Family violence in Victoria, Australia: a retrospective case-control study of forensic medical casework.

OBJECTIVE: To identify the risk factors and assault characteristics of family violence among victims referred for forensic medical examination in Victoria, Australia. METHODS: A retrospective 1:1 case-control study was conducted, comparing adult family violence victims and non-family violence victims examined by clinical forensic practitioners from the Victorian Institute of Forensic Medicine, between July 2015 and June 2016. Data were extracted from victims' forensic medical casework. Chi-square or Fisher's exact tests and Mann-Whitney U tests were used to examine group differences. A multiple logistic regression analysis was used to determine independent predictors of family violence. RESULTS: One hundred and forty-three family violence victims (97.2% female, Mdnage = 29, 90.2% intimate partner violence) were identified and gender- and age-matched with controls. Family violence victims had significantly higher odds of reporting a history of violence victimisation (OR = 5.20; 95% CI, 2.54 to 10.66) and current pregnancy (OR = 5.28; 95% CI, 1.09 to 25.46) than controls. Family violence was significantly more likely than non-family violence to occur in the victim's home, and to involve physical assault, use of weapon(s), trauma to the neck and anal sexual assault. Family violence victims sustained significantly more physical injuries, and were more likely to be injured to almost every bodily location, than controls. CONCLUSION: This study highlights the importance of assessing and managing risk for family violence following initial victimisation and throughout pregnancy. Findings further indicate that family violence is more dangerous (i.e. more likely to involve severe forms of assault and cause injury) than non-family violence.

Acute Alcohol Co-Ingestion and Hospital-Treated Deliberate Self-Poisoning: Is There an Effect on Subsequent Self-Harm?

The aim of this study was to determine the relationship between alcohol co-ingestion in an index deliberate self-poisoning (DSP) episode with repeated DSP and subsequent suicide. A retrospective cohort study was conducted involving 5,669 consecutive index presentations to a toxicology service following DSP between January 1, 1996, and October 31, 2010. Records were probabilistically matched to National Coronial Information System data to identify subsequent suicide. Index DSPs were categorized on co-ingestion of alcohol, and primary outcomes analyzed were repetition of any DSP, rates of repeated DSP, time to first repeat DSP, and subsequent suicide. Co-ingestion of alcohol occurred in 35.9% of index admissions. There was no difference between those who co-ingested alcohol (ALC+) and those who did not co-ingest alcohol (ALC-) in terms of proportion of repeat DSP, number of DSP events, or time to first repeat DSP event. Forty-one (1.0%) cases were probabilistically matched to a suicide death; there was no difference in the proportion of suicide between ALC+ and ALC- at 1 or 3 years. There was no significant relationship between the co-ingestion of alcohol in an index DSP and subsequent repeated DSP or suicide. Clinically, this highlights the importance of mental health assessment of patients that present after DSP, irrespective of alcohol co-ingestion at the time of event.

Challenges with take-home naloxone in reducing heroin mortality: a review of fatal heroin overdose cases in Victoria, Australia.

AIM: Take-home naloxone (THN) programs have been implemented in order to reduce the number of heroin-overdose deaths. Because of recent legislative changes in Australia, there is a provision for a greater distribution of naloxone in the community, however, the potential impact of these changes for reduced heroin mortality remains unclear. The aim of this study was to examine the characteristics of the entire cohort of fatal heroin overdose cases and assess whether there was an opportunity for bystander intervention had naloxone been available at the location and time of each of the fatal overdose events to potentially avert the fatal outcome in these cases. METHODS: The circumstances related to the fatal overdose event for the cohort of heroin-overdose deaths in the state of Victoria, Australia between 1 January 2012 and 31 December 2013 were investigated. Coronial data were investigated for all cases and data linkage was performed to additionally investigate the Emergency Medical Services information about the circumstances of the fatal heroin overdose event for each of the decedents. RESULTS AND DISCUSSION: There were 235 fatal heroin overdose cases identified over the study period. Data revealed that the majority of fatal heroin overdose cases occurred at a private residence (n = 186, 79%) and where the decedent was also alone at the time of the fatal overdose event (n = 192, 83%). There were only 38 cases (17%) where the decedent was with someone else or there was a witness to the overdose event, and in half of these cases the witness was significantly impaired, incapacitated or asleep at the time of the fatal heroin overdose. There were 19 fatal heroin overdose cases (8%) identified where there was the potential for appropriate and timely intervention by a bystander or witness. CONCLUSION: This study demonstrated that THN introduction alone could have led to a very modest reduction in the number of fatal heroin overdose cases over the study period. A lack of supervision or a witness to provide meaningful and timely intervention was evident in most of the fatal heroin overdose cases.

