OBJECTIVE: Alcohol contributes to a large number of deaths annually, in terms of both deaths fully attributed to alcohol (e.g., alcohol poisoning) and deaths where alcohol is a contributing cause (e.g., motor vehicle accidents). Nationally, alcohol-involved deaths are increasing. This study examines alcohol's role in substance-involved deaths and factors that are associated with alcohol involvement in the St. Louis, Missouri region. METHOD: The present study examined 7,641 substance-involved deaths that occurred in the St. Louis, Missouri region. Data were provided by city and county medical examiner offices and comprised all substance-involved deaths between 2011 and 2022. We examined the prevalence of alcohol stratified by manner of death, sex, and race. We conducted logistic regression predicting odds of alcohol involvement based on demographic factors, presence of medical conditions, involvement of other substances, and year of death. RESULTS: Overall, 26.29% (2,009/7,671) of substance-involved deaths involved alcohol, and annual alcohol-involved deaths increased by 54.33% from 2011 to 2022. Most substance-involved deaths were overdose deaths (82.54%
6,307/7,641). Alcohol-involved overdose deaths increased by 60.76% from 2011 to 2022. Prevalence of alcohol was higher for overdose deaths involving opioids and benzodiazepines (18%-24%) than for other drug classes (7%-16%). Odds of alcohol involvement in overdose deaths increased with age (odds ratio = 1.02, 95% CI [1.01, 1.02]) and were higher for males (odds ratio = 1.67, 95% CI [1.43, 1.96]). CONCLUSIONS: The St. Louis metropolitan area saw increases in alcohol-involved fatalities for all manner of deaths, particularly overdose deaths and deaths among Black men. To improve prevention strategies for alcohol fatalities, further research is needed to investigate the role of alcohol in polysubstance overdose deaths.