A Chronic Condition Disguised as an Acute Event: the Case for Re-thinking Stimulant Overdose Death

Thematic analysis of medical examiner narratives to understand the socio-spatial context, recency of drug use, and likely mechanism of stimulant toxicity deaths

BACKGROUND

Drug toxicity as a cause of death is challenging to establish and may be based on limited evidence, especially in deaths attributed to stimulants. We developed a method for characterizing stimulant deaths, focusing on potential mechanisms and opportunities for intervention.

METHODS

We used medical examiner case narratives and medical records from a mixed methods study of fatal acute stimulant toxicity in San Francisco. We coded case narratives for circumstances surrounding death events, including physical location, bystander presence, decedent disposition, and evidence of recent street drug use; medical records provided data on potential mechanism of death when not present in case narratives.

RESULTS

Of 101 deaths (70 stimulants-no-opioids, 31 stimulants-fentanyl), 85 were unwitnessed, including 69 unwitnessed deaths in spaces inaccessible to bystanders. Drug use was observed before collapse in 1 of 14 witnessed stimulant-no-opioid and 1 of 2 witnessed stimulant-fentanyl deaths. Among unwitnessed events, scene evidence of drug use was found in 36 of 56 stimulant-no-opioid and 25 of 29 stimulant-fentanyl deaths. Twelve of 14 witnessed stimulant-no-opioid deaths and none of two witnessed stimulant-fentanyl deaths included an apparent cardiovascular or cerebrovascular event.

CONCLUSIONS

Deaths occurred in physically and socially isolated contexts, limiting opportunities for bystander intervention. Compared to stimulant-fentanyl deaths, stimulant-no-opioid deaths may be more likely to be witnessed and involve a cardiovascular event, and less likely to involve recent drug use. Applying a thematic analysis of medical examiner records to a larger sample, including other opioid deaths, could guide prevention strategies.

Prevalence of adults with stimulant misuse and/or stimulant use disorder in Massachusetts, USA, 2014-2021

BACKGROUND AND AIMS

Stimulant-involved overdose deaths are increasing throughout the United States. Because stimulant misuse (i.e. taking a prescribed medicine not as directed) and stimulant use disorder contribute to the surging number of stimulant-related deaths, knowing the prevalence of stimulant misuse and use disorder is important. We aimed to estimate the prevalence of stimulant misuse and/or use disorder in Massachusetts from 2014 to 2021.

DESIGN, SETTING AND PARTICIPANTS

This was a cohort study using a multiple systems estimation approach (previously known as 'capture-recapture'), using multiple individually linked epidemiological data sources, located in the Commonwealth of Massachusetts, 2014-2021. People aged 18-64 years from administrative databases were linked at the individual level and included in the analysis.

MEASUREMENTS

Measurements included known and estimated counts of people with stimulant misuse and/or use disorder (as defined in each individual database) as well as total count and prevalence in Massachusetts. We performed both a stratified analysis using log-linear models to estimate the unknown population with stimulant misuse/use disorder and a single model analysis in which demographics were used as covariates. Uncertainty is characterized using 95% confidence intervals (95% CI) on the total counts and prevalence estimates.

FINDINGS

The number of known individuals increased during the study period from 31 037 in 2014 to 42 612 in 2021. Using the multiple systems estimation approach, the estimated prevalence of underlying stimulant misuse and/or use disorder population ranged from 4.1 to 7.1% during the study period in the stratified analysis and 4.2 to 6.8% in the single model. By race, the highest prevalence estimates were among the Black non-Hispanic population, which showed a prevalence of up to 14.5% (95% CI = 14.32%, 14.57%) in 2021.

CONCLUSIONS

The estimated prevalence of stimulant misuse and/or use disorder in Massachusetts from 2014 to 2021 ranged from 4% to nearly 7% of the population. People from racial minorities appear to be disproportionately affected compared with the white non-Hispanic population. The unknown population accounted for large proportions of the total estimated population.