An analysis of issues in the classification and reporting of heroin-related deaths.

AIMS: To investigate the extent of variability in the reporting of heroin-related deaths in Victoria, Australia. Additionally, to identify opportunities to improve the accuracy and consistency of heroin-related death reporting by examining variability in the attribution, death certification, classification and coding of heroin-related death cases. METHODS: Heroin-related deaths in Victoria, Australia during a 2-year period (2012-13) were identified using the National Coronial Information System (NCIS) and used as the 'gold standard' measure in this study. Heroin-related death data from the Australian Institute of Health and Welfare (AIHW) and Australian Bureau of Statistics (ABS) were then compared. Differences in the number of deaths reported as well as the classification and coding assigned to the identified heroin-related death cases were investigated by cross-referencing these data sets and examining the assigned ICD-10 codes. RESULTS: A total of 243 heroin-related deaths were identified through the NCIS compared with 165 heroin-related deaths reported by the AIHW and assigned the heroin-specific ICD-10 code of T40.1. Forty per cent of all the missed heroin-related death cases resulted from either the attribution of the death to morphine toxicity or with non-specific drug toxicity certification; 30% occurred where the cases had been attributed to heroin but there were irregularities in death certification. Additional missed heroin-related death cases occurred as a result of late initial registration of these deaths to the Registry of Births, Deaths and Marriages, and where these cases were then not assessed by the ABS for classification and coding purposes. CONCLUSIONS: In Victoria, Australia, in 2012 and 2013, the overall number of heroin-related deaths was under-reported by 32% compared with the number of deaths currently identified by the Australian Bureau of Statistics and reported by the Australian Institute of Health and Welfare.

Determining the effective dose of street-level heroin: A new way to consider fluctuations in heroin purity, mass and potential contribution to overdose.

BACKGROUND & AIMS: Heroin use is associated with a disproportionately high level of morbidity and mortality with most deaths attributable to drug overdose. Aggregate heroin purity data has been used to examine the relationship between overdose and variability in street-level heroin, however heroin purity data alone may not be the most appropriate nor a sensitive enough measurement tool for this assessment. The aim of this study was to measure the variability in effective dose of street-level heroin seizures, accounting for variation in both purity and mass, and determine the proportion of samples with higher than expected effective dose that would not be detected using a purity-only measure. METHODS: Data on Victorian heroin seizures ≤150mg in mass made between 01/01/2012 and 31/12/2013 were obtained from the Victoria Police Forensic Services Department. The effective dose of heroin in each sample was determined by multiplying the mass and purity variables. Effective dose outlier samples were considered as those containing either greater than 1.5-2 times or >2 times the median effective dose of heroin for the sample data. RESULTS: The 983 street-level heroin samples of ≤150mg had a median mass of 92mg (IQR of 43mg), a median purity of 13% (range 3.6%-80.9%) and a median effective dose of 12.0mg of heroin (IQR 6.6mg; range 0.4mg-111mg). Approximately one in 13 samples (8%) and one in 17 samples (6%) contained between 1.5-2 times and >2 times the median effective dose of heroin respectively. CONCLUSION: The effective dose of heroin is a more appropriate measure than purity to identify outlier samples that containing larger than expected doses of heroin compared to typical doses that may be expected by users. Together with other identified risk factors, fluctuation in the effective dose of heroin contained in street-level samples may contribute to the potential for overdose.

Catch and release: evaluating the safety of non-fatal heroin overdose management in the out-of-hospital environment.

