An illicit drug early warning system utilising comprehensive toxicological analysis of emergency department presentations in Victoria, Australia

ABSTRACT

Objective: In response to the evolving threat of illicit drug use, combined with anticipated SARS-CoV-2 (COVID-19) pandemicrelated market volatility, we created a multi-institution network supplying high-quality data on illicit drug presentations to Victorian emergency departments (EDs). Primary objective: timely data provision to a state Early Warning System (EWS) utilising multiple intelligence sources (including syringe residue and wastewater analysis) to inform public health interventions. Methods: The Emerging Drugs Network of Australia VIC (EDNAV) project is a multi-site prospective observational study collating de-identified clinical and analytical information within an electronic clinical registry (Research Electronic Data Capture secure web-based software platform). Case inclusion criteria individuals ≥16 years of age presenting with suspected illicit drug toxicity requiring venepuncture as part of standard care. Hospital ethics committee approved waiver of patient consent for inclusion of deidentified data. Nine metropolitan and one regional ED contributed blood samples for weekly toxicological analysis at the Victorian Institute of Forensic Medicine. Liquid chromatographytandem mass spectrometry (LC-MS/MS) screened for 327 pharmaceuticals and illicit substances, as well as 268 novel psychoactive substances. EDNAV data was reviewed weekly as a component of the state EWS. High-risk signals were disseminated to government and external stakeholders. Results: During September 2020 - March 2021, 320 cases were analysed (70% male, mean age 30 years, 72% ambulance arrival). Sedation (Glasgow Coma Score (GCS)<9, 35%) and agitation (33%) were the commonest reasons for presentation;33% of patients required parenteral sedation, and 18% were administered naloxone. In addition, 8% were intubated and 11% required critical care admission;85% had a Poisoning Severity Score of ≥2. There were two deaths. There were 815 separate detections (345 illicit substances, 470 pharmaceuticals). At least one illicit drug was detected in 87% of cases (> 1 illicit drug in 43%). Common illicit drugs included methylamphetamine (52% of cases), gamma-hydroxybutyrate (GHB), 3,4-methylenedioxymethamphetamine (MDMA), cocaine and opioids. Eight novel benzodiazepines, 7 cathinones, 5 hallucinogens, 3 synthetic cannabinoid receptor agonists (SCRAs) and one novel opioid (Beta-U10) were detected. In 90% of cases, reported exposure differed from analytical findings. During COVID-19 related lockdowns, there was evidence of substance substitution including benzodiazepines in products sold as heroin. Three public health warnings were released in association with EDNAV findings (Nethylpentylone in cocaine, 25B-NBOH sold as lysergic acid diethylamide (LSD), paramethoxymethamphetamine (PMMA) sold as MDMA). Conclusion: For the first time in Victoria, a network of healthcare institutions working together enabled timely detection of illicit drug related harm, facilitating early public health warnings and notification of peer-based harm reduction services.