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Chang et al. [1] report on demographics, causes of death and other significant conditions among people who had opioids and/or stimulants detected in their unintentional acute drug toxicity death between 2013 and 2023. We have published similar analyses to distinguish chronic disease diagnoses and health service visits before death for decedents in British Columbia (BC), Canada, with opioids and/or stimulants deemed relevant to death [2]. Chang et al.’s [1] inclusion of non-substance–related contributors to death derived from death certificates fills a critical gap in the literature, as prior analyses (to our knowledge) have not examined how such contributing causes differ by opioid and/or stimulant detection. Although our analyses identified chronic disease diagnoses that may have contributed to death, we did not adjudicate these as contributing causes. Consistent with Chang et al., [1] we identified cardiovascular disease (CVD) as most prevalent among stimulant-only toxicity deaths, suggesting that some stimulant-related deaths may result from acute complications of chronic disease exacerbated by stimulant use. In our analysis, the stimulant toxicity group had higher rates of musculoskeletal, circulatory, respiratory and cardiovascular disease, however, after adjusting for age, only CVD remained associated with stimulant-only deaths. In contrast, in Chang et al.’s [1] study, associations between chronic disease and stimulant-toxicity death persisted after age-adjustment. One explanation is that drug toxicity triggered or exacerbated undiagnosed or acute conditions captured on death certificates, but not identified through prior diagnoses in administrative health data. As such, Chang et al.’s [1] integration of contributing causes of death strengthens and extends existing hypotheses regarding the role of chronic disease in stimulant-related mortality and affirms the findings of recent studies, which have identified rising rates of stimulant-involved CVD mortality in the past decade in the United States [3, 4]. As stimulants are increasingly relevant in drug poisoning deaths in BC—increasing from 68% in 2015 to approximately 80% in 2024 [5]—it is important to distinguish stimulant-only from stimulant-involved mortality to develop effective, tailored strategies for polysubstance users. One promising finding in our study was that over 60% of decedents had a health service visit in the year before death, suggesting a potential intervention point at which tailored services could be offered, such as treatments to address CVD and/or reduce exposure to illicit stimulants [6]. Heather Palis: Conceptualization; writing—original draft; writing—review and editing. Jennifer Vincent: Writing—original draft; writing—review and editing; conceptualization. Juls Budau: Writing—review and editing; writing—original draft; conceptualization. Kevin Hu: Conceptualization; writing—original draft; writing—review and editing. Andrew Tu: Conceptualization; writing—original draft; writing—review and editing. None.