Background: The aim of this study was to investigate the safety of the management of non-fatal heroin overdose in the out-of-hospital environment; irrespective of whether or not naloxone had been administered. Heroin toxicity-related deaths as well as heroin intoxication-related traumatic deaths following patient-initiated refusal of transport were investigated. Methods: Heroin-related deaths in the state of Victoria, Australia between 1 January 2012 and 31 December 2013 were investigated and data linkage to pre-hospital Emergency Medical Services performed, in order to identify whether the death was related to the last episode of care by paramedics. The number of non-fatal heroin overdose events over the study period were also examined. Results and discussion: There were a total of 3921 heroin-related attendances by paramedics during the study period, including 2455 cases that involved treatment but where the patient was not transported to hospital. There were also 243 heroin-related deaths identified over the study period and 93% (n = 225) of those cases were matched with Ambulance Victoria electronic patient care records. Data linkage revealed 31 heroin-related deaths where there had been a recent presentation with a non-fatal heroin overdose to paramedics; however, none of these deaths were related to that episode of care, including for 11 individuals that were treated on scene by paramedics but not transported to the hospital. Conclusions: This study demonstrated that the treatment of uncomplicated heroin overdose in the out-of-hospital environment was safe in terms of mortality, irrespective of whether or not naloxone had been administered. In all of the non-fatal heroin toxicity cases attended by paramedics, whether or not transported to hospital, death occurred as a result of a subsequent and unrelated heroin overdose.

Accurate identification of opioid overdose deaths using coronial data.

INTRODUCTION: Defining drug-related mortality is complex as these deaths can include a wide range of diseases and circumstances. This paper outlines a method to identify deaths that are directly due to fatal opioid toxicity (i.e. overdose), utilising coronial data. MATERIALS AND METHODS: The National Coronial Information System (NCIS), an online coronial database containing information on all deaths that are reported to a coroner in Australia, is used to develop methods to more accurately identify opioid overdose deaths. The NCIS contains demographic information, Medical Cause of Death, and associated documentation on toxicology, clinical and police investigations. RESULTS: Identifying overdose deaths using the coroner determined Medical Cause of Death provided greater capture, and specificity, of opioid overdose deaths. Distinguishing morphine from heroin-related deaths presented challenges, requiring analysis of clinical and investigative information in addition to toxicology results. One-quarter of the deaths attributed to morphine were recorded to heroin as a result of further investigation. There was also some underestimation of codeine-related deaths. Access to clinical and investigative information also yields important information in relation to comorbid conditions among these decedents, such as history of chronic pain, substance use issues and mental health problems. CONCLUSIONS: Reliance on toxicology results alone leads to an underestimate of heroin-related deaths. Differentiating between heroin and pharmaceutical opioid (e.g. morphine) overdose deaths has important public health and policy implications, particularly in relation to prescribing practices and development of a strategic response. Understanding comorbidities among these decedents is also important in efforts to reduce preventable causes of death such as opioid overdose.

Suicide among nursing home residents in Australia: A national population-based retrospective analysis of medico-legal death investigation information.

OBJECTIVES: Suicide among nursing home residents is a growing public health concern, currently lacking in empirical research. This study aims to describe the frequency and nature of suicide among nursing home residents in Australia. METHODS: This research comprised a national population-based retrospective analysis of suicide deaths among nursing home residents in Australia reported to the Coroner between July 2000 and December 2013. Cases were identified using the National Coronial Information System, and data collected from paper-based coroners' records on individual, incident, and organizational factors, as well as details of the medico-legal death investigation. Data analysis comprised univariate and bivariate descriptive statistical techniques; ecological analysis of incidence rates using population denominators; and comparison of age and sex of suicide cases to deaths from other causes using logistic regression. RESULTS: The study identified 141 suicides among nursing home residents, occurring at a rate of 0.02 deaths per 100 000 resident bed days. The ratio of deaths from suicide to deaths from any other cause was higher in males than females (OR = 3.56, 95%CI = 2.48-5.12, P = <0.001). Over half of the residents who died from suicide had a diagnosis of depression (n = 93, 66.0%) and had resided in the nursing home for less than 12 months (n = 71, 50.3%). Common major life stressors identified in suicide cases included the following: health deterioration (n = 112, 79.4%); isolation and loneliness (n = 60, 42.6%); and maladjustment to nursing home life (n = 42, 29.8%). CONCLUSIONS: This research provides a foundational understanding of suicide among nursing home residents in Australia and contributes important new information to the international knowledge base.

