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Objectives: To determine the numbers and types of medicines dispensed around the time of death to people who die by suicide; to compare the medicines recently dispensed and those recorded in post mortem toxicology reports. Design, setting, participants: Analysis of linked National Coronial Information System (NCIS) and Pharmaceutical Benefits Scheme (PBS) data from the Australian Suicide Prevention using Health Linked Data (ASHLi) study, a population‐based case series study of closed coronial cases for deaths of people in Australia aged ten years or more during 1 July 2013 – 10 October 2019 deemed by coroners to be the result of intentional self‐harm. Main outcome measures: Proportions of people to whom medicines were dispensed around the time of death, by medicine group, class, and specific medicine; comparison of medicines recently dispensed and those detected by post mortem toxicology. Results: Toxicology reports were available for 13 541 of 14 206 people who died by suicide (95.3%; 10 246 men, 75.7%); poisoning with medicines contributed to 1163 deaths (8.6%). At least one PBS‐subsidised medicine had been dispensed around the time of death to 7998 people (59.1%). For three medicine classes, the proportions of people in whom the medicines were detected post mortem and their death was deemed medicine‐related were larger for those without records of recent dispensing than for people for whom they had been dispensed around the time of death: antidepressants (17.7% v 12.0%), anxiolytics (16.3% v 14.8%), and sedatives/hypnotics (24.3% v 16.5%). At least one recently dispensed medicine not detected post mortem was identified for 6208 people (45.8%). Conclusions: A considerable proportion of people who died by suicide were not taking psychotropic medicines recently dispensed to them, suggesting non‐adherence to pharmacotherapy, and a smaller than expected proportion were using antidepressants. Conversely, medicines that had not recently been dispensed were detected post mortem in many people for whom poisoning with medicines was a contributing factor, suggesting medicine stockpiling. [ABSTRACT FROM AUTHOR]

Gabapentinoids is a class of drug with analgesic, anxiolytic, and anticonvulsant properties and has a reported increase in prescription, use, and adverse outcomes. Regional studies are scant, and postmortem toxicological data may characterise patterns of regional use and inform local interventions. Characterising drug and non-drug-related deaths with gabapentinoid detection may also aid in toxicology interpretation. A 5-year retrospective study on all deaths admitted to the Gold Coast University Hospital under where toxicological analysis was performed. Of the gabapentinoids, only pregabalin was detected over the study period, and annual rates of detection did not differ significantly over the period (7.4-12.4%). In cases where pregabalin was detected, it was 15 times more likely to be a drug-related death. Drug-related deaths where pregabalin was detected have higher levels of pregabalin, are younger, and had a greater proportion of concurrent opioid detection. Postmortem detection of pregabalin was associated with drug-related deaths. Higher levels, younger decedents, and concurrent use of opioids were found in drug-related deaths. Public health interventions and regulated prescribing to target concurrent pregabalin and opioid use may address the burden of pregabalin drug-related deaths., (© 2023. The Author(s).)

Patients presenting to the ED after using illicit drugs, including novel psychoactive substances, are a unique source of information on substances that are directly causing acute harm in the community. Conventionally, illicit drug intoxications are assessed and managed in EDs based on self-report and presenting symptoms, with no objective data on the causative agent. The Emerging Drugs Network of Australia (EDNA) is a national toxico-surveillance system that provides analytic data on these drugs, from sentinel Emergency Departments. It is a collaborative national network of emergency physicians, toxicologists, forensic laboratories and public health authorities. The key benefit of EDNA is the capacity to provide timely laboratory-confirmed toxicology data on emerging drug-related threats in the community. This leads to improvements in clinical, forensic laboratory and public health harm reduction responses, reflecting rapid translation of the research., (© 2024 Australasian College for Emergency Medicine.)

Motor vehicle driver fatalities (≥18 years) from the files at Forensic Science South Australia were reviewed from January 2008 to December 2018 for cases in which either positive blood sample for methamphetamine (MA) or an illegal blood alcohol concentration (BAC) >0.05g/100 ml were found. Three hundred driver deaths were found with MA detected in 28 cases (age range 21–62 years; ave. 37.8 years; M:F 23:5). Hundred and fifteen cases with a BAC > 0.05 g/100 ml were identified (age range 18–67 years; ave 35.7 years; M:F 95:20). No change was found in numbers of MA cases, although alcohol cases showed a significant decline (p < 0.001). Drunk driving‐related fatal crashes tended to occur in the evening (5 p.m. to 11 p.m.), while MA‐related fatal crashes had a longer peak extending from late evening until late morning (11 p.m. to 8 a.m.). This study has demonstrated that while roadside breath testing, legislative changes, and increased monitoring have resulted in reduced levels of drunk driving, similar safety countermeasures have had negligible effects on MA use in drivers. Continued monitoring of MA use by drivers will, therefore, be necessary to assess the possible effects, or not, of new countermeasures. [ABSTRACT FROM AUTHOR]

