Identification of three unexpected new psychoactive substances at an Australian drug checking service.

Drug checking is a harm reduction measure that provides people with the opportunity to confirm the identity and purity of substances before consumption. The CanTEST Health and Drug Checking Service is Australia's first fixed-site drug checking service, where clients can learn about the contents of the samples they provide while receiving tailored harm reduction and health advice. Three samples were recently presented to the service with the expectation of 4-fluoromethylphenidate (4F-MPH) 1, methoxetamine (MXE) 2 and 3-methylmethcathinone (3-MMC) 3. The identity of all three samples did not meet these expectations and remained unknown on-site, as no high confidence identifications were obtained. However, further analysis by nuclear magnetic resonance spectroscopy, high resolution gas chromatography-electron ionisation-mass spectrometry and liquid chromatography-electrospray ionisation-mass spectrometry at the nearby Australian National University allowed for the structure elucidation of the three samples as 4-fluoro-α-pyrrolidinoisohexanophenone (4F-α-PiHP) 4, 1-(4-fluorobenzyl)-4-methylpiperazine (4F-MBZP) 5 and N-propyl-1,2-diphenylethylamine (propylphenidine) 6, respectively. Given all three samples were not of the expected identity and have not yet been described as new psychoactive substances in the literature, this study presents a full characterisation of each compound. As exemplified by this rapid identification of three unexpected new psychoactive substances, drug checking can be used as an effective method to monitor the unregulated drug market.

A step change model analysis of the establishment of pill testing in one Australian jurisdiction.

This paper applies the theory of change model (Kotter in Harv Bus Rev 2:59-67, 1995; Moore et al. in Viet Nam J Public Health 1(1):66-75, 2013) to describe the pathway that lead to Australia's first pill testing/drug checking services in Canberra, in the Australian Capital Territory. The paper takes each step of the model and illustrates the key activities that largely occurred over an approximately 24 month period resulting in the service being operational on 29 April 2018. The paper demonstrates that leadership, advocacy and activism are key components, alongside evidence, to bringing about public policy change. It provides a unique insight to the extensive efforts undertaken to achieving the first legally sanctioned pill testing at festivals in Australia and provides a positive case study for those seeking to introduce contested harm reduction services in the drug and alcohol field.

Most common principal diagnoses assigned to Australian emergency department presentations involving alcohol use: a multi-centre study.

OBJECTIVES: Alcohol is the most widely consumed psychoactive substance in Australia and the consequences of alcohol consumption have enormous personal and social impacts. This study aimed to describe the principal diagnoses of emergency department (ED) presentations involving alcohol use in the previous 12 hours at eight hospitals in Victoria and the Australian Capital Territory, Australia. METHODS: Twelve months' data (1 July 2018 - 30 June 2019) were collected from eight EDs, including demographics, ICD-10 codes, hospital location and self-reported drinking in the preceding 12 hours. The ten most common ICD-10 discharge codes were analysed based on age, sex and hospital geographic area. RESULTS: ICD codes pertaining to mental and behavioural disorders due to alcohol use accounted for the highest proportion in most EDs. Suicide ideation/attempt was in the five highest ICD codes for all but one hospital. It was the second most common alcohol-related presentation for both males and females. CONCLUSIONS: Alcohol plays a major role in a range of presentations, especially in relation to mental health and suicide. IMPLICATIONS FOR PUBLIC HEALTH: The collection of alcohol involvement in ED presentations represents a major step forward in informing the community about the burden of alcohol on their health resources.

Driving change: A partnership study protocol using shared emergency department data to reduce alcohol-related harm.

BACKGROUND: Sharing anonymised ED data with community agencies to reduce alcohol-related injury and assaults has been found effective in the UK. This protocol document outlines the design of an Australian multi-site trial using shared, anonymised ED data to reduce alcohol-related harm. DESIGN AND METHOD: Nine hospitals will participate in a 36 month stepped-wedge cluster randomised trial. After a 9 month baseline period, EDs will be randomised in five groups, clustered on geographic proximity, to commence the intervention at 3 monthly intervals. 'Last-drinks' data regarding alcohol use in the preceding 12 h, typical alcohol consumption amount, and location of alcohol purchase and consumption, are to be prospectively collected by ED triage nurses and clinicians at all nine EDs as a part of standard clinical process. Brief information flyers will be delivered to all ED patients who self-report risky alcohol consumption. Public Health Interventions to be conducted are: (i) information sharing with venues (via letter), and (ii) with police and other community agencies, and (iii) the option for public release of 'Top 5' venue lists. OUTCOMES: Primary outcomes will be: (i) the number and proportion of ED attendances among patients reporting recent alcohol use; and (ii) the number and proportion of ED attendances during high-alcohol hours (Friday and Saturday nights, 20.00-06.00 hours) assigned an injury diagnosis. Process measures will assess logistical and feasibility concerns, and clinical impacts of implementing this systems-change model in an Australian context. An economic cost-benefit analysis will evaluate the economic impact, or return on investment.

An Effective Risk Minimization Strategy Applied to an Outdoor Music Festival: A Multi-Agency Approach.

