fueled in part by the Covid-19 epidemic.

For example, an analysis released by the White House last June found that overdose deaths were up by 11.4% from January to April of 2020, relative to the same period in 2019. Further, CDC late last year released data showing that deaths caused by synthetic opioids were up by 38% during the year leading up to May 2020, relative to the year leading up to June 2019.

And now, CDC data updated this week shows more than 81,000 Americans died from drug overdoses during the 12-month period ending in June 2020, which is the highest number of drug-overdose deaths ever recorded in the United States. The figure is up by more than 20% when compared with the same period the previous year.

In addition, for a new study published in JAMA Psychiatry, researchers analyzed data from almost 190 million ED visits and found that the number of ED visits for opioid-drug related overdoses surged by 29% from 2019 to 2020. Even more troublingly, the researchers found that from mid-April (when the coronavirus pandemic first took hold in the United States) to the end of 2020, the weekly rate of ED visits for drug overdoses rose by as much as 45% when compared with same period in 2019.

"People are feeling a lot more despair, anxiety, and rootlessness," and that can "lea[d] to more problematic drug use and more risk of overdose," Brendan Saloner, a substance use disorder researcher at the Johns Hopkins Bloomberg School of Public Health, told the Associated Press' Carla Johnson.

And Nora Volkow, director of the National Institute on Drug Abuse, told The Hill's Marty Johnson that the coronavirus epidemic is particularly concerning because America has multiple "things colliding: the stress of the uncertainty of what's going to happen with [Covid-19], and also the uncertainty of what's going to happen to you, (with high levels of) unemployment, or if you are studying, what will happen to your education. And then the social distancing and isolation that makes the whole process much worse."

But America's drug crisis will continue to affect the patients and the U.S. health care system long after the pandemic ends, experts say.

Kevin Roy—chief policy officer for Shatterproof, a nonprofit focused on addressing substance use disorders—told The Hill's Jessie Hellmann, "We're going to solve Covid in the near term, and hopefully we're on the path to doing that. But this addiction crisis was grave and gathering before that, and it's only gotten worse." He added, "A recognition that we had an existing public health crisis before Covid is really, really critical because we have to address it."

To do so, experts say policymakers and health care providers need to focus on increasing access to care for substance use disorders, including medication-assisted treatment.

"While everyone's focus is appropriately on the pandemic, we can't lose sight of these other huge issues," Robert Rodriguez, an ED physician at Zuckerberg San Francisco General Hospital, told STAT News' Usha Lee McFarling.

Trend 2: Alcohol misuse—and related health conditions—increased in 2020

Alcohol misuse also increased amid the pandemic—along with serious medical conditions associated with alcohol misuse, health care providers say.

In a study published late last year in JAMA Network Open, researchers found that Americans were consuming more alcohol during the coronavirus epidemic than they did the year prior. For the study, researchers surveyed 1,771 Americans between April 29 and June 9, 2019. The researchers then surveyed 1,540 of those people again between May 28 and June 16, 2020.

According to the researchers, overall alcohol consumption increased 14% between the two survey waves, and heavy drinking—which was defined as five or more drinks for men and four or more drinks for women within a couple of hours—increased by 18.8%. The researchers also discovered an increase in Short Inventory of Problems (SIP) scores, which assess "adverse consequences associated with alcohol use in the past three months." Overall, SIP scores increased by 30% between the survey waves.

The findings are in line with health care providers' reports of seeing more patients who've misused alcohol, as well as more cases of serious medical conditions associated with alcohol misuse, such as alcoholic hepatitis and liver failure, California Healthline's Eli Cahan reports.

Although national data on liver disease in 2020 isn't available yet, Brian Lee, a transplant hepatologist, told Cahan that admissions for alcohol-related liver disease at Keck Hospital of USC increased by 30% in 2020 relative to 2019. Similarly, specialists at hospitals affiliated with the Harvard University, Mount Sinai Health System, Northwestern University, and the University of Michigan told Cahan that admission rates for alcohol-related liver disease had grown by 50% since March 2020.

Haripriya Maddur, a hepatologist at Northwestern Medicine, told Cahan that many of her patients with alcohol use disorders "were doing just fine" before the pandemic took hold, but amid increased stress caused by the pandemic, "all of the sudden, [they] were in the hospital again."

The increases in alcohol-related liver disease could affect patients, hospitals, and health systems now and for years to come, Cahan reports. "High levels of alcohol ingestion lead to a constellation of liver diseases due to toxic byproducts associated with the metabolism of ethanol," Cahan writes. "In the short term, these byproducts can trigger extensive inflammation that leads to hepatitis. In the long term, they can lead to the accumulation of fatty tissue, as well as the scarring characteristic of cirrhosis—which can, in turn, cause liver cancer."

And ultimately, the disease can cost people their lives. "More than 1 in 20 patients with alcohol-related liver failure die before leaving the hospital," Cahan writes, "and alcohol-related liver disease is the leading cause for transplantation." Further, Cahan notes that research has shown people with liver disease are three times more likely to die from Covid-19 than those who don't have liver disease.

Trend 3: Reports indicate Americans smoked more in 2020

Another concerning trend that emerged in 2020 was an increase in cigarette smoking, after years of declines.

CDC data released in 2019 showed that the percentage of American adults who smoked cigarettes hit an all-time low of 13.7% in 2018. Further, U.S. cigarette unit sales for years "had been falling at an accelerating rate, hitting 5.5% in 2019, as smokers quit or switched to alternatives like e-cigarettes," the Wall Street Journal's Jennifer Maloney writes.

But that decline stopped in 2020. Maloney reports that recent data from Altria Group, a leading cigarette manufacturer in the United States, showed "the U.S. cigarette industry's unit sales were flat" in 2020 when compared with 2019, and industry officials said some e-cigarette users switched back to traditional cigarettes.

Altria said the coronavirus pandemic likely buoyed U.S. cigarette sales, as some people smoked more while spending more time at home and had more money to spend on cigarettes because they weren't spending as much on entertainment, gas, and travel.

Anecdotal evidence backs Altria's claims. Maria Neuman, a 51-year-old freelance writer who lives in Los Angeles, told the New York Times' Monica Corcoran Harel that she had quit smoking, but she restarted when America's coronavirus epidemic took hold. "Last night, I blistered through seven cigarettes because I was watching a movie,” said Neuman said. "It's bad enough that I started smoking again during a pandemic. Now, I'm smoking inside."

And Milo Martin, a 57-year-old poet in Los Angeles, told Neuman, "Being quarantined is a great opportunity to sit around and smoke. It's an existential exercise to tangibly see yourself breathing."

Cigarette smoking may be especially dangerous now, as smoking increases a person's risk of developing a severe case of Covid-19. And beyond the pandemic, increases in cigarette smoking could have long-lasting effects. Research published last month found that, in many areas of the United States, at least 20% of cancer deaths are linked to smoking. And CDC estimates that smoking-related illness costs the country $300 billion each year, including close to $170 billion in direct medical cases costs for adults.

Overall, experts say it's important for health care providers to encourage smokers to quit, especially amid the pandemic.

"There has never been a better time to try to quit," the FDA spokesperson told Maloney.