Aims: To determine trends in 3,4 methylenedioxymethamphetamine (MDMA)‐related death rates across Australia, Finland, Portugal and Turkey and to analyse the toxicology and causes of death across countries. Design Analysis of MDMA‐related deaths extracted from a national coronial database in Australia (2001–19) and national forensic toxicology databases in Finland (2001–17), Portugal (2008–19) and Turkey (2007–17). Presentation of MDMA use and seizure data (market indicators). Setting: Australia, Finland, Portugal and Turkey. Cases All deaths in which MDMA was considered by the forensic pathologist to be contributory to death. Measurements Information collected on cause and circumstances of death, demographics and toxicology. Findings A total of 1400 MDMA‐related deaths were identified in Turkey, 507 in Australia, 100 in Finland and 45 in Portugal. The median age ranged from 24 to 27.5 years, and males represented between 81 and 94% of the deaths across countries. Standardized mortality rates significantly increased across all four countries from 2011 to 2017 during a period of increased purity and availability of MDMA. The underlying cause of death was predominantly due to drug toxicity in Australia (n = 309, 61%), Finland (n = 70, 70%) and Turkey (n = 840, 60%) and other causes in Portugal (n = 25, 56%). Minorities of all deaths across the countries were due to MDMA toxicity alone (13–25%). These deaths had a significantly higher blood MDMA concentration than multiple drug toxicity deaths in Australia, Finland and Turkey. Drugs other than MDMA commonly detected were stimulants (including cocaine, amphetamine and methamphetamine) (Australia 52% and Finland 61%) and alcohol (Australia 46% and Portugal 49%). In addition to MDMA toxicity, benzodiazepines (81%) and opioids (64%) were commonly identified in these deaths in Finland. In comparison, synthetic cannabinoids (15%) and cannabis (33%) were present in a minority of deaths in Turkey. Conclusions: Deaths related to 3,4 methylenedioxymethamphetamine (MDMA) increased in Australia, Finland, Portugal and Turkey between 2011 and 2017. Findings show MDMA toxicity alone can be fatal, but multiple drug toxicity remains more prevalent. [ABSTRACT FROM AUTHOR]

Objective: ED presentations because of illicit use of psychotropic drugs and pharmaceuticals result in significant medical harm and resource consumption. Patient assessment is complicated by the regular emergence of new psychoactive substances, difficulties associated with their identification and a lack of information about their effects. Here we report the protocol for the Emergency Department Admission Blood Psychoactive Testing (EDABPT) programme, an observational study utilising clinical data capture and definitive drug identification to assess the medical impact and patterns of illicit drug use in the community, and their geographic and temporal fluctuations. The study provides data to an early warning system targeting an improved public health response to emerging drugs of concern. Methods: Enrolment of adult patients presenting with suspected illicit drug use occurs at four major EDs in a single urban setting. Clinical and demographic data are collected by treating clinicians. Blood samples are collected at presentation and frozen on site prior to transport to a specialised forensic facility for comprehensive toxicological screening. Results: Results are fed back to clinicians and disseminated more broadly via an existing local early warning system. Targeted warnings and public health releases are instigated where heightened risk or harm is identified. Conclusion: The study pairs city‐wide patient enrolment with analytically confirmed toxicology results to allow broad sampling and identification of illicit drugs causing medical harm. It provides a mechanism for the identification of new agents as they emerge in the community, delivers a relevant and reliable source of information for public health agencies and clinicians and supplements existing local early warning mechanisms. [ABSTRACT FROM AUTHOR]

Deaths caused by barbiturate overdoses have increased in the past decade, especially as a result of suicide attempts. Pentobarbitone is a central nervous system depressant used for sedation and euthanasia in veterinary medicine. However, pentobarbitone analysis is not commonly available in the hospital setting; hence, its occurrence in overdoses is under-reported. Herein we describe a patient who ingested pentobarbitone obtained from the Internet with the purpose of ending his life. He became comatose and required ventilation for 6 days. While critically ill, the drug and a barbiturate test kit were found in his room at his residence. Toxicological analysis of the patient's blood determined the presence of pentobarbitone at levels of 91, 56, and 19 mg/L at 11, 59, and 107 h after ingestion, respectively. With supportive care, the patient made a full recovery. He stated that he believed the liquid was to be pentobarbitone, and that he had received advice on its use from an online forum that he had found on a dark web marketplace. In this report, we highlight the process by which we facilitated pentobarbitone analysis with a rapid turnaround time, which helped to inform clinical management and raise awareness among clinicians. The access was made through the Prescription, Recreational and Illicit Substance Evaluation (PRISE) programme, which is a collaborative network among the New South Wales (NSW) Ministry of Health, NSW Poisons Information Centre (PIC), and NSW Health Pathology Forensic & Analytical Science Service (FASS). Key points • We report a patient with confirmed severe pentobarbitone toxicity who developed coma, respiratory failure, barbiturate related skin and vascular manifestations who required intensive care for 6 days. • The diagnosis of pentobarbitone poisoning can be missed as it is not routinely included in Australian standard hospital urine drug screens, and it may not cross-react with phenobarbitone testing which may be more readily available. • Timely access to comprehensive toxicology testing with rapid turnaround time assists diagnosis for unknown toxicity, and enhances case management and public health interventions. • The PRISE programme in Australia is a collaboration between multiple health functional units in NSW, Australia that provides timely access to extensive toxicology testing for severe and unusual toxicity from drugs or substance-related toxicities. [ABSTRACT FROM AUTHOR]

The described procedure provides a rapid technique for the detection and semi-quantitation of a large number of drugs in blood. This procedure uses a minimal sample volume and employs a one-step liquid extraction and automated data processing to yield rapid turnaround times. A total of 327 of the most commonly used medicinal and illicit drugs in Australia were selected including various amphetamines, anesthetics, antidepressants, antipsychotics, anticonvulsants, benzodiazepines, beta blockers, opioid and nonopioid analgesics, stimulants, THC and a large number of synthetic cannabinoids and other novel psychoactive substances. The extracts were subject to 5-minute chromatography using a Kinetex C18 50 × 4.6 mm 2.6 μm solid-core analytical column and analyzed using a Sciex 3200 Q-TRAP MS-MS (+ ESI, MRM mode, two transitions per analyte). The method was fully validated in accordance with international guidelines. Matrix effects and extraction efficiencies were acceptable with most analytes showing > 80% response and low variation (within 25%RSD). Cannabinoids were most affected by the matrix and yielded poorest recovery values but were still detectable. Precision, accuracy, repeatability and multipoint linearity were assessed for all analytes. The method has been used in routine practice in the forensic toxicology service at the Victorian Institute of Forensic Medicine in over 6000 coronial investigations using both postmortem and clinical blood specimens. This technique has greatly increased throughput, reduced turnaround times and allowed for rapid same-day analysis of results when needed. The method is routinely used in routine overnight testing with results reported to pathologists within 4 h of data acquisition. This rapid toxicological technique is used in conjunction with other investigative processes such as full-body CT imaging, review of case circumstances and medical histories to provide an efficient death investigation process. [ABSTRACT FROM AUTHOR]