Specific Event Identifiers a. Event type: Outdoor music festival. b. Event onset date: December 3, 2016. c. Location of event: Regatta Point, Commonwealth Park. d. Geographical coordinates: Canberra, Australian Capital Territory (ACT), Australia (-35.289002, 149.131957, 600m). e. Dates and times of observation in latitude, longitude, and elevation: December 3, 2016, 11:00-23:00. f. Response type: Event medical support. Abstract Introduction Young adult patrons are vulnerable to risk-taking behavior, including drug taking, at outdoor music festivals. Therefore, the aim of this field report is to discuss the on-site medical response during a music festival, and subsequently highlight observed strategies aimed at minimizing substance abuse harm. METHOD: The observed outdoor music festival was held in Canberra (Australian Capital Territory [ACT], Australia) during the early summer of 2016, with an attendance of 23,008 patrons. First aid and on-site medical treatment data were gained from the relevant treatment area and service. RESULTS: The integrated first aid service provided support to 292 patients. Final analysis consisted of 286 patients' records, with 119 (41.6%) males and 167 (58.4%) females. Results from this report indicated that drug intoxication was an observed event issue, with 15 (5.1%) treated on site and 13 emergency department (ED) presentations, primarily related to trauma or medical conditions requiring further diagnostics. CONCLUSION: This report details an important public health need, which could be met by providing a coordinated approach, including a robust on-site medical service, accepting intrinsic risk-taking behavior. This may include on-site drug-checking, providing reliable information on drug content with associated education. Luther M , Gardiner F , Lenson S , Caldicott D , Harris R , Sabet R , Malloy M , Perkins J . An effective risk minimization strategy applied to an outdoor music festival: a multi-agency approach. Prehosp Disaster Med. 2018;33(2):220-224.

Prehospital ketamine use by paramedics in the Australian Capital Territory: A 12 month retrospective analysis.

OBJECTIVE: The aim of this study was to describe prehospital use of ketamine by ACT Ambulance Service, and frequency of endotracheal intubation. METHODS: This was a retrospective study of patients receiving prehospital ketamine between 1 January and 31 December 2013. Episodes were identified from the prehospital electronic patient care records, then linkage to ED records at two receiving hospitals. Demographics, dose, indication and occasions of intubation were analysed. RESULTS: A total of 163 episodes were identified; 10 of these were excluded because of lack of identifying data or missing records (age 1-97 years [mean: 43, standard deviation: 21.7], 56% men). Median total dose was 60 mg (interquartile range 70; 5-400 mg) in three doses (interquartile range 3; 1-14 mg). For patients with a weight recorded (63%), median dose was 0.73 mg/kg. Indications were analgesia 68%, agitation/combative 25%, rapid sequence intubation 5% and others 2%. A total of 26 patients were endotracheally intubated, 11 prehospital (seven as an intended rapid sequence intubation and four combative patients with return of spontaneous circulation) and 15 in the ED. Of ED intubations, 10 were trauma patients and five were drug ingestion related. Patients receiving ketamine for combativeness were more likely to be intubated than those receiving it for analgesia (25 vs 7.2%; odds ratio: 3.46; 95% confidence interval: 1.12, 10.71). In those with a weight recorded, the mg/kg dose was not associated with subsequent intubation. CONCLUSIONS: Median dose for analgesia was comparable with other studies; dose for sedation was less than reported elsewhere. Intubation rate for patients receiving prehospital ketamine was 17%. Further study is recommended to assess the ED course of the non-intubated group of patients, and consideration should be given to non-weight-based methods of dose selection.

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.

Hot of Not: Physiological versus Meteorological Heatwaves-Support for a Mean Temperature Threshold.

The aim of this study was to determine whether a revised heat warning threshold provides an enhanced predictive tool for increases in Emergency Department heat-related presentations in Canberra, Australia. All Emergency Department triage records containing the word "heat", as well as those diagnosing a heat related illness for the summer periods 2013/2014, 2014/2015, and 2015/2016 were searched. Then a medical record review was conducted to confirm that the patient's presentation was related to environmental heat, which was defined by the final clinical diagnosis, presentation complaint and details of the patient's treatment. Researchers then compared this presentation data, to a mean threshold formula. The mean threshold formula included the past three consecutive daily mean temperatures and the last measured temperature upon presentation. This formula was designed to take into account the variance of night-time lows, with concurrent daily ambient temperatures, and was used to determine whether there was a correlation between heat-related presentations and increasing mean temperatures. Heat-related presentations appeared to occur when the mean threshold temperature reached 25 °C (77 °F), with significant increases when the mean threshold reached 30 °C (86 °F). These results confirm that a mean temperature of 30 °C corresponds to a relevant local public health heat-related threat.

A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment.