Stimulant-involved overdose deaths: Constructing dynamic hypotheses

The overdose epidemic in the United States is evolving, with a rise in stimulant (cocaine and/or methamphetamine)-only and opioid and stimulant-involved overdose deaths for reasons that remain unclear. We conducted interviews and group model building workshops in Massachusetts and South Dakota. Building on these data and extant research, we identified six dynamic hypotheses, explaining changes in stimulant-involved overdose trends, visualized using causal loop diagrams. For stimulant- and opioid-involved overdose deaths, three dynamic hypotheses emerged: (1) accidental exposure to fentanyl from stimulants; (2) primary stimulant users increasingly using opioids, often with resignation; (3) primary opioid (especially fentanyl) users increasingly using stimulants to balance the sedating effect of fentanyl. For stimulant-only overdose deaths, three additional dynamic hypotheses emerged: (1) disbelief that death could occur from stimulants alone, and doubt in testing capabilities to detect fentanyl; (2) the stimulant supply has changed, leading to higher unpredictability and thus higher overdose risk; and (3) long-term stimulant use contributing to deteriorating health and increasing overdose risk. These hypotheses likely each explain a portion of the recent trends in stimulant-involved overdoses. However, confusion and uncertainty around the drug supply emerged as a central theme, underscoring the chaotic and unpredictable nature of the stimulant market. Our findings indicate the need for research to develop targeted public health interventions, including analyzing the extent of the effect of contamination on overdoses, reducing confusion about the stimulant supply, and examining historical stimulant use trends.

Naloxone administration and survival in overdoses involving opioids and stimulants: An analysis of law enforcement data from 63 Pennsylvania counties

BACKGROUND

In consideration of rising opioid-stimulant deaths in the United States, this study explored rates of naloxone administration and survival in suspected opioid overdoses with, versus without, stimulants co-involved.

METHODS

The study analyzed 26,635 suspected opioid-involved overdoses recorded by law enforcement/first-responders in the Pennsylvania Overdose Information Network in 63 Pennsylvania counties, January 2018-July 2024. All measures, including suspected drug involvement, were based on first-responder assessment/report. Relative frequencies and chi-square tests were first used to compare suspected opioid overdoses with, versus without, stimulants (cocaine or methamphetamine) co-involved. Next, mediation analyses tested naloxone administration as a mediator in the association between stimulant co-involvement (in opioid overdoses) and survival.

RESULTS

Naloxone was reportedly administered in 72.2 % of the suspected opioid-no-cocaine overdoses, compared to 55.1 % of the opioid-cocaine-involved overdoses, and 72.1 % of the opioid-no-methamphetamine overdoses vs. 52.4 % of the opioid-methamphetamine-involved overdoses. With respect to survival rates, 18.0 % of the suspected opioid-no-cocaine overdoses ended in death, compared to 41.3 % of the opioid-cocaine overdoses; 18.1 % of the opioid-no-methamphetamine overdoses ended in death, versus 42.9 % of the opioid-methamphetamine overdoses. In mediation analyses (adjusted for demographics, county, year, and other drug co-involvement), naloxone administration mediated 38.7 % (95 % Confidence Interval [CI], 31.3-46.0 %) of the association between suspected cocaine co-involvement and survival and 39.2 % (95 % CI, 31.3-47.1 %) of the association between suspected methamphetamine co-involvement and survival.

CONCLUSIONS

Among suspected opioid overdoses recorded in the Pennsylvania Overdose Information Network, stimulant co-involvement was associated with lower naloxone administration and higher fatality, with naloxone partially mediating the association between stimulant co-involvement and death.

Prevalence of stimulant use and the role of opioid agonist treatment among people who inject drugs in France: Results from the COSINUS cohort study

INTRODUCTION

The co-use of stimulants and opioids, including opioid agonist treatment (OAT), is very prevalent worldwide. A large body of data exists on the association between stimulant use and its health complications, and on OAT effectiveness among people with opioid use disorder. However, few data exist on stimulant-opioid co-use among people receiving OAT. Using data from the COSINUS cohort study, we investigated the association between the type of OAT and problematic stimulant use among persons who inject drugs (PWID).

