Before a Fatal Overdose: Opioid, Not Stimulant, Prescriptions Stood Out in Pennsylvania

Overdose deaths involving stimulants have climbed sharply in the United States since 2010; in 2022, about 34,000 people died from overdoses involving stimulants with abuse potential — about 32% of all overdose deaths. Prescription opioids are an established risk factor for opioid overdose death, but the link between prescription stimulants and stimulant overdose deaths is unclear.

The Pennsylvania Department of Health linked 2017–2022 overdose deaths from CDC's State Unintentional Drug Overdose Reporting System to 2014–2022 data from the state's Prescription Drug Monitoring Program, looking at controlled substances each person filled in the 3 years before death. Stimulants were defined as amphetamine, cocaine, methamphetamine or other prescription stimulants.

Deaths by drug type

Of 30,045 overdose deaths, 28,053 (93%) had information on the drugs involved:

Deaths involving opioids alone fell, while deaths involving stimulants — alone or with opioids — rose, even as total unintentional overdose deaths declined and stimulant dispensing increased.

What they had been prescribed

• In every group, decedents had filled far more opioid than stimulant prescriptions.
• People who died of stimulants without opioids were the most likely to have filled an opioid prescription.
• Timing: when the last prescription before death was an opioid, the median gap to death was 138 days for opioid-only deaths but 299.5 days for stimulant-only and 281 days for combined deaths. When it was a stimulant, the gap was 50.5 days for opioid-only deaths and 24 days for the other two — likely reflecting monthly refills for chronic conditions such as attention deficit disorder.

What it means

The findings don't support the idea that more stimulant prescribing alone is driving stimulant-only overdose deaths. Instead, prior opioid prescribing stood out as a risk marker for fatal overdose from opioids, stimulants or both — and deserves more study as a risk factor even for non-opioid overdoses. Some people who use opioids report also using stimulants to counter the sedation of synthetic opioids such as fentanyl, a pattern that needs more attention. Identifying stimulant-specific risk factors could better guide harm reduction.

Limits: before July 2016, the monitoring program recorded only Schedule II drugs, so prescribing may be undercounted for deaths from January 2017 to June 2019; it can't capture drugs used without a prescription — and cocaine, methamphetamine and MDMA are mostly illicit; and it shows prescriptions filled, not taken, or why.

Sources

Based on Hayden S, Murzynski SM, Bolton A, Thomas Goetz C, "Controlled Substance Prescribing Patterns Among Fatal Overdose Decedents with an Opioid, Stimulant, or Both Contributing to Death — Pennsylvania, 2017–2022," Morbidity and Mortality Weekly Report 74(12), CDC; a work of the United States government in the public domain.