Deaths

Stimulant-involved deaths in LAC were identified using the International Classification of Disease, Tenth Revision (ICD-10) codes for stimulant-related conditions (i.e., abuse, dependence, use, or poisoning) in the underlying or multiple cause of death entries on the death certificate.

Stimulant overdose-involved deaths were identified using ICD-10 codes for both the drug overdose of all intents as the underlying cause of death, and stimulant poisoning codes in the multiple cause of death entries on the death certificate. 

Stimulant-Involved Deaths

In LAC from 2008-2020, there were a total of 8,184 deaths that listed a stimulant-related condition as a cause of death. The number of deaths increased substantially by 210% from 353 in 2008 to 2019. During the COVID-19 pandemic, the stimulant-related deaths had increased to 1,711 in 2020, a 50% rise from 2019. 

The age-adjusted rate of death per 100,000 population increased from 3.6 in 2008 to 16.1 in 2020 (Figure 1).

From 2008-2020, methamphetamine was the most frequently reported stimulant type among stimulant-involved deaths, identified in 5,653 (69%) of death certificates in LAC. The number of deaths involving methamphetamine escalated from 125 to 1,354 deaths over the period. The age-adjusted rate of death per 100,000 population increased considerably by 975% from 1.2 to 12.9 (Figure 2).

Cocaine-involved deaths accounted for 36% (2,952) of stimulant-related deaths in LAC from 2008-2020. The age-adjusted rate of death per 100,000 population declined by 42% from 2008-2013, but steadily increased thereafter by 230% from 1.4 to 4.5 (Figure 3).  

During the year of COVID-19 pandemic, methamphetamine-involved deaths had increased form 825 in 2019 to 1,354 in 2020 by 64%; cocaine-involved deaths had increased from 349 in 2019 to 486 in 2020 by 39%. (Figure 2 and 3)  

Cause of Death

In LAC from 2008-2020, stimulant poisoning (n=6,397, 78%) was the most likely cause of death listed on death certificates compared to other stimulant-related conditions among stimulant-involved deaths, followed by unspecified or uncomplicated stimulant use (n=2,485, 30%), and stimulant abuse (n=170, 2%). Dependence was rarely reported as a cause of stimulant-involved death (n=12) (Figures 4-5). 

(Note: Each decedent could have more than one stimulant-related condition listed on their death certificate)

Stimulant-Detected Deaths

Although detection of a drug does not necessarily implicate it as a cause of death, it provides important information on substance use behaviors and drug supply. 

According to LAC's Medical Examiner/Coroner's Office, overall, stimulants accounted for a large proportion of drug detected deaths in 2013-2019 (Figures 6-7).

Methamphetamine was detected in over 6,000 decedents during 2013-2019. Detection of methamphetamine greatly increased from 696 cases in 2013 to 1,285 cases in 2019, and increased 22% to 40% in 2019 (Figures 6). Since 2015, methamphetamine was the most commonly detected drug, surpassing narcotic analgesics. 

Cocaine was identified in over 1,800 cases during 2013-2017Detection of cocaine increased moderately from 342 in 2013 to 385 in 2017 (Figure 7)

(*Note: No cocaine data available for 2018 and beyond medical examiner toxicology)

Stimulant Overdose Deaths

Stimulant-involved overdose deaths are becoming a major concern in the US as their presence in death reports have been increasing over recent years. From 2016-2017, the national totals for overdose deaths relating to cocaine and psychostimulants had each increased over 30%, accounting for 20% (13,942) and 15% (10,333), respectively, of all drug overdose deaths in 2017 (Kariisa 2019).

Intent

From 2008-2020, nearly all (97%) of stimulant-involved overdose deaths that occurred in LAC are accidental, with a total of 5,020 deaths in LAC classified as unintentional. Less than 2% (n=68) were classified as suicide or were undetermined (n=63) (Figures 8-9). 

Overall

Stimulant overdose deaths accounted for over half (59%) of all stimulant-involved deaths in LAC from 2008-2020. 

The rate of death had gradually increased between 2008-2012, rapidly increased from 2012 to 2020. 

By 2020, the age-adjusted mortality rate for stimulant-involved overdose deaths was 12.1 per 100,000 population, which was a 908% increase from 2008. (Figure 10)

From 2019 to 2020, the overall stimulant overdose deaths had increased substantially by  927% from 753 to 1,273. (Figure 10).

Of the 11,839 drug overdose deaths from 2008-2020 in LAC, over one third (41%) involved stimulants.

From 2008-2010, less than 20% of drug overdose deaths involved stimulants. However, in following years, stimulant-involved overdose deaths rose steadily, accounting for approximately one-third of all drug-related overdose deaths in LAC by 2014. From 2015 and onward, stimulant overdose deaths became the predominant drug problem in LAC, resulting in 40%-63% of all fatal drug overdoses (Figure 11). 

