How Should Stimulant Deaths Be Counted? A Cross-Sectional Analysis of Deaths Attributed to Opioids, Stimulants, or Alcohol

Introduction: The different ways deaths are counted for surveillance—all attributable to alcohol versus acute toxicity for opioids or stimulants—have profound implications for understanding mortality and deploying prevention interventions. Objectives: To explore alternative strategies to count stimulant (cocaine, psychostimulants) deaths. Methods: We grouped substance-attributable deaths in San Francisco, CA, from 2015 to 2024 into mutually exclusive categories by involved substance (opioids, stimulants, alcohol). We used multivariable Poisson regression to determine prevalence ratios of additional contributing conditions (any, cardiac/hypertensive, or hepatobiliary and pancreatic) for each drug category, adjusted for age, sex, and race/ethnicity. We then used a postestimation technique to calculate adjusted predicted prevalence rates for each group. Results: The adjusted prevalence ratio of any additional conditions was significantly different across substance-attributable death categories ( P <0.001). Compared to stimulant deaths, opioid deaths had significantly lower prevalence of additional conditions [adjusted prevalence ratios (aPR): 0.51, 95% CI: 0.48–0.55], while alcohol deaths had higher prevalence (aPR: 1.24, 95% CI: 1.18–1.30). Opioid and alcohol deaths had a lower prevalence of cardiovascular conditions compared to stimulant deaths. Stimulant and alcohol deaths occurred at older ages than opioid deaths. Conclusions: More stimulant- and alcohol-attributable deaths without opioids include complex medical conditions compared to opioid deaths. Counting all attributable stimulant deaths, excluding opioids, may improve our understanding of these deaths and interventions to address health consequences of stimulant use.