Characteristics and circumstances of death related to new psychoactive stimulants and hallucinogens in Australia

A retrospective study of the characteristics and toxicology of cases of lysergic acid diethylamide (LSD)- and psilocybin-related death in Australia

BACKGROUND AND AIMS

Lysergic acid diethylamide (LSD) and psilocybin are used as recreational drugs, and there is renewed interest in their clinical use. The current study aimed to (1) determine the circumstances of death and case characteristics of LSD- and psilocybin-related death in Australia, 2000-23; and (2) determine the toxicological profile and major autopsy findings of these cases.

METHODS

This was a retrospective exploratory study of all cases of LSD- and psilocybin-related death in Australia, 2000-23, retrieved from the National Coronial Information System.

RESULTS

A total of 43 cases were identified: 33 LSD and 10 psilocybin. The median ages were 24 years [interquartile range (IQR) = 13, range = 16-53] (LSD) and 26 years (IQR = 18.5, range = 20-58) (psilocybin), and fewer than five cases were female. The most common circumstance of death among both groups was traumatic accident (LSD 36.4%, psilocybin 40.0%). There were 12 cases of self-harm, all of which involved LSD, all by physical means. In a fifth, death was attributed to multiple drug toxicity (LSD 18.2%, psilocybin 20.0%). In one case, death was attributed solely to LSD toxicity, while in a further two cases death was attributed to a cardiovascular event following LSD consumption (one LSD only, one multiple drug toxicity). In four psilocybin cases, the cause of death was undetermined. The most common clinical presentation was severe agitation (LSD 27.3%, psilocybin 20.0%). Median blood concentrations were LSD 0.8 μg/l (IQR = 1.7, range = 0.1-3), psilocin 20 μg/l (IQR = 53.5, range = 6-83). LSD was the only drug present in 25.0% of LSD cases and psilocybin in 20.0% of psilocybin cases. Pre-existing organ pathology was uncommon.

CONCLUSIONS

Lysergic acid diethylamide (LSD)- and psilocybin-related death in Australia from 2000 to 2023 was primarily due to traumatic injury, whether through accident or self-harm. Cases of acute toxic reactions that were attributed solely to LSD were rare.

Recent progress on the detection of animal-derived food stimulants using mass spectrometry-based techniques

Background

The misuse of animal-derived stimulants in food is becoming increasingly common, and mass spectrometry (MS) is used extensively for their detection and analysis. There is a growing demand for abused-substances detection, highlighting the need for systematic studies on the advantages of MS-based methods in detecting animal-derived stimulants.

Objective

We reviewed the application of chromatography-mass spectrometry to the screening and detection of food stimulants of animal origin. Specifically, we analyzed four common animal sources of synthetic steroids, β-receptor agonists, zearalenol (ZAL), and glucocorticoids. We also explored the potential of using chromatography-mass spectrometry to detect and analyze animal-derived foods.

Methods

We searched and screened the Web of Science and Google Scholar databases until April 2023. Our inclusion criteria included a publication year within the last 5 years, publication language of English, and the research fields of food analysis, environmental chemistry, and polymer science. Our keywords were "mass spectrometry," "anabolic androgenic steroids," "β-2agonists," "glucocorticoids," "zearalenone," and "doping."

Results

Although traditional techniques such as thin-layer chromatography and enzyme-linked immunoassays are simple, fast, and suitable for the initial screening of bulk products, they are limited by their relatively high detection limits. Among the methods based on MS, gas chromatography-mass spectrometry and liquid chromatography-tandem mass spectrometry are the most widely used for detecting food doping agents of animal origin. However, a sensitive method with high repeatability and a short analysis time for a large number of samples is still required. Advances in MS have enabled the detection of extremely low concentrations of these substances. Combining different techniques, such as high-resolution mass spectrometry, ultra-high performance liquid chromatography-tandem mass spectrometry, gas chromatography-combustion-isotope ratio mass spectrometry, ultra-high performance liquid chromatography-high resolution mass spectrometry, and two-dimensional chromatography, offers significant advantages for detecting trace illicit drugs in animal-derived foods. Due to advances in assay technology and sample preparation methods, sample collection and storage methods such as dried blood spots, dried urine spots, and volumetric absorptive microsampling are increasingly accepted because of their increased stability and cost-effectiveness.

