Fatal self-injury in the United States, 1999- 2018: Unmasking a national mental health crisis-Authors' reply.

Santaella-Tenorio and colleagues write that our conception of self-injury mortality (SIM) “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 [1].” We certainly concur that people who use drugs—or die by suicide—are stigmatized; however, we disagree that characterizing their behavior as self-injurious adds to unfortunate and unacceptable social stereotypes.

SIM was built from a nascent concept called ‘death from drug self-intoxication’ (DDSI), formulated by a multidisciplinary group of researchers and practitioners—epidemiologists, psychiatrists, emergency physicians, medical toxicologists, forensic pathologists and medical examiners, a health economist, philosopher and sociologist [2]. Fundamental to this concept was the recognition that the vast majority of drug intoxication deaths are not true accidents. They are foreseeable and preventable. These deaths reflect patterned self-harm that implicates substance acquisition and misuse, behavior that fundamentally alters the probability of killing oneself, whether with defined intent or inadvertently. Public health scientists recognised many years ago that potentially foreseeable deaths should not be considered ‘accidents [3],’ thus increasing attention to modifiable risk factors. We recognize that the criminal justice approach to ‘illicit’ drug use in the United States created an unacceptable stigmatization of those afflicted by these conditions, and the resulting societal separation of substance use disorders from other mental health conditions. However, failing to recognize the nature of self-injury fatalities or debunk the ‘accident’ designation on death certificates only serves to reinforce the unfortunate simplification and stereotyping that Santaella-Tenorio et al. seek to counteract.

The authors further confuse the argument by asking whether SIM should include deaths resulting from extreme sports or auto-racing. In fact, all competitive sports fully acknowledge the associated enhanced risk of morbidity and mortality and, in acknowledging this, participants engage in highly regulated forms of structural self-protection to mitigate those risks (physical training, protective clothing and gear, seat belts with enhanced features, etc.), as well as organizational surveillance and safety improvement efforts. We believe it is vital to see the same public health protections applied to our vulnerable mental health and substance use disorder populations. This would include military and first responders whose chronic pain management problems pose added vulnerability to substance misuse, addiction, both intentional and unintentional drug overdose, and suicide [4].

SIM is a public health orientated, behavioral classification—not a moral blaming and shaming one—aimed at attracting and channelling more resources for surveillance, aetiologic understanding, prevention and treatment than could be mustered by the continued siloing of its components. A first step involves moving beyond current paradigms that mischaracterize many overdose related fatalities [5].

Declaration of Competing Interest

None