Unintentional mortality associated with paracetamol and codeine preparations, with and without doxylamine, in Australia.

INTRODUCTION: Misuse of paracetamol, codeine and doxylamine combination analgesics may lead to addiction and mortality. This study aimed to (1) identify unintentional deaths in Australia associated with use of combination analgesic products containing paracetamol, codeine and doxylamine; (2) describe cases characteristics, including demographics and additional medication use; and (3) identify common factors associated with misuse and mortality of these medicines in Australia. DESIGN: This retrospective case series analysed National Coronial Information System data to identify cases of unintentional death attributable to paracetamol, codeine and doxylamine products between 2002 and 2012. SETTING: Three Eastern Australian states: New South Wales, Queensland, Victoria, comprising a population of approximately 18.6 million people. RESULTS: 441 unintentional deaths attributed to paracetamol/codeine products were identified; doxylamine was detected in 102 cases (23%). Overall unintentional death rates rose from 0.9-per-million in 2002 to 3.6-per-million in 2009, declining to 1.9-per-million in 2012. Median age at time of death was 48, half of all cases occurred between 35-54 years of age, and 57% were female. Concomitant medication use was detected in 79% of cases, including benzodiazepines, other opioids, psychiatric medications, alcohol and illicit drugs. Behaviours consistent with drug misuse including doctor/pharmacy shopping, excessive dosages and extended use, were identified in 24% of cases. CONCLUSIONS: This study identified 441 deaths associated with codeine-combination analgesic products across three Australian states; with an average of 40 deaths per year. Death commonly involved multiple substance use and abuse behaviours indicative of misuse and dependence.

The attribution of a death to heroin: A model to help improve the consistent and transparent classification and reporting of heroin-related deaths.

INTRODUCTION: Accurate attribution of heroin-related deaths, as well as the differentiation from other opioid analgesic-related deaths, is essential from a public health perspective. Heroin-related deaths involve a number of complexities where heroin-specific or non-specific metabolites and indicators (6-acetylmorphine [6-AM], morphine, and codeine) may or may not be detected. The aims of this study were therefore to develop a model for improved consistency in the attribution of heroin-related deaths and to determine areas of variation in the current decision-making processes. METHODS: A model was developed using different toxicological indicators of heroin use (6-AM, morphine to codeine ratio (M:C) or morphine alone) along with investigative evidence of heroin use (circumstances, scene and clinical findings) which were used to assign a weighted score. The combined scores for the toxicological and investigative evidence were used to determine the relative strength of association for the death being attributable to heroin according to three categories: suspected; likely; or strong. An expert panel was convened to validate the model and a series of test cases were provided to a cohort of forensic toxicologists and pathologists in order to identify sources of variation in decision-making within this group. The model was also evaluated for sensitivity and specificity by reviewing potential heroin-related cases and examining the evidence associated with the attribution of these cases to heroin or not. RESULTS AND DISCUSSION: Across all potential heroin-related death cases, the use of this model enabled a greater level of consistency in the attribution of death to heroin, especially in cases where 6-AM was not detected. The largest amount of variation in the attribution of a death to heroin was observed with potential intoxication-related deaths and in toxicity cases where a M:C ratio only was reported, even more than when no toxicological evidence was available. The reviewed cases highlighted the same variation in the attribution of a death to heroin, including a large number of cases that were attributed to morphine where 6-AM was not detected. CONCLUSION: This model provides a useful tool for improved accuracy and consistency in the differentiation, attribution and reporting of heroin-related deaths. Previously challenging cases where death occurred after a significant period of time and either no 6-AM was detected or no samples were taken, are able to be captured using this model.

A Cluster of Fentanyl-Laced Heroin Deaths in 2015 in Melbourne, Australia.