Demographics

Gender

Males made up the largest proportion (77%) of all stimulant-involved overdose deaths that occurred in LAC during 2008-2020. Despite both genders showing an increase in death counts over this period, there was a disparity when comparing gender rates. The age-adjusted rate for males increased more steeply by 933% from 1.8 to 18.6 per 100,000 population from 2008-2020; whereas the increase among females was more moderate from 0.7 to 5.5 per 100,000 population (Figures 12-13).

Age

Individuals aged 0-34 years had the highest number (n=1,333) of overall stimulant-involved overdose deaths in LAC, followed by those aged 45-54 years (n=1,289), adults aged 35-44 years (n=1,007), and those aged 55-64 years (n=990). Adults 65+ years had the lowest number of deaths compared to all other age groups (Figure 12). Adults aged 45-54 years had the largest number of reported deaths during 2008-2013, but in the following years, all age groups increased with no category consistently dominating (Figures 14-15).

Race/Ethnicity

Whites accounted for the greatest proportion (42%) of overall stimulant-involved overdose deaths, followed by Latinxs (34%), blacks (20%), and API (4%). Annual counts for overall stimulant mortality were consistently greater among whites, but the death rate was higher among blacks. From 2008-2020, the age-adjusted rate per 100,000 increased from 3.7 to 28.9 among blacks, and from 1.6 to 16.7 among whites. The age-adjusted mortality rate was lowest among Latinx's, but had increased the most rapidly by 1050% from 0.8 to 9.2 from 2008-2020 (Figures 16-17).

Methamphetamine Overdose Deaths

Overall there were a total of 3,606 deaths involving methamphetamine overdose in LAC from 2008-2020, comprising 74% of all stimulant-involved overdose deaths. 

Starting in 2008, 43 methamphetamine-related deaths had occurred in LAC. Following that year, the number of deaths had continued to rise with the highest increase taking place between 2012-2013. From 2014-2020, the age adjusted rate of death per 100,000 population increased by 560% from 1.5 to 9.9 (Figure 18).

Demographics

Gender

In 2008-2020, males accounted for 78% of all methamphetamine overdose deaths in LAC. The annual number of deaths among males consistently increased from 25 to 809 deaths from 2008 to 2020. The age-adjusted rate per 100,000 population among males increased from 0.5 to 15.5 from 2008 to 2020. Death counts among females were more stable and showed no sizable increase until 2015, The age-adjusted rate per 100,000 population among females increased by 450% from 0.8 to 4.4 from 2013 to 2020 (Figures 19-20).

Age

Methamphetamine overdose deaths occurred most frequently among those aged 0-34 years (n=981) and 45-54 years (n=981) during 2008-2020 (Figure 21). These two age groups had the greatest number of deaths annually from 2010-2020. However, all age groups had high rates and rapid increases in death rates over the period. Specifically, those aged 45-54 years had the highest rate of death in 2020 (r=20.4), followed by those aged 35-44 years (r=17.2), whereas fatal overdoses for those aged 18-34 years and 55+ had rates of 10.8 and 9.8 deaths per 100,000 population respectively (Figure 22).

Race/Ethnicity

From 2008-2020, whites accounted for nearly half (46%) of LAC overdose deaths involving methamphetamine, with Latinx's comprising 37%, blacks 12%, and API 5% (Figure 23). Throughout 2008-2020, there were consistently more whites with methamphetamine overdose deaths compared to Latinx’s and blacks. From 2014-2020, the age-adjusted rate of death per 100,000 population had increased substantially for white and Latinx increasing from 2.6 to 14.9 and 1.0 to 7.8, respectively. Although there were few methamphetamine overdose deaths that occurred among blacks prior to 2014, fatal methamphetamine overdoses among blacks became more prevalent and increased from 20 deaths to 165 deaths at an age-adjusted rate of 2.2 in 2014 to 19.2 deaths per 100,000 population in 2020 (Figure 24). 

Cocaine Overdose Deaths

The aged adjusted death rates per 100,000 population in LAC for cocaine overdose decreased 44% from 0.9 to 0.5 during 2008-2012, then began to surge in 2013 from 0.7 to 3 in 2020, with a total of 1,202 deaths from 2013-2020 (Figure 25).

Demographics

Gender

Males were the predominant gender group in LAC among decedents listing cocaine overdose as a cause of death during 2008-2020. There were moderate decreases in cocaine-involved deaths among males from 2008-2012, but from 2013-2020, the number deaths increased by 370% from 54 to 254. By 2020, age-adjusted rates per 100,000 among males was over two times that of females (4.7 vs. 1.4) (Figures 26-27).

Age

From 2008-2020, cocaine overdose deaths were more frequently reported in adults aged 0-34 years (n=453), followed by those aged 45-54 years (n=370), ages 55-64 years (n=346), ages 35-44 years (n=235)and older adults aged 65+ (n=111) (Figure 28). Most age groups had stable death counts with little variation across 2013-2020, except those aged 18-34 years, in which the annual death counts increased substantially from 16 deaths in 2014 to 123 in 2020 by 669% (Figure 29).

