Thanjira Jiranantakan’s research while affiliated with The University of Sydney and other places

Introduction Novel opioids, including non‐medical and non‐opium‐based opioids such as fentanyl analogues and nitazenes, pose a significant risk of harm due to their high potency. There is little published data on novel opioid detections and harms in Australia, yet they are implicated in multiple deaths. This study describes the detections and harms of novel opioids in New South Wales. Methods A retrospective analysis was conducted using four statewide datasets: Coronial Toxicology, the Illicit Drug Analysis Unit, the Prescription, Recreational and Illicit Substance Evaluation Program (PRISE), and the NSW Poisons Information Centre. These datasets were interrogated for available data (cases or substances seized by police) on novel opioid detections between 1 January 2019 and 31 May 2024. Results Overall, there were 106 novel opioid detections in 103 cases. PRISE identified 91% of clinical cases, reflecting the program's reach. Fentanyl analogues predominated until 2021, whereas nitazenes predominated from 2022. Most detections were acetylfentanyl ( n = 54), followed by isotonitazene detections ( n = 13). Positive detections were more frequent in urine compared to blood, supporting testing on both samples. Overall numbers were low, but they were often associated with harm, including deaths. Discussion and Conclusions We anticipate that these data underestimate the harms from novel opioids; for example, these drugs are not being tested routinely in laboratory testing of biological samples, and not all police seizures are analysed. A change in the predominant novel opioid was observed during the study period. Enhancing systems for readiness to detect and respond to novel opioids is vital, including resourcing laboratories.

Objective Recent years have seen sporadic reports in Australia of stimulants being contaminated with opioids. Since late 2023, there has been an increase in opioid overdoses among individuals in New South Wales (NSW) using substances believed to be cocaine or methamphetamine. We analysed the frequency and characteristics of these cases and describe our public health responses. Methods The Prescription, Recreational & Illicit Substance Evaluation (PRISE), operated by NSW health since July 2018, is a statewide surveillance, epidemiology, and toxicity response programme. We did a retrospective analysis of each case of opioid toxicity following use of cocaine or methamphetamine submitted to the PRISE programme from January 2022 to June 2024, categorising cases into confirmed, probable, and suspected. Results Thirty‐four cases were found, 19 involving cocaine and 15 involving methamphetamine. Twenty‐two (65%) were classified as confirmed, and 12 (35%) as probable. There were two deaths (6%). Twenty‐three cases (68%) were in Sydney. Multiple stakeholders reviewed trends and formulated public health responses, leading to the distribution of public drug warnings and media releases in November 2023 and February 2024 because of ongoing case detections. Conclusions The increase in detections, which continued in the months following the public health responses, underscores the need for comprehensive surveillance, response, monitoring, and reporting of this phenomenon in NSW. Engagement with clinicians and the community is essential for the success of this programme.

Objective: Adulteration, substitution or contamination of illicit substances can have clinically significant implications when other illicit substances are included. Such circumstances can present as clusters of poisonings, including severe toxicity and death following exposure to unexpected illicit substances. We report a cluster of laboratory-confirmed lysergic acid diethylamide (LSD) in a powder that was sold as cocaine and used recreationally. Methods: The Prescription, Recreational and Illicit Substance Evaluation (PRISE) program established by the New South Wales Ministry of Health includes State-based hospital toxicology services, Poisons Information Centre, Forensic & Analytical Science Service and emergency services to identify clusters of severe and unusual toxicity associated with substance use. PRISE criteria include a known cluster (geographically or situationally related) of people with acute severe toxicity, especially when accompanied by a toxidrome that is inconsistent with the history of exposure. A timely comprehensive drug screen and quantification is performed in eligible cases and the results are related to the clinical features. The need for a public health response is then considered. Four individuals inhaled a white powder that was sold as cocaine and developed severe toxicity that was not consistent with cocaine which prompted transfer to hospital for further management. Results: LSD was confirmed in four subjects, and the concentrations in 3 of the individuals were 0.04-0.06 mg/L which are among the highest reported in the literature. Common clinical features were hallucinations, agitation, vomiting, sedation, hypertension, and mydriasis. One subject required intubation and admission to the intensive care unit, two required overnight admission, and the fourth was discharged following oral diazepam after observation. No subject suffered persistent injury. Conclusions: A close working relationship between pre-hospital emergency services, hospital-based clinical services, public health authorities, and analytical laboratories appears to be advantageous. Favourable clinical outcomes are observed from LSD poisoning despite high exposures with good supportive care.

Objective: Communication Skills via Health Literacy (CSvHL) was a pilot elective communication skills training (CST) course, which allowed preclinical medical students to gain communication competence through the experience of being a health educator for high school students (HSSs). The efficacy of CSvHL was explored. Materials and Methods: All 10 medical students were prepared for their HSS-health-educator roles by participating in several observation sessions at an outpatient department and via communication workshops. In-field health education courses were subsequently delivered to HSSs by the medical students. Developments of the medical students’ communication skills were fostered through loops of learning activities and regular feedbacks. Assessments of the pre- and post-CSvHL communication skill levels by means of an OSCE, with adapted ComON Check were evaluated by each medical student, a standardized patient, and three medical instructors. Results: In general, the overall and category-specific average ComON Check scores of the whole class were significantly improved after the CSvHL course. The 3 communication defects with the lowest scores in the pre-CSvHL assessments were subsection division, summarization, and comprehension-check while counseling. Conclusion: CSvHL was successfully established as a preclinical-year CST course. The improvements in the ComON Check scores reflected the transformative learning gained from the hands-on experience, individualized CST, and 360° feedback OSCE for communication skill assessment.

Background There are limited epidemiological studies on emerging trends in suicide methodology relating to Internet promotion of toxic substances. We investigated time trends and demographic characteristics of deliberate self-poisonings with sodium nitrite/nitrate following Internet promotion for euthanasia in 2017 and a cluster of poisonings. Methods Retrospective observational study of the National Coronial Information System (2000 – June 2020), Poisons Information Centres, toxicology services (2004 – June 2020) and a scoping review including Embase and MEDLINE (2000 – June 2020) for deliberate self-poisonings with sodium nitrite/nitrate. We examined survival, date, gender, age, setting, geographical location, history of a terminal or psychiatric illness, product. Results We identified 66 deliberate self-poisonings, who were mostly male (65%) with a wide age distribution (median: 44 years; IQR: 24–66 years; range: 16–92 years; mode: 20–29 years). The majority had a fatal outcome (80%). A sudden and sustained step-increase in poisonings was seen from September 2017 (and the first death). Most cases (83%) had a psychiatric illness and no terminal illness (91%). There were 33 unique cases (mostly young adults) identified in the scoping review from eight countries. Conclusions The promotion of suicide methodology was associated with a dramatic change in harms from sodium nitrite/nitrate in the past two decades. The signal generated by poisons centre cases was confirmed using national coronial data and pooled poisoning data. Learning Outcomes State public health actions to date have focused on means restriction, improved antidote stocking and clinical education. National and international collaboration is needed for monitoring promoted lethal substances.