The prevalence of opioid use in therapeutic and recreational settings has steadily increased throughout the western world. The addition of fentanyl into heroin products can produce potentially dangerous consequences, even to opioid tolerant individuals who may be unaware of such additions. Following an observed spike of heroin-fentanyl related deaths in Melbourne, Australia, a study was undertaken to determine the prevalence of these cases. All reportable deaths occurring in Victoria during 2015 and submitted to the toxicology laboratory were analysed using LC-MS-MS to confirm the combination of the heroin marker 6-acetylmorphine and/or morphine, and fentanyl. Over 4,000 coronial cases in 2015 underwent toxicological analysis for these drugs, there were nine cases identified that involved fentanyl-laced heroin. There was no specific mention of fentanyl use in any of these cases. All occurred within 2 months and in two distinct locations. The first four deaths occurred within 3 days of each other, in neighboring suburbs. The ages ranged from 25 to 57 years with an average of 40 and median of 37 years, and consisted of eight males and one female. The average and median femoral blood concentration of fentanyl was 18 and 20 ng/mL (range: <1-45 ng/mL), and morphine 140 and 80 ng/mL (range: 20-400 ng/mL), respectively. All nine cases had 6-acetylmorphine detectable in blood. Urine analysis was also performed where available. A syringe, powder and spoon found at the scene of one case were also analysed and found to be positive for both heroin and fentanyl, which supported the likelihood of fentanyl-laced heroin. This is the first reported case series of fatalities involving heroin and fentanyl outside of North America in published literature. These findings may help inform public health and prevention strategies serving to decrease the potential for such fatalities in the future.

Fatal acute poisonings in Australian children (2003-13).

BACKGROUND AND AIMS: Fatal poisonings in children comprise a small proportion of cases investigated by an Australian coroner; however, they present a major opportunity for death prevention. This study aimed to examine fatal child poisonings in Australia to (1) estimate the rate of acute poisoning deaths in children; (2) describe the key characteristics of the cohort; and (3) describe the outcomes of coronial recommendations made as a death prevention measure. DESIGN: Retrospective case series. SETTING: The National Coronial Information System (NCIS), a database of cases reported to an Australian coroner. PARTICIPANTS: Ninety poisoning deaths reported to an Australian coroner between January 2003 and December 2013 involving children (≤ 16 years of age). MEASURES: Logistic regression, Pearson's correlation coefficient and descriptive statistics were used to examine the significance of associations. The primary outcome measures were poisoning type and cause of death. Covariates included age and mental illness. FINDINGS: There were marginally more males (52.2%) [confidence interval (CI) = 44.4-45.6] in the cohort and most occurred in the 13-16-year age group (58.9%) (CI = 7.5-12.5). Deaths were typically unintentional (61.1%) (CI = 17.9-27.1) and occurred in the home (68.9%) (CI = 6.8-15.7). The most common form of poisoning was due to opioids (24.4%), followed by carbon monoxide (20%) and volatile substances (18.9%) (CI = 18.5-19.6). Males had slightly higher odds of dying from prescription opioids compared with females [odds ratio (OR) = 1.9, CI = 0.7-5.1], but this was not statistically significant. A recommendation was made by a coroner in 12 cases, 10 of which related to poisons (including drugs). Of these, eight recommendations were implemented. CONCLUSIONS: In Australia between 2003 and 2013 there were on average eight acute poisoning deaths in children each year, most commonly involving prescription opioids and adolescents. There has been a downward trend in mortality since 2003. These cases generated more than twice as many recommendations for public safety compared with other Australian coroners' cases.

Drug-caused deaths in Australian medical practitioners and health-care professionals.