Significance

MS significantly improves the efficiency of detecting doping agents of animal origin. With the continuous development of MS technology, its application in the fields of doping detection and the analysis of doping agents of animal origin is expected to become more extensive.

Clinical characteristics in new psychoactive substance users: A single center study

New psychoactive substances (NPS) are emerging illegal substances or synthetic drugs that pose public health threats worldwide. This study was aimed at reporting the clinical characteristics of NPS and classical illicit substances used by patients who presented to the emergency room. We conducted a retrospective cohort study on patients with suspected illicit substance use who visited the emergency department (ED) with the suspicion of illicit substance use. We divided the patients into 4 groups based on the NPS testing results: NPS positive, NPS negative, NPS combined with classical illicit drugs (INPS), and subjects with negative testing results. The majority of patients in all groups were male. The NPS users were significantly younger than those with negative results on toxic testing (26.4 vs 37.5, P = .005 < 0.05). The heart rate of NPS users was significantly faster than that of the group with negative results of toxic testing (111.1 vs 93.5 beats per minute, P = .046). The heartbeats of INPS group were also significantly faster than those with a negative result in toxicology screen (119.6 vs 93.5 beats per minute, P = .024). Those who used classical illicit drugs combined with NPS had significantly higher palpitation than those with negative results of toxic testing (27.3% vs 3.1%, P = .017). Patients who were highly suspicious of NPS use were younger, had tachycardia, felt palpitations, and had fair oxygen saturation compared to patients who were negative for urine toxicity screening.

Co-designing drug alerts for health and community workers for an emerging early warning system in Victoria, Australia

BACKGROUND

Alerts about changes in unregulated drug markets may be useful for supporting health and community workers to anticipate, prevent, and respond to unexpected adverse drug events. This study aimed to establish factors influencing the successful design and implementation of drug alerts for use in clinical and community service settings in Victoria, Australia.

METHODS

An iterative mixed methods design was used to co-produce drug alert prototypes with practitioners and managers working across various alcohol and other drug services and emergency medicine settings. A quantitative needs-analysis survey (n = 184) informed five qualitative co-design workshops (n = 31). Alert prototypes were drafted based on findings and tested for utility and acceptability. Applicable constructs from the Consolidated Framework for Implementation Research helped to conceptualise factors that impact successful alert system design.

RESULTS

Timely and reliable alerts about unexpected drug market changes were important to nearly all workers (98%) yet many reported insufficient access to this kind of information (64%). Workers considered themselves 'conduits' for information-sharing and valued alerts for increasing exposure to drug market intelligence; facilitating communication about potential threats and trends; and improving capacity for effective responding to drug-related harm. Alerts should be 'shareable' across a range of clinical and community settings and audiences. To maximise engagement and impact, alerts must command attention, be easily recognisable, be available on multiple platforms (electronic and printable formats) in varying levels of detail, and be disseminated via appropriate notification mechanisms to meet the needs of diverse stakeholder groups. Three drug alert prototypes (SMS prompt, summary flyer, and a detailed poster) were endorsed by workers as useful for supporting their work responding to unexpected drug-related harms.

DISCUSSION

Alerts informed by coordinated early warning networks that offer close to real-time detection of unexpected substances can provide rapid, evidence-based drug market intelligence to inform preventive and responsive action to drug-related harm. The success of alert systems requires adequate planning and resourcing to support design, implementation, and evaluation, which includes consultation with all relevant audiences to understand how to maximise engagement with information, recommendations, and advice. Our findings about factors impacting successful alert design have utility to inform the development of local early warning systems.

'We don't live in a harm reduction world, we live in a prohibition world': tensions arising in the design of drug alerts

BACKGROUND

Drug alerts designed for health and community workforces have potential to avert acute harms associated with unpredictable illicit drug markets, by preparing workers to respond to unusual drug-related events, and distribute information to service users. However, the design of such alerts is complicated by diverse needs of individuals, and broader socio-political contexts. Here, we discuss the tensions that arose in the process of co-designing drug alert templates with health and community workers.