METHODS

COSINUS is a 12-month French cohort study of 665 PWID. Data were collected in face-to-face interviews at enrolment, at 6 and 12 months. We defined problematic stimulant use as daily use of and/or injecting stimulants. We used Bayesian model averaging (BMA) to identify factors associated with problematic stimulant use.

RESULTS

At baseline, 76% (n = 505) of the participants reported problematic stimulant use. The optimal model from the BMA estimation showed that, after adjusting on social precarity and daily injection, participants on prescribed morphine sulfate as an OAT (compared with methadone) and those who use daily unprescribed buprenorphine were less likely to report problematic stimulant use.

DISCUSSION AND CONCLUSIONS

Our work highlights the high prevalence of problematic stimulant use among PWID in France but also the potential association between the type of OAT taken and stimulant use, by suggesting a protective effect of morphine sulfate on stimulant use. Since it has a higher intrinsic activity than other opioids, PWID on this OAT may be less interested in stimulants. Our findings warrant further investigation in clinical studies.

Stimulant-Involved Cardiovascular Disease Mortality and Life Years Lost, 2014 to 2023

Background

Cocaine and methamphetamine, highly cardiotoxic stimulants, are associated with increased risks of hypertension, coronary artery disease, arrhythmias, cardiomyopathy, and stroke.

Objectives

This study examines trends in stimulant-involved cardiovascular disease (CVD) mortality in the U.S. from 2014 to 2023, analyzing CVD subtypes, stimulant type, population characteristics, and years of life lost (YLL).

Design

Trend analysis of age-adjusted mortality rates using serial cross-section mortality data from 2014 to 2023.

Methods

Using National Vital Statistics System data, we analyzed age-adjusted mortality rates (AAMRs) where CVD was the underlying cause of death and stimulants were contributing factors. We used Joinpoint regression to estimate average annual percent change (AAPC) and compare trends across groups. We calculated YLL based on age at death and demographic-specific life expectancies.

Results

From 2014 to 2023, stimulant-involved CVD mortality rose sharply (AAPC: 10.1%), contrasting with stable rates of overall CVD mortality (AAPC: 0.2%). Methamphetamine-involved deaths increased faster (AAPC: 13.8%) than cocaine-involved deaths (AAPC: 6.5%). Among CVD subtypes, cerebrovascular disease showed the steepest rise (AAPC: 15.9%), followed by hypertensive (12.1%) and ischemic heart diseases (7.9%). Older adults (⩾65 years) exhibited the most pronounced increase in stimulant-involved CVD mortality (AAPC: 20.2%), while non-Hispanic American Indian/Alaska Native populations experienced the highest AAPC among racial/ethnic groups (18.1%). Stimulant-involved CVD caused nearly 1 million years of YLL, predominantly among middle-aged males (687 430 YLL) and non-Hispanic White individuals (511 120 YLL). Methamphetamine involvement (580 570 YLL) exceeded that of cocaine (423 528 YLL). Within CVD types, ischemic heart disease was the leading cause (406 248 YLL).

Conclusions

Stimulant-involved CVD mortality has surged, especially among non-Hispanic American Indian/Alaska Native and non-Hispanic White populations and older adults, with cerebrovascular disease showing the largest increase among CVD subtypes. The findings reveal the importance of targeted prevention, screening, and intervention.

Managing Stimulant Use Among People With HIV: Harm-Reduction Strategies From Behavior to Medication

Stimulant use disorder poses substantial challenges to the health and well-being of people with HIV, contributing to increased HIV transmission risk and poor clinical outcomes. This article highlights the cultural significance of stimulant use, its epidemiology, and the latest evidencebased interventions for stimulant use disorder among individuals with HIV. Contingency management has emerged as the most effective treatment, with harm-reduction approaches serving as vital tools for improving the health of individuals unable or unwilling to achieve abstinence. Integrated care models that combine behavioral interventions, pharmacotherapy, and harm reduction offer a promising framework to improve health outcomes for people with HIV who use stimulants, addressing the intersection of stimulant use and HIV in care settings.

