JMIR Publications

ABSTRACT

Background:

Despite increasing fatal stimulant poisoning in the US, little is understood about the mechanism of death. The psychological autopsy (PA) has long been used to distinguish accidental and suicidal deaths, including opioid overdose, but has not been used to study stimulant mortality.

Objective:

To develop and implement a large PA study to identify antecedents of fatal stimulant poisoning, seeking to maximize data gathering and ethical interactions during the collateral interviews.

Methods:

We ascertained death records from the California Electronic Death Reporting System (CA-EDRS) and the San Francisco Office of the County Medical Examiner (OCME) from June 2022 through December 2023. We selected deaths determined to be due to acute poisoning from cocaine or methamphetamine, which occurred 3-12 months prior, and were not attributed to suicide or homicide. We identified 31 stimulant-fentanyl and 70 stimulant-no-opioid decedents. We sought two informants for each decedent, who were able to describe the decedent across their life course. Informants were at least 18 years of age, communicated with the decedent within the year before death, and were aware that the decedent had been using substances during that year. Upon completion of at least one informant interview conducted by staff with bachelor’s or master’s degrees, we collected OCME, medical record, and substance use treatment data for the decedent. Planned analyses include LASSO regressions of quantitative data and thematic analyses of qualitative data.

Results:

We identified and interviewed at least one informant (N=141) for each decedent (N=101). Based on feedback during recruitment, we adapted our language to improve rapport including changing the term “accidental death” to “premature death”, offering condolences, and providing content warnings. As expected, family members were able to provide more data about the decedent’s childhood and adolescence, and nonfamily informants provided more data regarding behaviors proximal to death. We found that the interviews were stressful for both the interviewee and interviewer, especially when participants thought the study was intrusive or experienced significant grief during the interviews.

Conclusions:

In developing and implementing PA research on fatal stimulant poisoning, we noted the importance of recruitment language regarding cause of death and condolences with collateral informants. Compassion and respect were critical to facilitate the interview process and maintain an ethical framework. We discuss several barriers to our success and lessons learned while conducting PA interviews, as well as recommendations for future PA studies.