Age and organ maturity can influence drug toxicity in children; however, most clinical data and literature are based on drug concentrations in adults. Therefore, the interpretation of drugs detected in children is often difficult or not possible. Retrospective reviewing of pathology and toxicology information from postmortem cases may assist in future interpretations or identify drug trends. A search of the Forensic Science SA case files was undertaken over 15 years from January 2002 to December 2016 for all children (<13 years). Of the 412 pediatric coronial cases, toxicological information was available on 373. At least one drug was detected in 94 cases with paracetamol, ibuprofen, codeine and hospital‐administrated lignocaine and morphine among the most commonly detected agents. Methamphetamine, one of the most commonly abused illicit drugs in Australia, was found in seven cases. In the methamphetamine cases, deaths were associated with shared sleeping in three, pneumonia in one, and stillbirth in one. Methamphetamine was considered potentially contributory to death in two cases. The causes of death in the remaining two cases were undetermined. As six of the seven positive cases occurred in the 2012–2016 (n = 106) timeframe, an increase has occurred over recent years in the number of infants and young children presenting to forensic autopsy in South Australia who have detectable concentrations of methamphetamine. If this is an indication of a more generalized increased childhood exposure in the community there may be significant long‐term physical and psychological effects. [ABSTRACT FROM AUTHOR]

There is a paucity of research examining the utility of forensic toxicology in the investigation of premature external cause deaths of residents in nursing homes. The aim of this study is to describe the frequency and characteristics of toxicological analysis conducted in external cause (injury-related) deaths amongst nursing home residents in Victoria, Australia. This study was a retrospective cohort study examining external cause deaths among nursing home residents during the period July 1, 2000 to December 31, 2012 in Victoria, Australia, using the National Coronial Information System (NCIS). The variables examined comprised: sex, age group, year-of-death, cause and manner of death. One-third of deaths among nursing home residents in Victoria resulted from external causes ( n = 1296, 33.3%) of which just over one-quarter (361, 27.9%) underwent toxicological analysis as part of the medical death investigation. The use of toxicological analysis varied by cause of death with a relatively low proportion conducted in deaths from unintentional falls ( n = 286, 24.9%) and choking ( n = 36, 40.4%). The use of toxicological analysis decreased as the decedents age increased. Forensic toxicology has the potential to contribute to improving our understanding of premature deaths in nursing home residents however it remains under used and is possibly undervalued. [ABSTRACT FROM AUTHOR]

1. The European red fox Vulpes vulpes represents a continuing threat to both livestock and native vertebrates in Australia, and is commonly managed by setting ground-level baits impregnated with 1080 (sodium fluoroacetate) poison. However, the long-term effectiveness of such control campaigns is likely to be limited due to the ability of foxes to disperse over considerable distances and to swiftly recolonize areas from where they had been removed. 2. To investigate the effectiveness of fox baiting in a production landscape, we assessed the potential for foxes to reinvade baited farm property areas within the jurisdiction of the Molong Rural Lands Protection Board (RLPB), an area of 815 000 ha on the central tablelands of New South Wales, Australia. The spatial distribution and timing of fox baiting campaigns between 1998 and 2002 was estimated from RLPB records and mapped using Geographical Information System software. The effectiveness of the control campaign was assessed on the basis of the likely immigration of foxes from non-baited farms using immigration distances calculated from published relationships between dispersal distance and home range size. 3. Few landholders undertook baiting campaigns in any given year, and the area baited was always so small that no baited property would have been sufficiently far from an unbaited property to have been immune from immigrating individuals. It is likely, therefore, that immigration onto farms negated any long-term effects of baiting operations. This study highlights some of the key deficiencies in current baiting practices in south-eastern Australia and suggests that pest management programmes should be monitored using such methods to ensure they achieve their goals. [ABSTRACT FROM AUTHOR]

1. Mammalian predators are controlled by poison baiting in many parts of the world, often to alleviate their impacts on agriculture or the environment. Although predator control can have substantial benefits, the poisons used may also be potentially harmful to other wildlife. 2. Impacts on non-target species must be minimized, but can be difficult to predict or quantify. Species and individuals vary in their sensitivity to toxins and their propensity to consume poison baits, while populations vary in their resilience. Wildlife populations can accrue benefits from predator control, which outweigh the occasional deaths of non-target animals. We review recent advances in Australia, providing a framework for assessing non-target effects of poisoning operations and for developing techniques to minimize such effects. We also emphasize that weak or circumstantial evidence of non-target effects can be misleading. 3. Weak evidence that poison baiting presents a potential risk to non-target species comes from measuring the sensitivity of species to the toxin in the laboratory. More convincing evidence may be obtained by quantifying susceptibility in the field. This requires detailed information on the propensity of animals to locate and consume poison baits, as well as the likelihood of mortality if baits are consumed. Still stronger evidence may be obtained if predator baiting causes non-target mortality in the field (with toxin detected by post-mortem examination). Conclusive proof of a negative impact on populations of non-target species can be obtained only if any observed non-target mortality is followed by sustained reductions in population density. 4. Such proof is difficult to obtain and the possibility of a population-level impact cannot be reliably confirmed or dismissed without rigorous trials. In the absence of conclusive evidence, wildlife managers should adopt a precautionary approach which seeks to minimize potential risk to non-target individuals, while clarifying population-level effects through continued research. [ABSTRACT FROM AUTHOR]