Chronic disease diagnoses and health service use among people who died of illicit drug toxicity in British Columbia, Canada

BACKGROUND

Illicit drug toxicity (i.e., overdose) is the leading cause of death in British Columbia (BC) for people aged 10-59. Stimulants are increasingly detected among drug toxicity deaths. As stimulant use and detection in deaths rises, it is important to understand how people who die of stimulant toxicity differ from people who die of opioid toxicity.

METHODS

BC Coroners Service records were retrieved for all people who died of unintentional illicit drug toxicity (accidental or undetermined) between January 1, 2015, and December 31, 2019, whose coroner investigation had concluded and who had an opioid and/or stimulant detected in post-mortem toxicology and identified by the coroner as relevant to the death (N = 3788). BC Chronic Disease Registry definitions were used to identify people with chronic disease. Multinomial regression models were used to examine the relationship between chronic disease diagnoses and drug toxicity death type.

RESULTS

Of the 3788 deaths, 11.1% (N = 422) had stimulants but not opioids deemed relevant to the cause of death (stimulant group), 26.8% (N = 1014) had opioids but not stimulants deemed relevant (opioid group), and 62.1% (N = 2352) had both opioids and stimulants deemed relevant (opioid/stimulant group). People with ischemic heart disease (1.80 (1.14-2.85)) and people with heart failure (2.29 (1.25-4.20)) had approximately twice the odds of being in the stimulant group as compared to the opioid group.

CONCLUSIONS

Findings suggest that people with heart disease who use illicit stimulants face an elevated risk of drug toxicity death. Future research should explore this association and should identify opportunities for targeted interventions to reduce drug toxicity deaths among people with medical comorbidities.

Naloxone Administration and Survival in Overdoses Involving Opioids and Stimulants: An Analysis of Law Enforcement Data from 63 Pennsylvania Counties

Background

In consideration of rising opioid-stimulant deaths in the United States, this study explored rates of naloxone administration and survival in suspected opioid overdoses with, versus without, stimulants co-involved.

Methods

The study analyzed 26,635 suspected opioid-involved overdoses recorded by law enforcement/first-responders in the Pennsylvania Overdose Information Network in 63 Pennsylvania counties, January 2018-July 2024. All measures, including suspected drug involvement, were based on first-responder assessment/report. Relative frequencies and chi-square tests were first used to compare suspected opioid overdoses with, versus without, stimulants (cocaine or methamphetamine) co-involved. Next, mediation analyses tested naloxone administration as a mediator in the association between stimulant co-involvement (in opioid overdoses) and survival.

Results

Naloxone was reportedly administered in 72.2% of the suspected opioid-no-cocaine overdoses, compared to 55.1% of the opioid-cocaine-involved overdoses, and 72.1% of the opioid-no-methamphetamine overdoses vs. 52.4% of the opioid-methamphetamine-involved overdoses. With respect to survival rates, 18.0% of the suspected opioid-no-cocaine overdoses ended in death, compared to 41.3% of the opioid-cocaine overdoses; 18.1% of the opioid-no-methamphetamine overdoses ended in death, versus 42.9% of the opioid-methamphetamine overdoses. In mediation analyses (adjusted for demographics, county, year, and other drug co-involvement), naloxone administration mediated 38.7% (95% Confidence Interval [CI], 31.3%-46.0%) of the association between suspected cocaine co-involvement and survival and 39.2% (95% CI, 31.3%-47.1%) of the association between suspected methamphetamine co-involvement and survival.

Conclusions

Among suspected opioid overdoses recorded in the Pennsylvania Overdose Information Network, stimulant co-involvement was associated with lower naloxone administration and higher fatality, with naloxone partially mediating the association between stimulant co-involvement and death.

Safety strategies and harm reduction for methamphetamine users in the era of fentanyl contamination: A qualitative analysis

INTRODUCTION

In the United States, methamphetamine use is increasing and the context of its use has changed, with reports of illicitly manufactured fentanyl being mixed with methamphetamine (either deliberately or inadvertently). We explore risk-mitigating actions taken by people who use drugs to protect their health when using methamphetamine in that context.

