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. 2025 Feb:102:8-22.
doi: 10.1016/j.annepidem.2024.12.010. Epub 2024 Dec 21.

Misclassification of opioid-involvement in drug-related overdose deaths in the United States: A scoping review

Sarah Gutkind  1 , Megan E Marziali  2 , Emilie Bruzelius  3 , Zachary L Mannes  4 , Silvia S Martins  5 , Deborah S Hasin  6 , Pia M Mauro  7
Affiliations

Misclassification of opioid-involvement in drug-related overdose deaths in the United States: A scoping review

Sarah Gutkind et al. Ann Epidemiol. 2025 Feb.

Abstract

Purpose: Most drug-related deaths in the United States (US) in 2022 involved opioids. However, methodological challenges in overdose surveillance may contribute to underestimation of opioid involvement in the overdose crisis. This scoping review aimed to synthesize existing literature to examine the breadth and contributing sources of misclassification of opioid-related overdose deaths.

Methods: In October 2022, we searched PubMed, Web of Science, and Scopus for studies on overdose surveillance, death certificates, and medicolegal death investigation (MDI) systems in the US published in 2013-2022. Two reviewers independently screened abstracts, reviewed full-texts, and performed data extraction of study characteristics.

Results: We identified 17 studies examining misclassification in drug-related deaths. Across studies, opioid involvement in drug-related deaths was underestimated nationally by 20-35 %. Unspecified drug-related deaths differed by geographic areas and MDI systems and decreased over time. States/counties with coroner MDI systems were more likely to report unspecified overdose deaths than those with medical examiners. Integrating toxicology testing, death scene investigations, and other data with death certificates identified additional opioid-related overdose deaths, particularly those involving heroin.

Conclusions: Findings highlight the need for additional resources for surveillance efforts, training for coroners, and data integration to improve reporting of opioid involvement in overdose deaths to inform interventions.

Keywords: Cause of death; Death certificates; Fatal drug overdose; Opioid epidemic; Opioid overdose.

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Conflict of interest statement

Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Deborah S. Hasin reports a relationship with Syneos Health that includes: funding grants. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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