Abstract
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.