METHODS

We conducted qualitative interviews with 48 adults (18+) who used methamphetamine in the past three months at two sites in Nevada, USA and two sites in New Mexico, USA. Interviews were recorded, transcribed, and analyzed using thematic analysis.

RESULTS

Respondents described two rationales for employing harm reduction strategies. First, to prevent harm from methamphetamine containing illicit fentanyl, and second, to maintain their general wellbeing while using methamphetamine. Regarding methamphetamine containing illicit fentanyl, our findings highlight how respondents employ primary strategies like buying from trusted sources and secondary strategies such as spotting and selective use of harm reduction tools (i.e., fentanyl test strips) to reduce risks. To maintain their general wellbeing, participants reduced their use of methamphetamine as reasonably as possible, and used other substances like marijuana and alcohol alongside methamphetamine to counter the unwanted side effects of methamphetamine (i.e., hallucinations and paranoia). Use of these harm reduction strategies varied within situational and social contexts, and respondents usually developed these strategies based on their lived experiences.

CONCLUSION

Our findings uniquely demonstrate that people who use methamphetamine prioritize community driven, trust-based strategies within their social networks to mitigate risks in a fentanyl-contaminated drug environment. Additionally, our results indicate that harm reduction behaviors are influenced by multilevel risk environments, which include social, physical, economic, and political factors. Overall, these results highlight the potential for targeted interventions at the network level, which are responsive to complexities and shifts in drug market dynamics- such as illicit fentanyl in methamphetamine.

Accidental substance-related acute toxicity deaths in older adults in 2016 and 2017: a national chart review study

INTRODUCTION

Limited research exists on substance-related acute toxicity deaths (ATDs) in older adults (≥60 years) in Canada. This study aims to examine and describe the sociodemographic characteristics, health histories and circumstances of death for accidental ATDs among older adults.

METHODS

Following a retrospective descriptive analysis of all coroner and medical examiner files on accidental substance-related ATDs in older adults in Canada from 2016 to 2017, proportions and mortality rates for coroner and medical examiner data were compared with general population data on older adults from the 2016 Census. Chisquare tests were conducted for categorical variables where possible.

RESULTS

From 2016 to 2017, there were 705 documented accidental ATDs in older adults. Multiple substances contributed to 61% of these deaths. Fentanyl, cocaine and ethanol (alcohol) were the most common substances contributing to death. Heart disease (33%), chronic pain (27%) and depression (26%) were commonly documented. Approximately 84% of older adults had contact with health care services in the year preceding their death. Only 14% were confirmed as having their deaths witnessed.

CONCLUSIONS

Findings provide insight into the demographic, contextual and medical history factors that may influence substance-related ATDs in older adults and suggest key areas for prevention.

Presentation and Outcomes of Adults With Overdose-Related Out-of-Hospital Cardiac Arrest

Importance

Drug overdose (OD) is a public health challenge and an important cause of out-of-hospital cardiac arrest (OHCA). Existing studies evaluating OD-related OHCA (OD-OHCA) either aggregate all drugs or focus on opioids. The epidemiology, presentation, and outcomes of drug-specific OHCA are largely unknown.

Objective

To evaluate the temporal pattern, clinical presentation, care, and outcomes of adult patients with OHCA overall and according to the drug-specific profile.

Design, Setting, and Participants

This cohort study of adults with OHCA in King County Washington was conducted between January 1, 2015, and December 31, 2021. Etiology of OHCA was determined using emergency medical service, hospital, and medical examiner records. Etiology was classified as non-OD OHCA or OD-OHCA, with drug-specific profiles categorized as (1) opioid without stimulant, (2) stimulant without opioid, (3) opioid and stimulant, or (4) all other nonstimulant, nonopioid drugs. Statistical analysis was performed on July 1, 2023.

Exposure

Out-of-hospital cardiac arrest.

Main Outcomes and Measures

The primary outcome was survival to hospital discharge. The secondary outcome was survival with favorable functional status defined by Cerebral Performance Category 1 or 2 based on review of the hospital record.

