Commentary on Roberts <i>et al</i> .: Trends in methamphetamine‐related deaths in the UK and USA—increasing mortality, but in different contexts

Deaths related to methamphetamine use are increasing in both the UK and the USA, but in different contexts. We must continue to monitor this situation and use targeted prevention, harm reduction and treatment efforts to reduce not only deaths, but also use and related morbidity. Roberts et al. [1] examined characteristics of methamphetamine-related deaths in the UK from 1997 to 2024. Using coronial records submitted to the National Programme on Substance Use Mortality (NPSUM), the authors identified a total of 136 decedents in the UK with methamphetamine implicated in their death over the study period, with methamphetamine-related deaths described as increasing over time [1]. Given that methamphetamine-related deaths have also increased in the USA, we sought to compare these UK findings with US trends to determine differences and similarities that can possibly inform public health response more globally. Roberts et al. reported that methamphetamine-related deaths appear to have increased in the UK over the past two decades, with eight deaths identified in 2005–2010, 24 in 2016–2020 and 47 in 2021–2024 [1]. The authors also noted that decedents over the study period were overwhelmingly male (over 90%) and the prevalence of co-detection of gamma-hydroxybutyrate (GHB; 15%), mephedrone (10%) and ketamine (8%) suggests that many fatal exposures were likely among populations who use methamphetamine as a party drug or for sexual purposes (‘chemsex’) [2]. While this population was one of the main populations known for methamphetamine use in the USA in the 2000s [3], the prevalence of methamphetamine use and related harms in the USA began to increase among a broader range of demographic and geographic groups in the 2010s [4], particularly among people who used illicit opioids [5]. In the USA, the age-adjusted rate of overdose deaths involving psychostimulants other than cocaine (primarily methamphetamine) was stable between 2003 (n = 1179 deaths, 0.4 deaths per 100 000 population) and 2010 (n = 1854 deaths, 0.6 deaths per 100 000), but then increased through 2021 (n = 32 537 deaths, 10.0 deaths per 100 000), with 34 855 deaths reported in 2023 (the most recent year of non-provisional data available) [6]. Although a direct comparison of these US trends with those reported by Roberts et al. is complicated owing to different definitions of methamphetamine-related overdoses and different population sizes (as population-adjusted rates were not reported for the UK), we do want to acknowledge the public health impact of the raw number of lives lost in the USA compared with the UK (e.g. in 2023 alone: 34 855 deaths versus 18 deaths). Increasing psychostimulant-related deaths in the USA have been widely attributed to increasing co-use of synthetic opioids (primarily illicitly manufactured fentanyl formulations) with psychostimulants [4, 5], which has been described as the ‘fourth wave’ of the US overdose crisis [7]. A recent analysis of methamphetamine-involved deaths reported to the US Centers for Disease Control and Prevention’s State Unintentional Drug Overdose Reporting System (SUDORS) between January 2021 and June 2024 (n = 96 614) found that 69% of the deaths co-involved opioids [8]. In contrast, only 20 methamphetamine-related deaths in the UK from 1997 to 2024 (15%) had any opioids implicated (n = 10 heroin, n = 6 methadone) [1]. Thus, while methamphetamine-related deaths are increasing in both the UK and the USA, the magnitude and drivers of these increases appear to be substantially different, requiring different public health approaches to reduce methamphetamine-related harms in both countries. As the demographic profiles of persons who use methamphetamine and patterns of methamphetamine use continue to shift, it has become increasingly important to monitor changes in methamphetamine-involved mortality. We commend Roberts et al. for the granularity of their analysis of specific substances identified in UK deaths over such an extensive time frame. Typically, when examining overdose mortality trends in the USA, most analyses of specific drug involvement rely on International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) multiple cause-of-death codes in National Vital Statistics System death certificate data, which groups methamphetamine with other phenylethylamines and other stimulants, such as synthetic cathinones, in the broader T43.6 ‘psychostimulants with abuse potential’ category. While this group is widely considered to consist of ‘primarily’ methamphetamine-related deaths (with many authors continuing to cite a 2018 US Drug Enforcement Administration report when making this assertion, which notes that 85%–90% of psychostimulant deaths from 2010 to 2015 mentioned methamphetamine in the death certificate [9]), this lack of specificity adds some uncertainty to our understanding of trends in methamphetamine-involved overdose deaths in the USA. We in the USA are also restricted in our ability to examine the co-involvement of specific party drugs (e.g. GHB, ecstasy/MDMA) when using ICD-10 multiple cause-of-death codes, which limits our understanding of changes in drug-related mortality within this population. Although efforts continue to be made to improve drug overdose mortality reporting in the USA, such as SUDORS, which funds US states to report more detailed data on unintentional and undetermined intent drug overdose death (and allows for examinations of methamphetamine-specific deaths [8]), additional work in this area is needed. Nicole D. Fitzgerald: Conceptualization (equal); writing—original draft (lead); writing—review and editing (supporting). Joseph J. Palamar: Conceptualization (equal); funding acquisition (lead); writing—original draft (supporting); writing—review and editing (equal). This work was supported by the National Institute on Drug Abuse of the National Institutes of Health under award numbers R01DA057289 (Palamar), U01DA051126 (Palamar) and T32DA031099 (Hasin & Martins). J.J.P. has consulted for the Washington/Baltimore High Intensity Drug Trafficking Areas program. The authors have no other potential conflicts of interest to report.