BACKGROUND AND AIMS: There are numerous factors putting health-care professionals (HCP) at a higher risk of substance abuse and premature death, including high-stress jobs, access to controlled substances, long hours of practice and constant contact with the critically ill. This study aimed to examine fatal drug toxicity in this high-risk cohort, in order to: (1) estimate the rate of drug-caused deaths of Australian HCPs; (2) describe the key characteristics of the cohort; and (3) examine the relationship between HCP occupation and drug type, or intent. DESIGN: Retrospective cohort study. SETTING: The National Coronial Information System (NCIS), a database of cases reported to an Australian coroner. PARTICIPANTS: A total of 404 drug-caused deaths reported to an Australian coroner between 2003 and 2013 involving HCPs (including medical practitioners, paramedics, nurses, dentists, psychologists, pharmacists and veterinarians). MEASURES: χ2 tests and descriptive statistics were used to examine relationships. The primary outcome measures were drug type and intent. Covariates included occupation type, mental illness and self-harm. FINDINGS: Females comprised nearly two-thirds of the cohort. The highest number of cases involved nurses (62.87%) and medical practitioners (18.07%). The mortality rate was highest among the veterinary group [confidence interval (CI) = 42.21-58.79]. Most were intentional self-harm deaths (50.25%), followed by unintentional deaths (37.62%) (CI = 92.15-109.85). Mental illness was common, diagnosed in almost half of cases (46.04%), with the majority involving depression (CI = 33.48-44.12). Specific drugs were associated significantly with certain professions, such as intravenous barbiturates among veterinarians (χ2(7)  = 237.391). A number of cases reported additional stressors, such as relationship, work-place or financial issues, and drugs were diverted from the work-place in nearly a fifth of cases. CONCLUSIONS: Between 2003 and 2013, Australian health-care professionals averaged 37 deaths per year attributed to drug toxicity, with a mortality rate of nearly five deaths per 1000 employed HCPs. Drug-caused deaths among HCPs in Australia commonly involve females in their mid-40s, with a diagnosis of mental illness, personal and professional stress and the intent to self-harm.

An update on oxycodone: lessons for death investigators in Australia.

Oxycodone is one of the most abused prescription drugs. Iatrogenic factors that lead to oxycodone-related death, such as mis-prescribing, present an opportunity for death prevention if identified early. This study investigated deaths involving oxycodone in Australia to explore potentially inappropriate prescribing and the coroner's investigation. The National Coronial Information System identified cases from 2001 to 2011 where oxycodone was detected by toxicological analysis. There were 806 oxycodone-related deaths, with a significant increase in the 11-year period, from 21 deaths in 2001, up almost sevenfold in 2011 (139 deaths). Most deaths were caused by combined drug toxicity (63.4%) or oxycodone toxicity alone (11.8%). Most individuals were male (59.1%), aged 35-44 years (26.7%), who died unintentionally (56.4%), with mental illness (52.1%) and/or a history of acute or chronic pain (46.2%). 312 cases (39%) described a legitimate prescription for oxycodone, of which most involved non-cancer related chronic pain. About three quarters of the indications were deemed appropriate. There were at least 43 different indications treated with oxycodone that were inappropriate. The majority of oxycodone-related cases involved minor to no description of the drugs involved (n = 600; 74.4%). A moderate description of oxycodone involvement was given in 162 cases (20.1%), while only 44 cases (5.5%) involved a thorough examination and recommendations from the coroners on oxycodone and other drugs involved in death. This study emphasized the need for medical practitioners to exercise caution when prescribing oxycodone and for coroners to provide more consistent and detailed information regarding drug use, in order to identify and implement preventive strategies.

The prevalence of duloxetine in medico-legal death investigations in Victoria, Australia (2009-2012).

The drug duloxetine (Cymbalta(®)) is a newer antidepressant which has been available in Australia since 2008. Duloxetine is a serotonin and noradrenaline reuptake inhibitor (SNRI), which is associated with adverse effects in the first 6 weeks of therapy, including tachycardia and worsening symptoms in people with advanced heart failure. It is also associated with serotonin toxicity in combination with certain drugs. Few reports have been published in the toxicology literature regarding duloxetine and its prevalence in coroners' cases. This study documents the prevalence of duloxetine in coronial cases between 2009 and 2012 and seeks to better understand the role of duloxetine in deaths where concomitant use with other drugs may cause adverse outcomes. Duloxetine was analyzed in blood specimens taken for the purpose of assisting the pathologist in determining a cause of death and analyzed using a validated LC-MS/MS method employed for overnight screening. There were 34 cases where duloxetine was detected of which 19 were attributed to drug toxicity. The median femoral blood concentration in the cohort was 0.14 mg/L (range 0.01-1.42 mg/L). Many deaths involved the concomitant use of numerous other medications; up to 13 other drugs were co-detected in a case. Over half of the deaths were attributed to fatal combined drug toxicity. SSRIs and venlafaxine that may have increased the risk of serotonin toxicity in combination with duloxetine were detected in five cases. Metoclopramide, contraindicated with duloxetine use, was detected in two cases. NSAIDs (n=11), antipsychotics (n=15) and benzodiazepines (n=14) were also commonly co-detected. Heart disease was observed in over 40% of the cohort, mostly in the form of coronary artery disease or cardiomegaly. Death involving duloxetine alone was uncommon (n=4); however with certain comorbidities and co-administered drugs, the risk of a fatal event is increased, particularly in the setting of other pro-serotonergic agents. In deaths where duloxetine is detected and the cause of death is believed to be natural or unascertained, it is essential that other serotonin drugs or inappropriate drug combinations be examined for their possible contribution to death.