METHODS

We conducted five in-depth digital co-design workshops with 31 workers employed in alcohol and other drug and urgent care settings. Our approach to analysis was informed by Iterative Categorisation and reflexive thematic analysis methods.

RESULTS

We identified five key tensions. First, there is a need to provide comprehensive information to meet the information needs of a diverse group of workers with varying knowledge levels, while also designing alerts to be clear, concise, and relevant to the work of individuals. Second, it is important that alerts do not create 'information overload'; however, it is also important that information should be available to those who want it. Third, alert design and dissemination must be perceived to be credible, to avoid 'alert scepticism'; however, credibility is challenging to develop in a broader context of criminalisation, stigmatisation, and sensationalism. Fourth, alerts must be carefully designed to achieve 'intended effects' and avoid unintended effects, while acknowledging that it is impossible to control all potential effects. Finally, while alerts may be intended for an audience of health and community workers, people who use drugs are the end-users and must be kept front of mind in the design process.

CONCLUSIONS

The co-design process revealed complexities in designing drug alerts, particularly in the context of stigmatised illicit drug use, workforce diversity, and dissemination strategies. This study has highlighted the value of developing these important risk communication tools with their target audiences to ensure that they are relevant, useful, and impactful. The findings have informed the development of our drug alert prototypes and provide local context to complement existing best-practice risk-communications literature.

Clinical characteristics of new psychoactive substances: A multicenter study

BACKGROUND

New psychoactive substances (NPS) are synthetic alternatives to illicit drug abuse that are not under international control but may pose a public health threat. Moreover, the symptoms and signs of NPS users may be quite variable. This study aimed to figure out the clinical characteristics of NPS users presented to the emergency department (ED).

METHODS

A total of 1385 cases were tested via urine toxicity screening from March 25, 2019, to January 28, 2020, in six medical centers, and ten hospitals, in Taiwan. A total of 123 non-NPS cases and 77 NPS-use cases were enrolled in this study. We compared the patient data-vital signs, presentation, co-morbidities, behaviors, symptoms, electrocardiograms, laboratory data, length of stays-and outcomes of NPS users and non-NPS drug users.

RESULTS

NPS users were 5.7 years younger than the non-NPS drug users (37 vs. 42.7 years, p = 0.022). Presently, NPS users had a 2.6-fold (27.2%) higher rate of suicide and a 2.9-fold (11.7%) greater possibility of violence than non-NPS drug users. Moreover, in NPS users, eye-opening was affected at a scale of 3.1 versus 3.4 (p = 0.048) in non-NPS drug users in the evaluation of consciousness and they experienced a 4.3-fold greater feeling of palpitation (p = 0.024) and had 8.1-fold higher chance of presenting facial flush (p = 0.032) than non-NPS drug users.

CONCLUSION

NPS users are relatively younger, are more likely to experience facial flush and palpitation and engage in more self-harm, violence, and suicide than non-NPS drug users. Physicians need to pay attention to people who have altered, bizarre mental statuses with the clinical characteristics described above.

An Update on the Implications of New Psychoactive Substances in Public Health

The emergence of new psychoactive substances has earned a great deal of attention, and several reports of acute poisoning and deaths have been issued involving, for instance, synthetic opiates. In recent years, there have been profound alterations in the legislation concerning consumption, marketing, and synthesis of these compounds; rapid alert systems have also been subject to changes, and new substances and new markets, mainly through the internet, have appeared. Their effects and how they originate in consumers are still mostly unknown, primarily in what concerns chronic toxicity. This review intends to provide a detailed description of these substances from the point of view of consumption, toxicokinetics, and health consequences, including case reports on intoxications in order to help researchers and public health agents working daily in this area.

Characteristics of fatal 'novel' synthetic opioid toxicity in Australia

BACKGROUND

Aims: To determine 1. The characteristics of all recorded cases of fatal drug poisoning involving novel synthetic opioids (NSOs) in Australia; 2. The toxicology of cases; and 3. The major autopsy findings.