Results

In this cohort study, there were 6790 adult patients with emergency medical services-treated OHCA from a US metropolitan system. During the 7-year study period, there were 702 patients with OD-OHCA (median age, 41 years [IQR, 29-53 years]; 64% male [n = 450] and 36% female [n = 252]) and 6088 patients with non-OD OHCA (median age, 66 years [IQR, 56-77 years]; 65% male [n = 3944] and 35% female [n = 2144]). The incidence of OD-OHCA increased from 5.2 (95% CI, 3.8-6.6) per 100 000 person-years in 2015 to 13.0 (95% CI, 10.9-15.1) per 100 000 person-years in 2021 (P < .001 for trend), whereas there was no significant temporal change in the incidence of non-OD OHCA (P = .30). OD-OHCA were more likely to be unwitnessed (66% [460 of 702] vs 41% [2515 of 6088]) and less likely to be shockable (8% [56 of 702] vs 25% [1529 of 6088]) compared with non-OD OHCA. Unadjusted survival was not different (20% [138 of 702] for OD vs 18% [1095 of 6088] for non-OD). When stratified by drug profile, combined opioid-stimulant OHCA demonstrated the greatest relative increase in incidence. Presentation and outcomes differed by drug profile. Patients with stimulant-only OHCA were more likely to have a shockable rhythm (24% [31 of 129]) compared with patients with opioid-only OHCA (4% [11 of 295]) or patients with combined stimulant-opioid OHCA 5% [10 of 205]), and they were more likely to have a witnessed arrest (50% [64 of 129]) compared with patients with OHCA due to other drugs (19% [14 of 73]) or patients with combined stimulant-opioid OHCA (23% [48 of 205]). Patients with a combined opioid-stimulant OHCA had the lowest survival to hospital discharge (10% [21 of 205]) compared with patients with stimulant-only OHCA (22% [29 of 129]) or patients with OHCA due to other drugs (26% [19 of 73]), a difference that persisted after multivariable adjustment.

Conclusions and Relevance

In a population-based cohort study, the incidence of OD-OHCA increased significantly from 2015 to 2021, with the greatest increase observed among patients with a combined stimulant-opioid OHCA. Presentation and outcome differed according to the drug-specific profile. The combination of increasing incidence and lower survival among among patients with a opioid-stimulant OHCA supports prevention and treatment initiatives that consider the drug-specific profile.

A qualitative study of interest in and preferences for potential medications to treat methamphetamine use disorder

INTRODUCTION

We examined acceptability of and preferences for potential medications for treating methamphetamine use disorder (MUD) among people who use methamphetamine and examined how benefits and drawbacks of methamphetamine use affect perceived acceptability and preferences.

METHODS

We conducted qualitative interviews as part of a larger study in 2019-2020. The interview assessed patterns of substance use (including methamphetamine), benefits and drawbacks of methamphetamine use, and interest in a medication to treat MUD. Analysis used an inductive thematic approach, guided by three primary questions: (1) would participants be interested in taking a potential medication for MUD?; (2) what effects would they would like from such a medication?; and (3) what would their ideal treatment route and schedule be (e.g. daily pill, monthly injection)?.

RESULTS

We interviewed 20 people reporting methamphetamine use in the past 3 months (10 from Reno, Nevada, USA and 10 from Rio Arriba County, New Mexico, USA). Seven used exclusively methamphetamine, while thirteen used other substances in addition to methamphetamine. Most were enthusiastic about a potential medication to treat MUD. Of those who were not interested (n = 5), all indicated no current concerns about their methamphetamine use. Perceived functional benefits of methamphetamine use (i.e., energy, counteracting opioid sedation, and improved social and emotional wellbeing) informed preferences for a replacement-type medication that would confer the same benefits while mitigating drawbacks (e.g., psychosis, hallucinations, withdrawal). Opinions on preferred dosing varied, with some preferring longer acting medications for convenience, while others preferred daily dosing that would align with existing routines.