The toxicology and comorbidities of fatal cases involving quetiapine.

The use of quetiapine in Australia has increased rapidly in recent years. Anecdotal and post-marketing surveillance reports indicate an increase in quetiapine misuse in prisons as well as an increase in its availability on the black-market. This study examined a cohort of quetiapine-associated deaths occurring in Victoria, Australia, between 2001 and 2009, to determine the prevalence of deaths associated with this drug and to determine whether misuse represents a legitimate concern. Case details were extracted from the National Coronial Information System. There were 224 cases with an average age of 43 years of age (range 15-87 years). The cause of death was mostly drug toxicity (n = 114, 51 %), followed by natural disease (n = 60, 27 %), external injury (n = 31, 14 %) and unascertained causes (n = 19, 8 %). Depression and/or anxiety were common, observed in over a third of the cohort (80 cases, 36 %). About 20 % of cases did not mention a psychiatric diagnosis at all which raises the question of whether quetiapine had been prescribed correctly in these cases. Cardiovascular disease was the most commonly reported illness after mental disease. Quetiapine ranged in concentration from the limit of reporting (0.01 mg/L) to 110 mg/L. The median concentration of quetiapine was much lower in the natural disease deaths (0.25 mg/L) compared with drug caused deaths (0.7 mg/L). The most commonly co-administered drug was diazepam in 81 (36 %) cases. There were a small number of cases where quetiapine contributed to a death where it had not apparently been prescribed, including the death of a 15 year old boy and one of a 34 year old female. Overall, misuse of quetiapine did not appear to be a significant issue in this cohort; use of the drug only occasionally led to fatalities when used in excess or concomitantly with interacting drugs. However, considering that it is a recent social concern, it is possible that analysis of cases post 2009 would reveal more cases of quetiapine abuse. Close monitoring of quetiapine is therefore advised to prevent adverse outcomes, particularly in vulnerable populations such as substance abusers.

A review of methadone deaths between 2001 and 2005 in Victoria, Australia.

This study examined methadone-associated deaths reported to the Coroner in Victoria, Australia, between 2001 and 2005. There were 206 deaths involving methadone, attributed predominantly to drug toxicity (137 cases), in addition to natural disease (24 cases), external injuries (44 cases) and one case where the cause was unascertained. The number of deaths each year did not rise significantly. There were 38 cases involving Physeptone(®) for chronic pain, 36 cases (14%) that were regarded as diversion deaths and 9 cases where the source of methadone was unknown. The remainder involved patients in opioid replacement therapy. Diversion deaths were signified by the unprescribed use of methadone by an individual not possessing a valid permit from the Victorian Department of Health. In these cases, the Coroner also described illicit use of the drug in the findings. Fifty-one individuals (25%; 15 female and 36 males) died within 14 days of commencing opioid replacement therapy with methadone administered via syrup. Many of these cases involved rapid dose increases of up to 25mg per day. The median starting dose was 35 mg and the median (mean; range) blood methadone concentration was 0.5mg/L (0.6 mg/L; 0.1-3.0mg/L). A number of cases were identified as having too high a starting dose, with 44% starting on 40 mg or more. The OD4-methadone index indicated a substantial increase in relative methadone toxicity from around 28 per million DDDs in the early 1990 s to over 60 in 2005. Ninety-eight percent of cases involved the use of other CNS depressants including: opioids, antidepressants, antipsychotics and ethanol, with benzodiazepines most common (88% confirmed positive). Improvements in the management of ORT, particularly in the induction period, has the potential to reduce mortality of patients receiving methadone.