METHODS

Review of all fatal poisonings related to NSOs in Australia 2000-2021 identified in the National Coronial Information System.

RESULTS

Thirty-one cases were identified, 96.8% due to unintentional drug toxicity. The mean age was 31.9 years and 87.1% were male. Only six were aged over forty. A history of substance use problems was documented in 80.6% and 58.1% had a history of injecting drug use. In 32.3% the final route of administration of a NSO was by non-injecting routes of administration. Ten NSOs were identified. Fentanyl analogues were present in 67.2%, most commonly furanylfenatyl (19.4%). Other NSO types were present in 39.7%, most commonly U-47700 (35.5%). Substances other than NSOs were present in 90.3%, most commonly benzodiazepines (67.7%) and other opioids (51.6%). A CNS depressant in addition to NSOs was present in 90.3%, and a new psychoactive substance other than a NSO in 25.8%. Pulmonary oedema was diagnosed in 82.6%, aspiration of vomitus in 30.4%, and acute bronchopneumonia in 17.4%.

CONCLUSIONS

Ten NSOs were identified. Case characteristics suggest a younger cohort whose profile is more typical of use of other NPS than of the established opioids. A large proportion used NSOs by non-injecting routes of administration.

Polysubstance use poisoning deaths in Canada: an analysis of trends from 2014 to 2017 using mortality data

Background

Over the past decade, rates of drug poisoning deaths have increased dramatically in Canada. Current evidence suggests that the non-medical use of synthetic opioids, stimulants and patterns of polysubstance use are major factors contributing to this increase.

Methods

Counts of substance poisoning deaths involving alcohol, opioids, other central nervous system (CNS) depressants, cocaine, and CNS stimulants excluding cocaine, were acquired from the Canadian Vital Statistics Death Database (CVSD) for the years 2014 to 2017. We used joinpoint regression analysis and the Cochrane-Armitage trend test for proportions to examine changes over time in crude mortality rates and proportions of poisoning deaths involving more than one substance.

Results

Between 2014 and 2017, the rate of substance poisoning deaths in Canada almost doubled from 6.4 to 11.5 deaths per 100,000 population (Average Annual Percent Change, AAPC: 23%, p < 0.05). Our analysis shows this was due to increased unintentional poisoning deaths (AAPC: 26.6%, p < 0.05) and polysubstance deaths (AAPC: 23.0%, p < 0.05). The proportion of unintentional poisoning deaths involving polysubstance use increased significantly from 38% to 58% among males (p < 0.0001) and 40% to 55% among females (p < 0.0001). Polysubstance use poisonings involving opioids and CNS stimulants (excluding cocaine) increased substantially during the study period (males AAPC: 133.1%, p < 0.01; females AAPC: 118.1%, p < 0.05).

Conclusions

Increases in substance-related poisoning deaths between 2014 and 2017 were associated with polysubstance use. Increased co-use of stimulants with opioids is a key factor contributing to the epidemic of opioid deaths in Canada.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12678-z.

New Psychoactive Substances and Suicidality: A Systematic Review of the Current Literature

Background and Objectives: Over the past twenty years a large number of new psychoactive substances (NPS) have entered and modified the recreational drug scene. Their intake has been associated with health-related risks, especially so for vulnerable populations such as people with severe mental illness, who might be at higher risk of suicidality or self-injurious behavior. This paper aims at providing an overview of NPS abuse and the effects on mental health and suicidality issues, by performing a literature review of the current related knowledge, thereby identifying those substances that, more than others, are linked to suicidal behaviors. Materials and Methods: A comprehensive and updated overview of the literature regarding suicidality and NPS categories has been undertaken. An electronic search was performed, including all papers published up to March 2021, using the following keywords “NPS” OR “new psychoactive substances” OR “novel psychoactive substances” OR “synthetic cannabinoids” OR “phenethylamines” OR “synthetic cathinones” OR “tryptamines” OR “piperazines” OR “new synthetic opioids” OR “designer benzodiazepines” AND (“suicide” OR “suicidality”) NOT review NOT animal on the PubMed, Cochrane Library, and Web of Science online databases. Results: Suicidality and self-injurious behavior appear to be frequently associated with some NPS such as cathinones, synthetic cannabinoids, and new synthetic opioids. The results are organized according to the substances recorded. Conclusion: The growing use of NPS has become a significant clinical issue, causing increasing concern and challenges for clinicians working in both mental health and emergency departments. Thus, considering the associations between NPS and suicidality or self-injurious behaviors, areas where suicide-prevention efforts and strategies might be focused are the early detection, monitoring, and restriction of NPS.