Abstract: The geographic range and bloom frequency of the toxic dinoflagellate Alexandrium minutum and other members of the A. minutum group have been increasing over the past few decades. Some of these species are responsible for paralytic shellfish poisoning (PSP) outbreaks throughout the world. The origins of new toxic populations found in previously unaffected areas are typically not known due to a lack of reliable plankton records with sound species identifications and to the lack of a global genetic database. This paper provides the first comprehensive study of minutum-group morphology and phylogeny on a global scale, including 45 isolates from northern Europe, the Mediterranean, Asia, Australia and New Zealand. Neither the morphospecies Alexandrium lusitanicum nor A. angustitabulatum was recoverable morphologically, due to large variation within and among all minutum-group clonal strains in characters previously used to distinguish these species: the length:width of the anterior sulcal plate, shape of the 1′ plate, connection between the 1′ plate and the apical pore complex, and the presence of a ventral pore. DNA sequence data from the D1 to D2 region of the LSU rDNA also fail to recognize these species. Therefore, we recommend that all isolates previously designated as A. lusitanicum or A. angustitabulatum be redesignated as A. minutum. A. tamutum, A. insuetum, and A. andersonii are clearly different from A. minutum on the basis of both genetic and morphological data. A. minutum strains from Europe and Australia are closely related to one another, which may indicate an introduction from Europe to Australia given the long history of PSP in Europe and its recent occurrence in Australia. A minutum from New Zealand and Taiwan form a separate phylogenetic group. Most strains of A. minutum fit into one of these two groups, although there are a few outlying strains that merit further study and may represent new species. The results of this paper have greatly improved our ability to track the spread of A. minutum species and to understand the evolutionary relationships within the A. minutum group by correcting inaccurate taxonomy and providing a global genetic database. [Copyright &y& Elsevier]

To analyze the risk factors for suicide, premature death and all-cause death in a representative population of hospital-treated deliberate self-poisoning patients. A prospective cohort study using data-linkage between the Hunter Area Toxicology Service Database and the National Death Index of the Australian Institute of Health and Welfare, from January 1991 to December 2000. There were 4105 subjects, of whom 228 (5.6%) died, 122 (2.9%) by premature death and 58 (1.4%) by suicide. The probability of suicide after 10 years follow-up was 2%. The adjusted hazard ratios (95% CI) for suicide were: ‘disorders usually diagnosed in infancy, childhood and adolescence’, 5.28 (95% CI = 2.04−13.65): male gender, 4.25 (95% CI = 2.21−8.14); discharge to involuntary psychiatric hospital admission, 3.20 (95% CI = 1.78−5.76); and increasing age, 1.02 (95% CI = 1.01−1.04). Men and women showed different patterns of multivariate risks, although increased risk with increasing age and discharge to an involuntary psychiatric admission was true for both. The standardized all-cause mortality ratio (95% CI) was: for men, 6.42 (95% CI = 5.44−7.57), and for women 4.39 (95% CI = 3.56−5.41). The standardized suicide mortality ratio (95% CI) was: for men, 20.55 (95% CI = 15.24−27.73), and for women 22.95 (95% CI = 13.82−38.11). Men and women have different risk factors for subsequent suicide after self-poisoning. Hospital-treated self-poisoning patients have increased risk of subsequent suicide, premature and all-cause death. Psychiatric assessment, leading to discharge decisions, is worthwhile in identifying patients at long-term risk of suicide, premature and all-cause death. [ABSTRACT FROM AUTHOR]

A multi-center case-control study was conducted on 3398 fatally-injured drivers to assess the effect of alcohol and drug use on the likelihood of them being culpable. Crashes investigated were from three Australian states (Victoria, New South Wales and Western Australia). The control group of drug- and alcohol-free drivers comprised 50.1% of the study population. A previously validated method of responsibility analysis was used to classify drivers as either culpable or non-culpable. Cases in which the driver “contributed” to the crash (n=188) were excluded. Logistic regression was used to examine the association of key attributes such as age, gender, type of crash and drug use on the likelihood of culpability. Drivers positive to psychotropic drugs were significantly more likely to be culpable than drug-free drivers. Drivers with Δ9-tetrahydrocannabinol (THC) in their blood had a significantly higher likelihood of being culpable than drug-free drivers (odds ratio (OR) 2.7, 95% CI 1.02–7.0). For drivers with blood THC concentrations of 5 ng/ml or higher the odds ratio was greater and more statistically significant (OR 6.6, 95% CI 1.5–28.0). The estimated odds ratio is greater than that for drivers with a blood alcohol concentration (BAC) of 0.10–0.15% (OR 3.7, 95% CI 1.5–9.1). A significantly stronger positive association with culpability was seen with drivers positive to THC and with BAC ≥0.05% compared with BAC ≥0.05 alone (OR 2.9, 95% CI 1.1–7.7). Strong associations were also seen for stimulants, particularly in truck drivers. There were non-significant, weakly positive associations of opiates and benzodiazepines with culpability. Drivers positive to any psychoactive drug were significantly more likely to be culpable (OR 1.8, 95% CI 1.3–2.4). Gender differences were not significant, but differences were apparent with age. Drivers showing the highest culpability rates were in the under 25 and over 65 age groups. [Copyright &y& Elsevier]

