Drug and alcohol intoxication in major trauma: Associations, trends and outcomes over a decade.

OBJECTIVES: Drug and alcohol intoxication is common among injured patients altering trauma presentation and characteristics. However, uncertainty exists regarding the effect of intoxication on injury severity, as well as outcomes. The present study aims to provide an update on substance-use patterns and their association with traumatic presentation and outcome within a contemporary Australian context. METHODS: All major trauma patients captured in our centre's Trauma Registry between July 2010 and June 2020 were included. Demographic, injury characteristic, outcome and substance-use data were collected. Differences in injury severity and characteristics were explored using χ2 tests, while outcomes were modelled using adjusted binomial logistic regression. RESULTS: Among 9700 patients, 9% were drug-intoxicated prior to injury, while 9.4% were alcohol-intoxicated. Drug use almost tripled between 2010 (4.8%) and 2020 (13.3%), while alcohol intoxication fell, from 11.7% to 7.3%, over the same period. Although there were significant differences in trauma mechanism among intoxicated patients, group comparison found no difference in Injury Severity Score for any group. Regarding outcomes, all intoxication resulted in significantly greater odds (odds ratio 1.62-2.41) of ICU admission. No difference in mortality was found among individual substance-use groups; however, polysubstance-intoxicated patients had 3.52 times greater odds of dying (95% confidence interval 1.21-10.23) compared to non-intoxicated patients. CONCLUSION: Within this contemporary Australian population, we demonstrate escalating rates of drug intoxication and declining rates of alcohol intoxication prior to trauma. Intoxication was associated with more frequent violent and non-accidental injury, and despite no difference in severity, it was associated with worse outcomes.

Monitoring for fentanyl within Australian supervised injecting facilities: Findings from feasibility testing of novel methods and collaborative workshops.

BACKGROUND: Australia is yet to see widespread fentanyl-contaminated heroin, despite the established presence of fentanyl in other countries. International mortality trends alongside a local cluster of fentanyl-related deaths prompted interest in developing methods to monitor for fentanyl and other potentially harmful novel psychoactive substances (NPS) in Australia. METHODS: We tested novel methods to monitor for fentanyl and other NPS. From 2017-2021, clients from supervised injecting facilities (SIFs) in Melbourne and Sydney, Australia, contributed urine screens (UDS) with BTNX Rapid Response™ fentanyl test strips (FTS) paired with surveys, and injecting equipment associated with opioid overdoses for laboratory analysis. A single site piloted drug checking using FTS with laboratory confirmation. Two workshops were conducted with SIF staff, content experts and people with lived experience to determine how results can inform practices within SIFs. RESULTS: Of the 911 UDS with FTS conducted, less than 1% (n=8) yielded positive results that were not explained by self-reported pharmaceutical fentanyl use, with two laboratory confirmed fentanyl positive results. Injecting equipment from 59 overdoses was tested and neither fentanyl nor other NPS were identified. Drug checking with FTS (n=34) indicated the presence of fentanyl on three tests. Two specimens were subsequently sent for laboratory testing and classified as false positives as the presence of fentanyl was not confirmed. Workshop participants (n=21) felt routine monitoring with FTS currently had limited value. A process for using pre-defined signals to trigger surveillance was developed. CONCLUSION: The high false positive rates with FTS, relative to the small number of positive results and potential for them to undermine confidence in FTS emphasised the need for confirmatory testing. The role of routine surveillance was unclear within the current low-fentanyl context, however, a process was developed to upscale testing should signals of increased fentanyl prevalence in the Australian heroin market emerge.

Eliminating hepatitis C in Australia: a novel model of hepatitis C testing and treatment for people who inject drugs at a medically supervised injecting facility.

OBJECTIVE: To evaluate the feasibility of testing and treating people who inject drugs at a supervised injecting facility for hepatitis C virus (HCV) infection. DESIGN: Retrospective cohort study. SETTING, PARTICIPANTS: People who inject drugs who attended the Melbourne supervised injecting facility, 30 June 2018 - 30 June 2020. MAIN OUTCOME MEASURES: Proportion of people tested for hepatitis C; proportions of people positive for anti-HCV antibody and HCV RNA, and of eligible people prescribed direct-acting antiviral (DAA) treatment; sustained virological response twelve weeks or more after treatment completion. RESULTS: Of 4649 people who attended the supervised injecting facility during 2018-20, 321 were tested for hepatitis C (7%); 279 were anti-HCV antibody-positive (87%), of whom 143 (51%) were also HCV RNA-positive. Sixty-four of 321 had previously been treated for hepatitis C (20%), 21 had clinically identified cirrhosis (7%), eight had hepatitis B infections (2%), and four had human immunodeficiency virus infections (1%). In multivariate analyses, people tested for hepatitis C were more likely than untested clients to report psychiatric illness (adjusted odds ratio [aOR], 9.65; 95% confidence interval [CI], 7.26-12.8), not have a fixed address (aOR, 1.59; 95% CI, 1.18-2.14), and to report significant alcohol use (aOR, 1.57; 95% CI, 1.06-2.32). The median number of injecting facility visits was larger for those tested for hepatitis C (101; interquartile range [IQR], 31-236) than for those not tested (20; IQR, 3-90). DAA treatment was prescribed for 126 of 143 HCV RNA-positive clients (88%); 41 of 54 with complete follow-up data were cured (76%). CONCLUSIONS: People who attend supervised injecting facilities can be tested and treated for hepatitis C on site. Models that provide streamlined, convenient hepatitis C care promote engagement with treatment in a group in which the prevalence of hepatitis C is high.