CONCLUSION

Participants were excited about a potential for a medication to treat MUD. Their preferences were informed by the functional role of methamphetamine in their lives and a desire to maintain the stimulant effects while mitigating harms of illicit methamphetamine. Treatment outcomes that emphasize functioning and wellbeing, rather than abstinence, should be explored.

Multiple substance use and blood pressure in women experiencing homelessness

Background

Substance use increases risk of cardiovascular events, particularly among women with additional risk factors like housing instability. While multiple substance use is common among unstably housed individuals, relationships between multiple substance use and cardiovascular risk factors like blood pressure are not well characterized.

Methods

We conducted a cohort study between 2016 and 2019 to examine associations between multiple substance use and blood pressure in women experiencing homelessness and unstable housing. Participants completed six monthly visits including vital sign assessment, interview, and blood draw to assess toxicology-confirmed substance use (e.g., cocaine, alcohol, opioids) and cardiovascular health. We used linear mixed models to evaluate the outcomes of systolic and diastolic blood pressure (SBP; DBP).

Results

Mean age was 51.6 years; 74 % were women of color. Prevalence of any substance use was 85 %; 63 % of participants used at least two substances at baseline. Adjusting for race, body mass index and cholesterol, cocaine was the only substance significantly associated with SBP (4.71 mmHg higher; 95 % CI 1.68, 7.74) and DBP (2.83 mmHg higher; 95 % CI 0.72, 4.94). Further analysis found no differences in SBP or DBP between those with concurrent use of other stimulants, depressants, or both with cocaine, compared to those who used cocaine only.

Conclusions

Cocaine was the only substance associated with higher SBP and DBP, even after accounting for simultaneous use of other substances. Along with interventions to address cocaine use, stimulant use screening during cardiovascular risk assessment and intensive blood pressure management may improve cardiovascular outcomes among women experiencing housing instability.

Association of Opioid and Stimulant Use Disorder Diagnoses With Fatal and Nonfatal Overdose Among People With a History of Incarceration

IMPORTANCE

Studies have suggested a rise in opioid- and stimulant-involved overdoses in recent years in North America. This risk may be acute for individuals who have had contact with the criminal justice system, who are particularly vulnerable to overdose risk.

OBJECTIVE

To examine the association of opioid and/or stimulant use disorder diagnoses with overdose (fatal and nonfatal) among people with histories of incarceration.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, population-based health and corrections data were retrieved from the British Columbia Provincial Overdose Cohort, which contains a 20% random sample of residents of British Columbia. The analysis included all people in the 20% random sample who had a history of incarceration between January 1, 2010, and December 31, 2014. Outcomes were derived from 5-years of follow-up data (January 1, 2015, to December 31, 2019). Statistical analysis took place from January 2022 to June 2022.

EXPOSURES

Substance use disorder diagnosis type (ie, opioid use disorder, stimulant use disorder, both, or neither), sociodemographic, health, and incarceration characteristics.

MAIN OUTCOMES AND MEASURES

Hazard ratios (HRs) are reported from an Andersen-Gill model for recurrent nonfatal overdose events and from a Fine and Gray competing risk model for fatal overdose events.

RESULTS

The study identified 6816 people (5980 male [87.7%]; 2820 aged <30 years [41.4%]) with histories of incarceration. Of these, 293 (4.3%) had opioid use disorder only, 395 (6.8%) had stimulant use disorder only, and 281 (4.1%) had both diagnoses. During follow-up, 1655 people experienced 4026 overdoses including 3781 (93.9%) nonfatal overdoses, and 245 (6.1%) fatal overdoses. In adjusted analyses, the hazard of both fatal (HR, 2.39; 95% CI, 1.48-3.86) and nonfatal (HR, 2.45; 95% CI, 1.94-3.11) overdose was highest in the group with both opioid and stimulant use disorder diagnoses.

CONCLUSIONS AND RELEVANCE

This cohort study of people with a history of incarceration found an elevated hazard of fatal and nonfatal overdose among people with both opioid and stimulant use disorder diagnoses. This study suggests an urgent need to address the service needs of individuals who have had contact with the criminal justice system and who co-use opioids and stimulants.