{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T18:04:36Z","timestamp":1787853876992,"version":"build-2784847793"},"reference-count":28,"publisher":"Wiley","issue":"2","license":[{"start":{"date-parts":[[2025,9,17]],"date-time":"2025-09-17T00:00:00Z","timestamp":1758067200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"funder":[{"DOI":"10.13039\/100000026","name":"National Institute on Drug Abuse","doi-asserted-by":"publisher","award":["R01DA056449"],"award-info":[{"award-number":["R01DA056449"]}],"id":[{"id":"10.13039\/100000026","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Addiction"],"published-print":{"date-parts":[[2026,2]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background and aims<\/jats:title>\n                    <jats:p>Deaths attributed to a combination of opioids and stimulants have risen dramatically in recent years, largely attributed to fentanyl, yet little is understood about which drug class is primarily responsible. Attributing death to acute substance toxicity is complex and lacks clear standards. We aimed to determine whether additional causes of death and other significant conditions among deaths attributed to fentanyl were similar regardless of stimulant involvement, and distinct from deaths involving stimulants without opioids.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Cross\u2010sectional analysis using records from the California Electronic Death Registration System.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting and cases<\/jats:title>\n                    <jats:p>Unintentional acute toxicity deaths involving fentanyl or stimulants (methamphetamine or cocaine) occurring in San Francisco, USA, during 2013\u20132023.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Measurements<\/jats:title>\n                    <jats:p>We compared demographic characteristics and causes of death or other significant conditions (cardiovascular, cerebrovascular, other medical cause, or no other additional cause) among five mutually exclusive groups of deaths: stimulants without opioids (stimulant\u2010only), fentanyl with stimulants (fentanyl\u2010stimulant), fentanyl without stimulants (fentanyl\u2010only), other opioids (e.g., heroin, oxycodone) with stimulants (\u201cother opioid\u2010stimulant\u201d), and other opioids without stimulants (\u201cother opioids\u2010only\u201d). We conducted separate unadjusted and adjusted multivariable logistic regression models for each outcome (cardiovascular, cerebrovascular, other medical, or no additional cause). The primary analysis included results for the fentanyl groups.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Findings<\/jats:title>\n                    <jats:p>\n                      Of 4475 deaths attributed to acute opioid and\/or stimulant toxicity, 24% involved stimulants\u2010only, 45% fentanyl\u2010stimulants, and 12% fentanyl\u2010only; the remaining 20% involved other opioids. Stimulant\u2010only decedents were the oldest (mean age 54\u2009years), followed by fentanyl\u2010stimulant (47\u2009years) and fentanyl\u2010only (44\u2009years;\n                      <jats:italic>p<\/jats:italic>\n                      \u00a0&lt;\u20090.001 for all). The adjusted odds of having cardiovascular, cerebrovascular, or other medical causes of death (adjusted odds ratios [aORs] from 0.03 to 0.52, with 95% confidence intervals [CIs] from 0.01 to 0.68) were lower and the odds of no additional cause of death (aORs from 2.53 to 3.31, with 95% CIs from 2.00 to 3.40) were higher for both groups of deaths involving fentanyl compared with deaths attributed to stimulants\u2010only. There were no statistically significant differences in causes of death when comparing fentanyl\u2010only with fentanyl\u2010stimulant deaths. Findings were similar for other opioid deaths.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>In San Francisco, USA, causes of death and other significant condition characteristics among deaths attributed to fentanyl appear to be similar regardless of the involvement of stimulants, but are markedly different from deaths involving stimulants without opioids. When reporting on drug\u2010related mortality and developing interventions, deaths attributed to a combination of fentanyl and stimulants may be appropriately considered in the context of opioid overdose prevention, while deaths attributed to stimulants without opioids may require a response focused on preventing and treating underlying chronic medical conditions.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/add.70190","type":"journal-article","created":{"date-parts":[[2025,9,17]],"date-time":"2025-09-17T07:45:06Z","timestamp":1758095106000},"page":"288-294","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["Refining cause of death attribution among opioid, opioid\u2010stimulant and stimulant acute toxicity deaths"],"prefix":"10.1111","volume":"121","author":[{"ORCID":"https:\/\/orcid.org\/0009-0008-3163-0343","authenticated-orcid":false,"given":"Yi\u2010Shin Grace","family":"Chang","sequence":"first","affiliation":[{"name":"Center on Substance Use and Health San Francisco Department of Public Health  San Francisco CA USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nora","family":"Anderson","sequence":"additional","affiliation":[{"name":"Center on Substance Use and Health San Francisco Department of Public Health  San Francisco CA USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kyna","family":"Long","sequence":"additional","affiliation":[{"name":"Center on Substance Use and Health San Francisco Department of Public Health  San Francisco CA USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ciaran","family":"Murphy","sequence":"additional","affiliation":[{"name":"Department of Medicine University of California San Francisco  San Francisco CA 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