The incidence of alcohol and drugs in fatally injured drivers were determined in three Australian states; Victoria (VIC), New South Wales (NSW) and Western Australia (WA) for the period of 1990–1999. A total of 3398 driver fatalities were investigated which included 2609 car drivers, 650 motorcyclists and 139 truck drivers. Alcohol at or over 0.05 g/100 ml (%) was present in 29.1% of all drivers. The highest prevalence was in car drivers (30.3%) and the lowest in truckers (8.6%). WA had the highest rate of alcohol presence of the three states (35.8%). Almost 10% of the cases involved both alcohol and drugs. Drugs (other than alcohol) were present in 26.7% of cases and psychotropic drugs in 23.5%. These drugs comprised cannabis (13.5%), opioids (4.9%), stimulants (4.1%), benzodiazepines (4.1%) and other psychotropic drugs (2.7%). 8.5% of all drivers tested positive for Δ9-tetrahydrocannabinol (THC) and the balance of cannabis positive drivers were positive to only the 11-nor-Δ9-tetrahydrocannabinol-9-carboxylic acid (carboxy-THC) metabolite. The range of THC blood concentrations in drivers was 0.1–228 ng/ml, with a median of 9 ng/ml. Opioids consisted mainly of morphine (n=84), codeine (n=89) and methadone (n=33), while stimulants consisted mainly of methamphetamine (n=51), MDMA (n=6), cocaine (n=5), and the ephedrines (n=61). The prevalence of drugs increased over the decade, particularly cannabis and opioids, while alcohol decreased. Cannabis had a larger prevalence in motorcyclists (22.2%), whereas stimulants had a much larger presence in truckers (23%). [Copyright &y& Elsevier]

Aim: To describe the assignment of International Classification of Disease (ICD)-10 alcohol codes as underlying or contributory causes of death by the Australian Bureau of Statistics during mortality coding for suicides according to the blood alcohol concentration (BAC) detected at autopsy., Design: Population-based case-series descriptive analysis., Setting and Participants: Data for all alcohol-related (Alc+) suicide deaths (aged 15+) in Australia from 2010-2015 (n = 3132) from the National Coronial Information System., Measurements: Alc+ suicides were categorised as those with a post-mortem BAC ≥0.05 g/100 mL. The outcome variable was whether the case was assigned an ICD-10 alcohol code (F10.0-F10.9, R78.0, T51, X45 and/or X65). We estimated OR for the assignment of codes in Alc+ suicides using BAC as the key predictor. We also examined several covariates that have been implicated in the risk of Alc+ suicides., Findings: An ICD-10 alcohol code was assigned during the mortality coding process in 47.6% (n = 1491) of Alc+ suicides. Higher BAC was associated with higher odds of having a code assigned; cases with a BAC over 0.20 g/100 mL over were twice as likely to have an alcohol code assigned (adjusted OR [AOR] = 2.06, 95% CI = 1.59, 2.67) compared with cases with a BAC of 0.050-0.075 g/100 mL. Compared with New South Wales, higher likelihood of code assignment was found in Northern Territory (AOR = 3.85, 95% CI = 2.32, 6.63) and Western Australia (AOR = 2.89, 95% CI = 2.27, 3.68). Compared with 15-24 year olds, 25-44 (AOR = 0.79, 95% CI = 0.63, 0.99) and 65-84 year olds (AOR = 0.63, 95% CI = 0.43, 0.93) were less likely to have a code assigned., Conclusions: An ICD-10 alcohol code was not assigned as an underlying or contributory cause of death in over half of suicides in Australia (2010-2015) with a BAC ≥0.05 g/100 mL. The higher the BAC detected at autopsy, the more likely cases were to be assigned an alcohol code during the mortality coding process., (© 2020 Society for the Study of Addiction.)

The described procedure provides a rapid technique for the detection and semi-quantitation of a large number of drugs in blood. This procedure uses a minimal sample volume and employs a one-step liquid extraction and automated data processing to yield rapid turnaround times. A total of 327 of the most commonly used medicinal and illicit drugs in Australia were selected including various amphetamines, anesthetics, antidepressants, antipsychotics, anticonvulsants, benzodiazepines, beta blockers, opioid and nonopioid analgesics, stimulants, THC and a large number of synthetic cannabinoids and other novel psychoactive substances. The extracts were subject to 5-minute chromatography using a Kinetex C18 50 × 4.6 mm 2.6 μm solid-core analytical column and analyzed using a Sciex 3200 Q-TRAP MS-MS (+ ESI, MRM mode, two transitions per analyte). The method was fully validated in accordance with international guidelines. Matrix effects and extraction efficiencies were acceptable with most analytes showing > 80% response and low variation (within 25%RSD). Cannabinoids were most affected by the matrix and yielded poorest recovery values but were still detectable. Precision, accuracy, repeatability and multipoint linearity were assessed for all analytes. The method has been used in routine practice in the forensic toxicology service at the Victorian Institute of Forensic Medicine in over 6000 coronial investigations using both postmortem and clinical blood specimens. This technique has greatly increased throughput, reduced turnaround times and allowed for rapid same-day analysis of results when needed. The method is routinely used in routine overnight testing with results reported to pathologists within 4 h of data acquisition. This rapid toxicological technique is used in conjunction with other investigative processes such as full-body CT imaging, review of case circumstances and medical histories to provide an efficient death investigation process., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Pregabalin is an anticonvulsant and analgesic designed to treat neuropathic pain and partial seizure disorders and has been available in Australia as a prescription medication since 2005. Studies have found high rates of polydrug use associated with pregabalin and it is reportedly used recreationally for its euphoric and relaxing effects as well as to self-manage opioid withdrawal symptoms. A robust analytical method for the analysis of pregabalin using protein precipitation and LC/MS/MS was developed, validated and employed in routine case work. In recent years a substantial increase in pregabalin detections in coronial case submissions had been noted. This study examines the case characteristics and outcomes of 332 coronial cases submitted to the laboratory and analyzed for pregabalin between 2015 and 2017. Pregabalin was identified in approximately 5% of all coronial cases submitted during this time. A high rate of concurrent drug use with pregabalin was evident with the predominant classes being opioids, benzodiazepines and anti-depressants. Post-mortem blood pregabalin concentrations ranged from <0.05 to 140 mg/kg (median 5.5 mg/kg); however, limited interpretation of levels could be achieved as the drug was rarely identified in the absence of other drugs. Cause of death (COD) was found to be drug related in 58% of all cases, with mixed drug toxicity specifically mentioned as related to COD in 40% of cases., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

