Letter on Rocket's et al., manuscript: Fatal self-injury in the United States, 1999-2018: Unmasking a national mental health crisis.

Rockett et al. [1] propose a self-injury measure (SIM) to mitigate uncertainty in injury intention of death determinations. Their argument for fitting 80% of unintentional overdoses into the SIM “is predicated on the presence of repetitive self-harm behaviors, which are commonly associated with substance use disorders…”. We believe this classification reduces the complexity of fatal overdoses while perpetuating a stigmatizing narrative of people who use drugs, an already marginalized population, as careless and intentionally self-harming.

Much illicit opioid use is a self-treatment for occupation or military-produced physical pain [2], which should not be conflated with intentional self-harm. Importantly, contamination of heroin [3] and stimulant [4] drugs with fentanyl underlies most fatal overdose in recent years. The authors indicate that “Behaviorally such deaths qualify as SIM, even with no medicolegal corroboration of suicide.” However, this definition places the blame on those using substances, reinforcing the notion that all drug use and its consequences constitute a choice, while adding little to address the fentanyl contamination problem. If high-risk behaviors should be classified as SIM, should it also include those who die while competing in extreme sports or auto-racing?

We agree with the authors that interventions to overcome the overdose and suicide epidemics must address upstream social determinants, including criminalization of drug use, and involve policy change across multiple systems. Nevertheless, labeling almost all overdoses as self-injury behavior may obscure the distinctive drivers of the overdose epidemic.

Declaration of Competing Interest

The authors declare that there is no conflict of interest.