Infrequent detection of unintentional fentanyl use via urinalysis among people who regularly inject opioids in Sydney and Melbourne, Australia.

BACKGROUND AND AIM: The current phase of the North American 'opioid crisis' is characterised by illicit fentanyl use; however, the presence of illicit fentanyl in Australia is unknown. This study aimed to monitor unintentional fentanyl consumption in Australia. DESIGN: Rapid urine drug screens (UDS) paired with surveys conducted within supervised injecting facilities (SIFs) and confirmatory laboratory testing. SETTING: Sydney and Melbourne, Australia. PARTICIPANTS: Clients who used heroin within the past 2 days (n = 911 tests, 2017-2021). Participants were demographically similar to the overall client base (median age 43, 72% male). MEASUREMENTS: UDS were conducted using BTNX Rapid Response fentanyl urine strip tests with cross-reactivity to numerous fentanyl analogues. Positive urine samples were analysed using liquid chromatography coupled with tandem mass spectrometry. Surveys covered past 3 day drug use and lifetime report of fentanyl in heroin. FINDINGS: Two percent of participants reported intentional use of fentanyl, mostly through fentanyl patches. Of the 911 rapid UDS conducted, 17 (1.9%) yielded positive results. Eight of these (all from Melbourne) were not explained by survey-reported fentanyl use in the past 3 days. Of these 8 unexplained positives, confirmatory laboratory analysis was conducted on 6, with 4 deemed to be false positives, and 2 confirmed for the presence of fentanyl. This represents the first confirmation of unintended use of fentanyl type substances in this population. CONCLUSION: There is limited evidence of unintentional fentanyl use among people in Sydney and Melbourne, Australia who regularly inject heroin, suggesting that, currently, there is very little illicit fentanyl in Australian drug markets accessed by supervised injecting facilities attendees. This study demonstrates the feasibility of quick onsite testing to cost-effectively screen large samples for fentanyl; however, the high false positive rate emphasises the need for confirmation of positive tests through advanced analytical techniques.

Adapting harm reduction services during COVID-19: lessons from the supervised injecting facilities in Australia.

The COVID-19 crisis has had profound impacts on health service provision, particularly those providing client facing services. Supervised injecting facilities and drug consumption rooms across the world have been particularly challenged during the pandemic, as have their client group-people who consume drugs. Several services across Europe and North America closed due to difficulties complying with physical distancing requirements. In contrast, the two supervised injecting facilities in Australia (the Uniting Medically Supervised Injecting Centre-MSIC-in Sydney and the North Richmond Community Health Medically Supervised Injecting Room-MSIR-in Melbourne) remained open (as at the time of writing-December 2020). Both services have implemented a comprehensive range of strategies to continue providing safer injecting spaces as well as communicating crucial health information and facilitating access to ancillary services (such as accommodation) and drug treatment for their clients. This paper documents these strategies and the challenges both services are facing during the pandemic. Remaining open poses potential risks relating to COVID-19 transmission for both staff and clients. However, given the harms associated with closing these services, which include the potential loss of life from injecting in unsafe/unsupervised environments, the public and individual health benefits of remaining open are greater. Both services are deemed 'essential health services', and their continued operation has important benefits for people who inject drugs in Sydney and Melbourne.

What data are available on the extent of illicit drug use and dependence globally? Results of four systematic reviews.

BACKGROUND: We systematically reviewed availability and quality of data on the prevalence of use and dependence on meth/amphetamine, cannabis, cocaine and opioids. METHODS: Multiple search strategies: (a) peer-reviewed literature searches (1990-2008) using methods recommended by the Meta-analysis of Observational Studies in Epidemiology (MOOSE) group; (b) systematic searches of online databases; (c) Internet searches to find other published evidence of drug use; (d) repeated consultation and feedback from experts around the globe; (e) a viral email sent to lists of researchers in the illicit drug and HIV fields. Data were extracted and graded according to predefined variables reflecting quality of data source. RESULTS: Qualitative evidence of illicit drug use and dependence was found for most countries, which hold over 98% of the world's population aged 15-64 years. Countries where use was identified but prevalence estimates had not been made (evidence of drug supply, trafficking, reports of use, treatment data) were mainly from Asia, Africa, the Middle East, and Oceania. Estimates of the prevalence of use were located in 77 countries for meth/amphetamine, 95 for cannabis, 86 for cocaine and 89 for opioids. Dependence prevalence estimates existed in very few countries; 9 meth/amphetamine dependence estimates, 7 cannabis dependence estimates, 5 cocaine dependence estimates, and 25 opioid dependence estimates were located. CONCLUSIONS: Data on the extent of meth/amphetamine, cannabis, cocaine and opioid use and dependence must be improved in quality and coverage. Dependence estimates are lacking even in high income countries that have required resources. Responses to illicit drug dependence require better estimates of its scale.