The routine analysis of driver specimens for gamma-hydroxybutyrate (GHB) is rarely performed by toxicology laboratories as the physical and chemical properties of GHB make it unamenable to the screening methods usually employed. The prevalence of the drug in driver populations has therefore only rarely been reported. This study outlines the results of the routine analysis for GHB in the blood of motor vehicle drivers in Queensland, Australia, over an eight-year period (2011-2018). The methodology for GHB analysis was updated over the course of the study; screening for GHB was conducted using GC/FID or GC/MS between 2011 and 2016 and by LC/MS/MS from 2017 onwards. Due to the endogenous nature of GHB, any specimens containing greater than 5mg/kg GHB were subjected to quantitative analysis by either; GC/MS after liquid-liquid extraction and derivatisation with BSTFA+1%TMCS (2011-2016), or by LC/MS/MS analysis after solvent precipitation from 2017 onwards. Of the 15,061 specimens analysed, 160 were positive for GHB (1.1% of all cases, range 0.4-1.8%). GHB positive drivers were 66.9% male (33.1% female) and had an average age of 32 years. The mean GHB concentration identified was 89mg/kg (range 6-354mg/kg). GHB was found to be closely associated with amphetamine type substances (ATS), particularly methylamphetamine. Though GHB was present in only 2.2% of all ATS positive specimens submitted to the laboratory, 91.2% of all GHB positive cases contained an ATS. Other drugs commonly co-administered with GHB were THC, cocaine, benzodiazepines and erectile dysfunction drugs. GHB was found to be more commonly identified in drivers from city areas and a geographical localisation of the use of the drug was identified in the Gold Coast region of Queensland., (Copyright © 2019. Published by Elsevier B.V.)

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., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Cocaine is a potent sympathomimetic drug that is associated with cardiotoxicity, including ventricular arrhythmia, systemic hypertension, acute myocardial infarction and left ventricular hypertrophy. The use of cocaine in Australia has risen steadily since the late 1990s. What remains unclear in the literature is whether cocaine-associated death can occur in the absence of other contributing factors, such as concomitant drug use or natural disease. A search was conducted on the National Coroners Information System database, to identify all deaths occurring in Victoria, Australia, between January 2000 and December 2011, where cocaine or its metabolites were detected by post-mortem toxicological analysis. All cases were closed by the Coroner. These cases were examined with regards to case circumstances, pathology and toxicology results, and coronial findings, to determine the prevalence of cardiotoxicity and the involvement of cocaine in the deaths compared with other contributing factors. There were 49 cases where cocaine, benzoylecgonine, ecgonine methyl ester, methylecgonine or cocaethylene, were detected in the 11-year period. The individuals ranged in age from 16 to 70 years (median 30). There were 36 males. In 22 cases the cause of death was determined to be drug toxicity, 22 were external injury and 5 were attributed to natural disease. The concentration of cocaine in the cases was relatively low (range 0.01-3 mg/L, median 0.1 mg/L). Cocaine metabolites were detected frequently in blood and urine: benzoylecgonine (46 cases); ecgonine methyl ester (12 cases); cocaethylene (8 cases); and methylecgonine (9 cases). Opioids were commonly detected (23 cases), in addition to amphetamines (15 cases), ethanol (17 cases) and benzodiazepines (12 cases). Of the 43 cases receiving a full autopsy, there were 14 cases involving significant heart disease. This included coronary artery disease (11 cases), an enlarged heart (5 cases), myocarditis and contraction band necrosis. Cocaine is detected relatively infrequently in Victorian coronial cases. However it appears to be associated with a significant degree of cardiotoxicity, particularly coronary artery disease and ventricular hypertrophy, independent of cocaine concentration., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

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., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Pathology files at Forensic Science South Australia were examined over a 14-year period, from January 1997 to March 2011 for cases of physician suicide. Nine cases were identified (ages, 30-69 years; median = 41 years; M:F = 3:1). Three cases (33.3%) had a history of prescription drug abuse, and eight cases (88.9%) died from lethal drug self-administration. Intravenous administration of drugs was the favored method in seven cases. In only one case was an alternative method used, involving jumping from a high building. A history of depression and/or suicidal ideation was noted in six cases (66.7%). The methods of self-destruction contrasted with the general population where hanging, carbon monoxide poisoning, and gunshot wounds are more common. Availability and knowledge of lethal effects have been shown to be important determinants in the choice of methods of suicide. Access to drugs should therefore be carefully monitored in physicians with histories of depression and/or substance abuse., (© 2012 American Academy of Forensic Sciences.)