Evaluating Trends in Novel Psychoactive Substances Using a Sentinel Population of Electronic Dance Music Festival Attendees

Electronic dance music (EDM) festivals have become a popular venue for recreational drug use, including the use of traditional stimulants like 3,4-methylenendioxymethamphetamine (MDMA) and novel psychoactive substances (NPS). Using this cohort of people who use drugs recreationally, this study sought to collect biological specimens and self-reported drug use data from EDM festival attendees in the United States to monitor regional and temporal trends related to NPS use and turnover between 2014 and 2017. Oral fluid samples were collected at three United States EDM festival locations, including Miami, Florida (2014 to 2017); Tampa, Florida (2017) and Atlanta, Georgia (2017). Samples were screened by liquid chromatography-quadrupole time-of-flight mass spectrometry and confirmed by liquid chromatography-tandem mass spectrometry. Over the 4 years, 1,233 oral fluid samples were collected. With respect to self-reported drug use, 63% of respondents reported medicinal and/or recreational drug use within the last week. When comparing 4 years of data from Miami (2014 to 2017), NPS trends showed the disappearance of alpha-PVP after 2014 followed by a significant increase in ethylone positivity in 2015 and rapid decrease in 2016. Dibutylone was identified for the first time in Miami 2016, and N-ethyl pentylone was identified for the first time in Miami 2017. Additionally, 3,4-methylenendioxymethamphetamine positivity steadily increased from 2014 to 2017. A comparison across study sites (Miami, Tampa and Atlanta) and specific trends with respect to novel simulant use are described within. Using this opportunistic approach of monitoring drug trends, we have found that peak positivity of novel stimulants usually is within a year of their first detection. Understanding the dynamics of NPS drug markets will allow laboratories to plan for resource allocation and scope updates within a timely fashion to assist with the detection and confirmation of these emerging substances in samples submitted for forensic analysis.

Method development for the identification of methoxpropamine, 2-fluoro-deschloroketamine and deschloroketamine and their main metabolites in blood and hair and forensic application

The constant increase of new psychoactive substances, often available on the illicit drug market as 'research chemicals', poses a concern for public health and a significant analytical and legislative challenge. Β-keto-arylcyclohexamines represent a class of dissociative anesthetics recently introduced on the market of New Psychoactive Substances (NPS). There is still a lack of information about the pharmacological activity of many of such substances, usually depending on the potential chemical modifications introduced to circumvent the law. Furthermore, their intake may not be fully intentional, since consumers do not always have knowledge of the content of online purchases. The present study describes the characterization by liquid chromatography-high resolution mass spectrometry (LC-HRMS), using a benchtop Orbitrap instrument, of the novel ketamine analogues methoxpropamine, 2-fluoro-deschloroketamine and deschloroketamine, found in the post-mortem blood and hair samples from a forensic case of suicide by fall from height, and of some of their metabolites. This allowed the development of analytical methods for the determination of both the β-keto-arylcyclohexamines and the metabolites in LC-HRMS and in LC-MS/MS, providing a starting point for studying their toxicokinetics.

Characteristics and circumstances of death related to the self-administration of ketamine

BACKGROUND AND AIMS

Ketamine is used for anaesthesia, sedation and the treatment of mood disorders, but is also widely used for non-medical purposes. This study aimed to: (1) determine the characteristics and circumstances of all recorded cases of self-administered ketamine-related death in Australia, 2000-19 and (2) determine the toxicology and major organ pathology of cases.

DESIGN

Retrospective study of all Australian cases in which self-administered ketamine was a mechanism contributory to death, retrieved from the National Coronial Information System.

SETTING

Australia-wide.