CONTEXT: Synthetic cannabinoids (SCs) such as "Spice", "K2", etc. are widely available via the internet despite increasing legal restrictions. Currently, the prevalence of use is typically low in the general community (<1%) although it is higher among students and some niche groups subject to drug testing. Early evidence suggests that adverse outcomes associated with the use of SCs may be more prevalent and severe than those arising from cannabis consumption. OBJECTIVES: To identify systematically the scientific reports of adverse events associated with the consumption of SCs in the medical literature and poison centre data. METHOD: We searched online databases (Medline, PsycInfo, Embase, Google Scholar and Pubmed) and manually searched reference lists up to December 2014. To be eligible for inclusion, data had to be from hospital, emergency department, drug rehabilitation services or poison centre records of adverse events involving SCs and included both self-reported and/or analytically confirmed consumption. RESULTS: From 256 reports, we identified 106 eligible studies including 37 conference abstracts on about 4000 cases involving at least 26 deaths. Major complications include cardiovascular events (myocardial infarction, ischemic stroke and emboli), acute kidney injury (AKI), generalized tonic-clonic seizures, psychiatric presentations (including first episode psychosis, paranoia, self-harm/suicide ideation) and hyperemesis. However, most presentations were not serious, typically involved young males with tachycardia (≈ 37-77%), agitation (≈ 16-41%) and nausea (≈ 13-94%) requiring only symptomatic care with a length of stay of less than 8 hours. CONCLUSIONS: SCs most frequently result in tachycardia, agitation and nausea. These symptoms typically resolve with symptomatic care, including intravenous fluids, benzodiazepines and anti-emetics, and may not require inpatient care. Severe adverse events (stroke, seizure, myocardial infarction, rhabdomyolysis, AKI, psychosis and hyperemesis) and associated deaths manifest less commonly. Precise estimates of their incidence are difficult to calculate due to the lack of widely available, rapid laboratory confirmation, the variety of SC compounds and the unknown number of exposed individuals. Long-term consequences of SCs use are currently unknown.

Chemical analysis of four capsules containing the controlled substance analogues 4-methylmethcathinone, 2-fluoromethamphetamine, alpha-phthalimidopropiophenone and N-ethylcathinone.

In August 2007, four capsules containing white powders, said to have originated from an Israel-based Internet company "Neorganics", were anonymously delivered to the Royal Adelaide Hospital, South Australia. The capsules were analysed and the active components were identified including 4-methylmethcathinone, 2-fluoromethamphetamine, alpha-phthalimidopropiophenone and N-ethylcathinone, all of which were unlisted within South Australian controlled substance regulations. We examined the relevant scientific literature surrounding these chemicals and present both GCMS and NMR data for 4-methylmethcathinone and alpha-phthalimidopropiophenone, which have previously received little attention. We also present the vapour- and condensed-phase infrared spectra (IR) of 4-methylmethcathinone as these have also not been reported in the literature previously. We discuss the issues surrounding whether these chemicals can be classified as controlled substance analogues and the likely impact this could have on prosecutions of individuals distributing these products.

Terror Australis 2004: preparedness of Australian hospitals for disasters and incidents involving chemical, biological and radiological agents.

OBJECTIVE: To assess the level of preparedness of Australian hospitals, as perceived by senior emergency department physicians, for chemical, biological and radiological (CBR) incidents, as well as the resources and training available to their departments. METHODS: Detailed questionnaires were mailed to the directors of the 86 hospital emergency departments (EDs) in Australia accredited by the Australasian College for Emergency Medicine. Questions covered hospital planning, available resources and training, and perceived preparedness. RESULTS: Responses were received from 76 departments (88%): 73 reported that their ED had a disaster plan, with 60 (79%) having a contingency plan for chemical, 57 (75%) for biological, and 53 (70%) for radiological incidents. Specific staff training for managing patients from a conventional mass casualty incident was given in 83% of EDs, falling to 66% for a CBR incident. Forty-three per cent reported that their plan involved staff managing contaminated patients, but availability of personal protective equipment and decontamination facilities varied widely. Although 41% believed their ED could cope with a maximum of 20 patients in the first 2 hours after a conventional incident, this increased to 71% for a CBR incident. Staff training was considered the main funding priority (59%). CONCLUSIONS: This survey raises significant questions about the level of preparedness of Australian EDs for dealing with patients from both conventional and CBR incidents. Hospitals need to review their plans and functionality openly and objectively to ensure that their perceived preparedness is consistent with reality. In addition, they urgently require guidance as to reasonable expectations of their capacity. To that end, we recommend further development of national standards in hospital disaster planning and preparedness.

Methaemoglobinaemia: an explosive case.

Methaemoglobinaemia is an important perturbation to recognise, as untreated it may cause severe tissue hypoxia and cell death. We describe a case of methaemoglobinaemia acquired in an unusual manner, during an explosion at an explosives manufacturing plant.

Truth hurts--hard lessons from Australia's largest mass casualty exercise with contaminated patients.

In response to the increasing threat of a mass casualty incident involving chemical, biological or radiological agents, and concern over the preparedness of our hospital system to cope with patients from such an incident, we conducted the largest hospital-based field exercise involving contaminated patients that has been held in Australia. In the present paper, we outline the background to, and methodology of, Exercise Supreme Truth, and the efforts made to increase its realism. We focus our discussion on three issues highlighted by the exercise, which we believe have enormous implications for the development of hospital chemical, biological or radiological plans and the likelihood of their success--hospital security, crowd control and decontamination.