In mid 2009 Victoria introduced compulsory drug testing of blood taken from all injured drivers taken to hospital. Δ(9)-Tetrahydrocannabinol (THC), methylamphetamine (MA) and 3,4-methylenedioxy-methylamphetamine (MDMA) are prohibited and if drivers are positive to any amount an automatic penalty is enforced. Laboratory screens were conducted on preserved blood using ELISA testing for cannabis metabolite and methylamphetamines and a fully validated LC-MS/MS method for 105 drugs including THC, amphetamines, opioids, benzodiazepines, antidepressants and antipsychotics and a number of other psychoactive substances using a minimum of two transitions per drug. Conventional GC-testing for ethanol was used to screen and quantify the presence of alcohol. 1714 drivers were tested and showed alcohol in 29% (≥ 0.01 g/100mL) and drugs in 35%. The positive rate for the three drugs prohibited by legislation was 12.5%. The prevalence of THC, MA and MDMA was 9.8%, 3.1%, and 0.8%, respectively. The range of THC concentrations in blood was 2-42 ng/mL (median 7) of which 70% had a concentration of 10 ng/mL or higher. The range of concentrations for MA and MDMA was 0.02-0.4 and 0.03-0.3mg/L (median for both drugs was 0.05 mg/L). Drugs of any type were detected in 35% of cases. The other drugs were largely prescribed drugs such as the antidepressants (9.3%) and benzodiazepines (8.9%). Neither 6-acetylmorphine nor cocaine (or benzoylecgonine) was detected in these cases., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

A fast and sensitive method was developed for detecting delta-9-tetrahydrocannabinol (THC) in oral fluid by liquid chromatography-tandem mass spectrometry (LC-MS/MS). The method is suitable for samples of small volume and low concentration. For method development and validation, neat oral fluid (200 μL) spiked with THC and d(3)-THC (internal standard) was extracted via liquid-liquid extraction (LLE). The LLE method had an extraction efficiency of 75% with no significant matrix effects observed in either diluted or neat oral fluid samples. LC was performed on a Zorbax Eclipse XDB-C18 Rapid Resolution HT column (2.1 mm × 50 mm, 1.8 μm particle size) with positive electrospray ionisation and selected reaction monitoring. The total run time was an efficient 3.5 min in isocratic elution mode. The limit of quantification was 1 ng/mL and the analysis was linear over the range of 1-500 ng/mL with a correlation coefficient of 0.9998. The imprecision (RSD) of the method was 13% and inaccuracy (MRE) was 4%. The method was subsequently applied to two neat oral fluid samples taken from a chronic cannabis smoker. It was also applied to buffer diluted residual oral fluid samples (n=48) collected using the Cozart RapiScan(®) system through the Roadside Drug Testing Program (RDTP) in NSW, Australia. A stability study was performed that revealed freezing or refrigerating resulted in comparable decreases in THC recovery from neat oral fluid at the end of two weeks of storage. Storage at room temperature even for one day invoked significant losses and is not recommended., (Crown Copyright © 2011. Published by Elsevier Ireland Ltd. All rights reserved.)

Oral fluid (OF) has become a popular specimen to test for presence of drugs, particularly in regards to road safety. In Victoria, OF specimens from drivers have been used to test for the presence of methylamphetamine (MA) and Δ(9)-tetrahydrocannabinol (THC) since 2003 and 3,4-methylenedioxy-N-methylamphetamine (MDMA) since 2006. LC-MS/MS has been used to test the most recent 853 submitted OF specimens from Victoria Police for 31 drugs of abuse including those listed in the Australian Standard AS4760-2006. At least one proscribed drug was detected in 96% of drivers, of which MA was the most common (77%), followed by THC (42%), MDMA (17%) and the combination of all three (3.9%). Opioids were detected in 14% of drivers of which 4.8% were positive for 6-acetylmorphine and 3.3% for methadone. The incidence of the opioids tramadol (1.2%) and oxycodone (1.1%) were relatively low. Cocaine (8.0%) was as commonly detected as benzodiazepines (8.0%), and was almost always found in combination with MA (7.9%). Samples positive to benzodiazepines were largely due to diazepam (3.5%) and alprazolam (3.4%), with only 0.2% of drivers combining the two. Ketamine was also detected in 1.5% of cases. While the incidences of the proscribed drugs itself are concerning, it is clear that many drivers are also using other drugs capable of causing impairment., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

A retrospective review of suicides occurring among Aboriginal people in the community in South Australia over a 5-year period was undertaken from January 2005 to December 2009. Twenty-eight cases were identified, consisting of 21 males (age range 16-44 years, mean 29.9 years) and 7 females (age range 23-45 years, mean 32.0 years). Deaths in all cases were caused by hanging (100%). Toxicological evaluation of blood revealed alcohol (39.3% of cases), cannabinoids (39.3%), benzodiazepines (10.7%), opiates (7.1%), antidepressants (7.1%), amphetamines (3.6%) and volatiles (3.6%). This study has demonstrated that the method of suicide overwhelmingly preferred by indigenous victims in South Australia is hanging. The precise reasons for this preference are uncertain, however, an indigenous person in South Australia presenting as a suicide where a method other than hanging has been used would be exceedingly uncommon, raising the possibility of alternative manners of death., (Copyright © 2011 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

All cases of fatal oxycodone toxicity presenting to the New South Wales Department of Forensic Medicine over the period January 1, 1999, to December 31, 2008, were retrieved. A total of 70 cases were identified. The mean age was 48.9 years, 58.6% were men, 21.4% were suicides, and in 30% oxycodone had not been prescribed to the decedent. Injecting drug users constituted 27.1% of cases, and oxycodone tablets were injected immediately prior to death by 21.4%. The mean blood oxycodone concentration was 0.40 mg/L (range 0.06-53.00 mg/L). In all cases, psychoactive substances other than oxycodone were also detected, most frequently hypnosedatives (68.6%), other opioids (54.3%), antidepressants (41.4%), and alcohol (32.9%). Preexisting systemic disease was common: cardiovascular (64.2%), pulmonary (49.3%), hepatic (66.7%), and renal (43.9%)., (© 2011 American Academy of Forensic Sciences.)