CASES

Sixty-eight cases, with a mean age of 35.2 years (standard deviation = 11.5, range = 16-63), 76.5% male.

MEASUREMENTS

Information was collected on cause of death, demographics, circumstances of death, toxicology and major organ pathology.

FINDINGS

Death was attributed to toxicity in 82.3% of cases (accidental, 58.8%; deliberate, 23.5%), suicide by violent means (8.8%) and traumatic accident (8.8%). In six cases the decedent had been prescribed ketamine. In 32.4% the final route of ketamine administration was by injection. The fatal incident predominantly occurred in a private environment (72.1%). Ketamine was present in the blood of 90.1% and other biomarkers in the remainder. The median blood ketamine concentration was 0.2 mg/l (0.02-6.9 mg/l). Other drugs were detected in 95.5% of cases: opioids (59.1%), hypnosedatives (57.6%), psychostimulants (50.0%), alcohol (27.3%), Δ-9-tetrahydrocannabinol (18.2%), antidepressants (28.8%) and antipsychotics (9.1%). Pulmonary oedema was present in 82.2% of cases that underwent autopsy and pneumonia in 26.7%.

CONCLUSIONS

The typical case of self-administered ketamine-related death in Australia, 2000-19, was a male in his mid-30s who had used multiple drugs, with the fatal incident most commonly occurring in a private setting. Death due to accidental drug toxicity was the most common manner of death, but suicide was highly prevalent.

New psychoactive substances in Australia: patterns and characteristics of use, adverse effects, and interventions to reduce harm

PURPOSE OF REVIEW

To summarize the most recent peer-review literature on new psychoactive substances (NPS) within Australia.

RECENT FINDINGS

NPS use among the general Australian population is low, yet more pervasive among specific subpopulations. There is considerable heterogeneity among people who use NPS, however, overall, they are not unique from those who use more established illicit drugs. NPS have been shown to be highly adulterated, used as contaminants, variable in dose, and changeable as to the specific substances available over time. Further, analyses of coroners' cases highlight the importance of consumer understanding of NPS effects, particularly where they differ substantially to their more traditional illicit drug counterparts (e.g., synthetic vs. plant cannabinoids). One study posited that legislative approaches to NPS have been (partially) effective in reducing harms, and there are new systems being established to identify NPS-related health harms.

SUMMARY

There have been few studies recently published on NPS in Australia (n = 17), however, findings mostly align with the international literature with respect to the rapidly changing nature of the NPS market, the use of NPS as adulterants, and associated harms. These themes highlight the need for proactive, novel approaches to rapidly identify, and respond to emerging drugs of concern.

Characteristics and circumstances of death related to gamma hydroxybutyrate (GHB)

Introduction: Gamma hydroxybutyrate (GHB) has gained substantial popularity as an illicit recreational drug. The current study aimed to: (1) determine the characteristics and circumstances of death of all recorded cases of GHB-related death in Australia, 2001-2019; (2) determine the toxicology of cases; and (3) determine major organ pathology.Methods: Retrospective study of all Australian cases in which GHB was a mechanism contributory to death retrieved from the National Coronial Information System (n = 74). Information was collected on cause of death, demographics, circumstances of death, toxicology and major organ pathology.Results: The mean age was 31.5 years and 70.3% were male. The predominant circumstance of death was accidental drug toxicity (79.7%), including five cases attributed to a combination of toxicity and natural disease. Other deaths were due to trauma (12.2%) and suicide (8.2%). The fatal incident overwhelmingly occurred in a home environment (82.4%). In all cases, GHB was consumed orally. The median GHB blood concentration was 210 mg/L (range 13-1350 mg/L), and was significantly higher in toxicity cases than others (258 vs. 98 mg/L, p < .01). Other substances were present in 92.2%, most commonly psychostimulants (64.1%), hypnosedatives (28.2%) and alcohol (20.3%). Resuscitation was attempted in 20.3% of cases. Acute pneumonia (36.7%) and aspiration of vomitus (30.6%) were common.Conclusions: The typical case was a young male, who swallowed GHB and used it with other substances, most commonly at home. While acute drug toxicity was the most common cause of death, there was a substantial minority due to trauma or suicide.