Drug-related deaths in a metropolitan setting: a 10-year study of toxicological patterns

Substance-related mortality represents a critical public health challenge, particularly in metropolitan environments characterized by dynamic illicit drug markets. This study aimed to evaluate demographic characteristics, temporal trends, and evolving toxicological profiles of substance-related deaths within a major metropolitan forensic catchment area in Türkiye. A 10-year retrospective analysis was conducted evaluating medico-legal autopsies (n = 15,486) performed between 2012 and 2021. Among these, 1.02% (n = 158) were definitively attributed to acute substance intoxication. The cohort was predominantly male (97.5%) with a mean age of 29.1 years. Multivariable analysis revealed that the 2017–2021 study period was an independent predictor of synthetic cannabinoid-related mortality (aOR = 2.73; p = 0.014), while fatalities were significantly less likely to occur in hospital settings for synthetic cannabinoid-related cases (aOR = 0.16; p < 0.001). Weekly distribution patterns showed significant clustering on weekends (Saturday-Sunday n = 65), and toluene-related deaths disappeared completely in the second 5-year period (p = 0.017). Although 22.8% of decedents had prior addiction treatment contact, this did not mitigate mortality risk across substance categories. These findings demonstrate an evolving illicit drug market dominated by high-toxicity synthetic compounds and highlight critical gaps in continuity of care. The integration of longitudinal forensic surveillance with targeted post-discharge relapse-prevention protocols is essential to mitigate premature urban mortality.