Serotonin-active drugs are detected relatively frequently in Victorian deaths. During 2002-2008, there were 1123 fatalities where one or more of the serotonin-active drugs tramadol, venlafaxine, fluoxetine, sertraline, citalopram, paroxetine and MDMA, were detected. These deaths were reviewed using pathology, toxicology and police reports, to determine the contribution of these drugs to the cause of death, particularly if serotonin toxicity was the mechanism of death. There were 28 cases of most interest to this research because of the presence of the target drugs and the circumstances suggesting the likelihood of serotonin toxicity involvement in death. There were 5 cases of reported serotonin toxicity and 23 other deaths suspected to have involved this form of toxicity. Tramadol featured most commonly out of the seven target drugs and was frequently detected in combination with serotonergic antidepressants. MDMA was also detected relatively commonly and was associated with moclobemide in 4 cases of confirmed serotonin toxicity. There were an additional 1095 cases where natural disease, external injury or the misuse of other drugs caused death, of which 2 reported the incidental contribution of serotonin toxicity.

To determine the effects of a sudden and sustained reduction in heroin purity on the toxicology of heroin overdose, 959 consecutive heroin overdose cases autopsied at the NSW Department of Forensic Medicine (1/1/1998-31/12/2006) were analysed. There was a significant reduction in blood morphine concentration across the study period (beta=-0.07), declining from a median of 0.50mg/L in the years 1998-2000 prior to 0.40mg/L in the period 2001-2006. There was no significant change in the proportion of alcohol positive cases, but the proportion of benzodiazepine positive cases increased across time (OR 1.11), as did methadone positive cases (OR 1.12). The decline in blood morphine concentrations remained significant after controlling for these factors (beta=-0.07). In determining toxic and lethal morphine concentrations, the fact that the toxicology of overdose is responsive to changes in the opioid street market needs to be borne in mind.

In the present study, the effects of amphetamine-class drugs were examined in cases reported to the Victorian coroner from 2001 to 2005 to determine if death can occur from the use of amphetamine-class drugs alone. A total of 169 cases were reviewed where a forensic autopsy detected amphetamine(s) in the blood. Pathology, toxicology, and police reports were analyzed in all cases to ascertain the involvement of amphetamine-class drugs in these deaths. In Victoria, methamphetamine (MA) is the principal abused amphetamine-class followed by methylenedioxymethamphetamine (MDMA). There were six cases in which a cerebral hemorrhage caused death and three cases in which serotonin syndrome was established as being caused by the interaction of MDMA and moclobemide. There were 19 cases in which long-term use of amphetamines was associated with heart disease. There were three cases where amphetamine-class drugs alone were regarded as the cause of death, of which two cases exhibited high levels of MDMA and lesser amounts of MA and/or amphetamine. There were no cases in which significant natural disease was absent and death was regarded as caused by the use of MA. There was no correlation between blood concentration of drug and outcome.

To determine the prevalence and circumstances of psychoactive substances amongst nonoverdose completed suicide, 1436 consecutive cases autopsied at the NSW Department of Forensic Medicine over the period 1/1/1997-12/31/2006 were analyzed. Substances were detected in 67.2% of cases, and illicit drugs in 20.1%. Alcohol was present in 40.6% of cases. Males were more likely to be positive for alcohol, cannabis, and psychostimulants, and females for pharmaceuticals. Illicits were associated with younger age. Alcohol was most prominent amongst toxicity cases, as were opioids, psychostimulants amongst gunshot cases, and pharmaceuticals amongst drownings. Cases in which drug and alcohol histories were noted were more likely to have a substance detected. Alcohol was more common where a suicide note was left and where relationship problems were involved. Pharmaceuticals were more common where a previous attempt was noted. Licit and illicit substances are strongly associated with suicide, even when the method does not involve drug overdose.

To determine the prevalence and circumstances of psychoactive substances amongst homicide victims, 485 consecutive cases autopsied at the NSW Department of Forensic Medicine (1/1/1996-12/31/2005) were analyzed. Substances were detected in 62.6% of cases, and illicit drugs in 32.8%. Alcohol, cannabis, opioids, and psychostimulants were most commonly detected. Alcohol and cannabis were both more prevalent amongst males. Mean ages were significantly younger for decedents who tested positive for a substance and for an illicit drug. Cases where death resulted from a physical altercation were more likely to have had alcohol and cannabis present. Illicit drugs were prominent amongst firearms deaths. The proportion of alcohol positive cases increased from 25.0% on Monday to 49.4% for Saturdays/Sundays. Alcohol was more common in incidents in the 0001-0600 h and 1800-2400 h periods. Psychoactive substances appear to substantially increase the risk of homicide, although there are important differences between drug classes in the circumstances of such incidents.

There were 13,176 roadside drug tests performed in the first year of the random drug-testing program conducted in the state of Victoria. Drugs targeted in the testing were methamphetamines and Delta(9)-tetrahydrocannabinol (THC). On-site screening was conducted by the police using DrugWipe, while the driver was still in the vehicle and if positive, a second test on collected oral fluid, using the Rapiscan, was performed in a specially outfitted "drug bus" located adjacent to the testing area. Oral fluid on presumptive positive cases was sent to the laboratory for confirmation with limits of quantification of 5, 5, and 2 ng/mL for methamphetamine (MA), methylenedioxy-methamphetamine (MDMA), and THC, respectively. Recovery experiments conducted in the laboratory showed quantitative recovery of analytes from the collector. When oral fluid could not be collected, blood was taken from the driver and sent to the laboratory for confirmation. These roadside tests gave 313 positive cases following GC-MS confirmation. These comprised 269, 118, and 87 cases positive to MA, MDMA, and THC, respectively. The median oral concentrations (undiluted) of MA, MDMA, and THC was 1136, 2724, and 81 ng/mL. The overall drug positive rate was 2.4% of the screened population. This rate was highest in drivers of cars (2.8%). The average age of drivers detected with a positive drug reading was 28 years. Large vehicle (trucks over 4.5 t) drivers were older; on average at 38 years. Females accounted for 19% of all positives, although none of the positive truck drivers were female. There was one false positive to cannabis when the results of both on-site devices were considered and four to methamphetamines.