Objectives: (1) Report sex-specific prevalence of coronavirus disease 2019 (COVID-19) test positivity among an opioid use disorder (OUD) cohort (2) Assess sex-specific rates of opioid overdose and mortality.

Methods: A retrospective cohort study was performed on all adult patients with OUD who received a COVID-19 test in calendar year 2020 at a large academic medical center in Richmond, Virginia. Our study outcomes were positive COVID-19 test, opioid overdose, and all-cause in-hospital mortality. Sex-stratified multivariable logistic regression assessed sociodemographic factors associated with COVID-19 test positivity.

Results: A total of 2,600 patients (males = 1,294, females = 1,306) with OUD received a COVID-19 test. Approximately 5% across both sexes tested positive for COVID-19 (p = 0.420), whereas 7% presented with an opioid overdose (males 10%; females 4%; p < 0.0001). However, mortality rates were similar across sex. Among males, individuals in the other racial group had increased odds of COVID-19 test positivity (adjusted odds ratio or AOR: 5.03, 95% confidence interval [CI]: 1.70–14.88), whereas black females had higher odds of COVID-19 test positivity (AOR: 1.92, 95% CI: 1.01–3.62) compared to their white counterparts.

Conclusions: Opioid overdose, more often than COVID-19, impacted the health of patients with OUD presenting to a public safety net health system. Despite a female advantage documented in the general population for COVID-19 susceptibility, COVID-19 test positivity rates were similar across sex in an OUD cohort; yet, racial disparities emerged with notable sex-related variation. Sex and gender are important variables that modify health outcomes, including OUD and COVID-19, and should be further investigated using an intersectionality framework.