A multicentre case series of analytically confirmed gamma-hydroxybutyrate intoxications in Western Australian emergency departments: Pre-hospital circumstances, co-detections and clinical outcomes.

INTRODUCTION: Gamma-hydroxybutyrate (GHB) use is associated with high risk of accidental overdose. This study examined the pre-hospital circumstances, demographic characteristics and clinical outcomes of analytically confirmed GHB emergency department (ED) presentations in Western Australia (WA). METHODS: This case series was conducted across three WA EDs involved in the Emerging Drugs Network of Australia, from April 2020 to July 2022. Patient demographics, pre-hospital drug exposure circumstances and ED presentation and outcome characteristics were collected from ambulance and hospital medical records of GHB-confirmed cases. RESULTS: GHB was detected in 45 ED presentations. The median age was 34 years and 53.3% (n = 24) were female. Most patients arrived at the ED by ambulance (n = 37, 85.7%) and required immediate emergency care (Australasian Triage Score 1 or 2 = 97.8%). One-third of patients were admitted to intensive care (n = 14, 31.1%). Methylamphetamine was co-detected in 37 (82.2%) GHB-confirmed cases. Reduced conscious state was indicated by first recorded Glasgow Coma Scale of ≤8 (n = 29, 64.4%) and observations of patients becoming, or being found, 'unresponsive' and 'unconscious' in various pre-hospital settings (n = 28, 62.2%). 'Agitated' and/or 'erratic' mental state and behavioural observations were recorded in 20 (44.4%) cases. DISCUSSION AND CONCLUSIONS: Analytically verified data from ED presentations with acute toxicity provides an objective information source on drug use trends and emerging public health threats. In our study, patients presenting to WA EDs with GHB intoxication were acutely unwell, often requiring intensive care treatment. The unexpectedly high proportion of female GHB intoxications and methylamphetamine co-ingestion warrants further exploration.

Illicit drugs in the emergency department: Can we determine on clinical grounds if patients are intoxicated? Results from the Western Australian Illicit Substance Evaluation (WISE) study.

INTRODUCTION: Presentations related to illicit drugs are a feature of emergency department practice. Clinicians may form a belief that a patient is intoxicated with illicit drugs based on patient self-report, clinical features on presentation and the local prevalence of illicit drug use. But evidence of the accuracy of this assessment is lacking. The Western Australian Illicit Substance Evaluation (WISE) study enrolled patients believed by their treating clinician to be intoxicated with illicit drugs, and this analysis aims to evaluate the validity of this belief. METHODS: A blood sample was taken on patient arrival and details of patient history, examination and interventions were collected by clinical and research staff. Toxicological examination of biological samples used liquid chromatography-mass spectrometry techniques including Quadrupole Time of Flight screening and Triple Quadrupole targeted analyses. RESULTS: Of 632 study presentations, 518 had illicit drugs detected representing a positive predictive value of 0.82 (95% confidence interval 78.7, 84.9). Those with illicit drugs detected were significantly less likely to arrive by police transport (p = 0.010) or to have used alcohol (p < 0.001). They were significantly more likely to report illicit drug use (p < 0.001) and a much smaller proportion were admitted to a psychiatric ward (3.5% vs. 19.3%, p < 0.0001). Heart rate and systolic blood pressure were significantly higher in the illicit drug group (p = 0.004 and p = 0.003). DISCUSSION AND CONCLUSIONS: In this study, the positive predictive value of clinicians determining if their patient had taken illicit drugs was 0.82. Contemporaneous biochemical analysis in the clinical setting would increase this accuracy and inform patient care.

Detection of intact insulin analogues in post-mortem vitreous humour-Application to forensic toxicology casework.

The application of proteomic techniques to forensic science widens the range of analytical capabilities available to forensic laboratories when answering complex toxicology problems. Currently, these techniques are underutilised in post-mortem toxicology because of the historic focus on smaller (<1,000 amu) drug molecules. Definitive confirmation of an insulin overdose by analysis of post-mortem biological matrices is rare and challenging, however can assist coronial investigations pertaining to accidental or intentional overdoses in both diabetic and nondiabetic populations. A semiautomated micro-solid phase extraction paired with mass spectrometry-based insulin methodology was developed and validated for routine use in a Forensic Coronial Toxicology Laboratory. This resulting work reports the first Australian cases where synthetic insulins were confirmed by mass spectrometry in the vitreous humour of Type 1 diabetics who intentionally or accidentally overdosed on their prescription medication glargine and aspart. The detection of glargine M1 in Case 1, aspart in Case 2 and glargine M1 was indicated in Case 3. This paper highlights advancements in forensic coronial toxicology and the promising potential of proteomic analysis in a forensic context.

An early warning system for emerging drugs of concern in the emergency department: Protocol for the Western Australian Illicit Substance Evaluation (WISE) study.

OBJECTIVE: An ever-increasing number of novel psychoactive substances are being detected worldwide. These emerging drugs have been demonstrated to cause toxicity in clusters, and deaths have been reported. We urgently need to learn more about their effects. We report the protocol for the Western Australian Illicit Substance Evaluation (WISE) study, a research project investigating illicit drug use in the ED. METHODS: Patients can be enrolled if the treating clinician strongly suspects they are currently intoxicated with a stimulant, hallucinogenic or cannabinoid drug; and an i.v. cannula or blood tests are required for routine clinical care. Patients are enrolled under a waiver of consent. A single additional blood tube is collected, de-identified and frozen on site. A temporary link between patient identification number and study identification number is retained for up to 10 business days post-hospital discharge to allow for clinical data collection, before this is destroyed and the patients become permanently de-identified. Samples are transported for external liquid chromatography-mass spectrometry analysis in batches once de-identified. RESULTS: The key outcome will be identification of any psychoactive drugs present in the blood sample, together with their respective concentration. This will be linked to the clinical effects, as well as being compared with the substance the patient believed they had taken. CONCLUSION: We consider the novel approach outlined forms a template for an early warning system for emerging drugs of concern, while also providing vital and comprehensive information on current drugs of abuse, their clinical effects and their impact on the health system.