Purpose To examine racial/ethnic differences and COVID-19 pandemic-related changes in key characteristics of drug overdose deaths in North Carolina. Methods We used North Carolina State Unintentional Drug Overdose Reporting System (NC-SUDORS) data to describe specific drug-involvement, bystander presence, and naloxone administration for drug overdose deaths by race/ethnicity during pre-COVID-19 (May 2019–February 2020) and COVID-19 periods (March 2020–December 2020). Results For all racial/ethnic groups, drug overdose death rates and the percentage with fentanyl and alcohol involvement increased from the pre-COVID-19 to COVID-19 period, with fentanyl involvement highest among American Indian/Alaska Native (82.2%) and Hispanic (81.4%) individuals and alcohol involvement highest among Hispanic individuals (41.2%) during the COVID-19 period. Cocaine involvement remained high among Black non-Hispanic individuals (60.2%) and increased among American Indian/Alaska Native individuals (50.6%). There was an increase in the percentage of deaths with a bystander present from the pre-COVID-19 to COVID-19 period for all racial/ethnic groups, with more than half having a bystander present during the COVID-19 period. There was a decrease in the percentage with naloxone administered for most racial/ethnic groups, with the lowest percentage among Black non-Hispanic individuals (22.7%). Conclusions Efforts to address increasing inequities in drug overdose deaths, including expanded community naloxone access, are needed