Race/Ethnicity

From 2008-2020, blacks had the highest proportion (38%) of cocaine-involved overdose deaths, followed by whites (31%), Latinxs (28%), and API (3%) (Figure 30). In general, blacks had the highest number of fatal cocaine overdoses during 2008-2020, with whites closely following, and Latinxs regularly having the lowest frequency of deaths. From 2008-2020, the age-adjusted mortality rate per 100,000 population increased for all race/ethnic groups, from 3.2 to 13 in blacks, 1.0 to 3 in whites, and 0.6 to 1.9 in Latinxs from 2008-2020 (Figure 31).

Co-involvement of Opioids

In recent years, many stimulant-related deaths in the US co-involved opioids. In 2017, opioids, were involved in 73% of cocaine, and 50% of psychostimulant overdoses (Karissa 2019). In particular, illicitly manufactured fentanyl (IMF) has been increasingly involved in stimulant deaths, while involvement by other illicit or prescription opioids decreased (Gladden, 2019). 

From 2016-2017, cocaine-related deaths that co-involved opioids increased 38%, whereas those independent of opioids increased 23%. Psychostimulant-related deaths that co-involved opioids increased 52%, while those that were independent of opioids increased 23% (Hoots 2019). 

Stimulants Overdose Deaths Co-involving Opioids

From 2008-2020, there were 1,600 overdose deaths in LAC in which both stimulants and opioids were mentioned as a cause of death. This accounted for 33% of all stimulant-related overdose deaths. 

Prior to 2013, only a small proportion of fatal stimulant overdoses co-involved opioids; but after 2013, the total number of deaths involving both stimulants and opioids started to increase consistently. From 2015-2019, deaths increased 311% from 82 to 337 deaths, and further increased to 715 in 2020 (Figure 32).

From 2016-2020, the increase in opioid co-involvement among stimulant overdose deaths occurred for all opioid types, but increased the most for synthetic opioids (2,309%), followed by heroin (206%), metho and natural/semi-synthetic opioids (13%) (Figure 33). 

Methamphetamine overdose deaths co-involving opioids increased gradually from 2009-2015, then sharply increased by 78 from 2015-2016, accounting for one-third of all methamphetamine overdose deaths in 2016. Methamphetamine overdose deaths co-involving opioids continued to increase to 565 deaths in 2020 (Figure 34) (Figure 34).

Although deaths involving synthetic opioids accounted for the smallest proportion among the opioid types, those accounted for the greatest increase between 2016-2018, with a 480% increase from 10 to 58 deaths. Deaths co-involving heroin had also increased from 49 to 80 deaths. From 2018-2020, overdose deaths co-involving synthetic opioid had increased substantially from 58 to 404 by 597% and in 2020 it had further surpassed heroin (n=182) and natural/semi-synthetic opioid deaths (n=49) (Figure 35).

Overdose deaths that involved both cocaine and opioids had followed a similar trend as overall cocaine overdose deaths, with a decrease from 2008-2012 before increasing in 2013. However, in 2013, cocaine overdose deaths co-involving opioids accounted for 28% of cocaine overdoses, with the proportions increasing to over 50% by 2018. From 2018-2020, the number had increased greatly by 110% from 103 to 216 (Figure 36).

Co-involvement by heroin was the only opioid type to decrease from 2016-2017, though it increased again from 2017-2018 by 100%. Co-involvement by synthetic opioids had the greatest increase, by 323% from 13 to 55 from 2016-2018 and then by 224% from 55 to 178 from 2018-2020 (Figure 37). 

References

CDC. Wide‐ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2022. Available from: http://wonder.cdc.gov

Gladden, R. M., O’Donnell, J., Mattson, C. L., & Seth, P. (2019). Changes in opioid-involved overdose deaths by opioid type and presence of benzodiazepines, cocaine, and methamphetamine—25 states, July–December 2017 to January–June 2018. Morbidity and Mortality Weekly Report, 68(34), 737.

Hoots, B., Vivolo‐Kantor, A., & Seth, P. (2020). The rise in non‐fatal and fatal overdoses involving stimulants with and without opioids in the United States. Addiction.

Kariisa, M., Scholl, L., Wilson, N., Seth, P., & Hoots, B. (2019). Drug overdose deaths involving cocaine and psychostimulants with abuse potential—United States, 2003–2017. Morbidity and mortality weekly report, 68(17), 388.

Los Angeles County Participant Reporting System (LACPRS). California Outcomes Measure System data for 2018.

National Drug Early Warning System (NDEWS) Coordinating Center ., 2015-2020. Los Angeles County Sentinel Community Site (SCS) Drug Use Patterns and Trends, for year 2013 to 2020. Available at https://ndews.umd.edu/publications/los-angeles-county-sentinel-community-site-scs. Note: Figure 1 counts were calculated from the percent of methamphetamine and cocaine deaths and total deaths for the years 2013-2015. Data for 2016 were based on estimated total and estimated methamphetamine frequencies.

Note: Age-adjusted rates were calculated using the 2000 US standard population distribution.