Drug checking to improve monitoring of new psychoactive substances in Australia

As has been reported previously in the Journal, 1 novel psychoactive stimulant drugs are now increasingly prevalent in patients presenting to hospital emergency departments. A further cluster of 11 patients showing confusing hallmarks of sympathomimetic poisoning but no identifiable substance presented to St Vincent ’ s Hospital in Sydney over a public holiday weekend in April 2015. Also, the start to the 2015 e 2016 summer festival season has included multiple deaths and hospitalisations following drug use at festivals, leading to calls for novel actions to protect public health. 2 Here, we take the opportunity to describe a method of harm minimisation that has been deployed in Europe and could potentially be deployed locally to tackle this problem. As has been reported previously in the Journal, 1 novel psychoactive stimulant drugs are now increasingly prevalent in patients presenting to hospital emergency departments. A further cluster of 11 patients showing confusing hallmarks of sympathomimetic poisoning but no identifiable substance presented to St Vincent ’ s Hospital in Sydney over a public holiday weekend in April 2015. Also, the start to the 2015 e 2016 summer festival season has included multiple deaths and hospitalisations following drug use at festivals, leading to calls for novel actions to protect public health. 2 Here, we take the opportunity to describe a method of harm minimisation that has been deployed in Europe and could potentially be deployed locally to tackle this problem

Risk of discharge against medical advice among hospital inpatients with a history of opioid agonist therapy in New South Wales, Australia: a cohort study and nested crossover-cohort analysis

Background: People who use illicit opioids have high rates of hospital admission. We aimed to measure the risk of discharge against medical advice among inpatients with a history of opioid agonist therapy (OAT), and test whether OAT is associated with lower risk of discharge against medical advice. Methods: We conducted a cohort study of patients admitted to hospital in an emergency between 1 August 2001 and 30 April 2018 in New South Wales, Australia. All patients had a previous episode of OAT in the community. The main outcome was discharge against medical advice, and the main exposure was whether patients had an active OAT permit at the time of admission. Results: 14,035/116,957 admissions (12 %) ended in discharge against medical advice. Admissions during periods of OAT had 0.79 (0.76−0.83; p < 0.001) times the risk of discharge against medical advice, corresponding to an absolute risk reduction of 3.0 percentage points. Risk of discharge against medical advice was higher among patients who were younger, male, identified as Aboriginal and/or Torres Strait Islander, and those admitted for accidents, drug-related reasons, or injecting-related injuries (such as cutaneous abscesses). In a subsample of 7793 patients included in a crossover-cohort analysis, OAT was associated with 0.84 (95 % CI 0.76−0.93; p < 0.001) times the risk of discharge against medical advice. Conclusions: Among patients with a history of OAT, one in eight emergency hospital admissions ends in discharge against medical advice. OAT enrolment at the time of admission is associated with a reduction of this risk

Addressing injecting related risks among people who inject both opioids and stimulants: Findings from an Australian survey of people who inject drugs

Background: Opioids and stimulants are the most commonly injected illicit drugs worldwide and in Australia. While some people who inject drugs (PWID) prefer either opioids or stimulants, others regularly use both opioids and stimulants. Limited available research indicates that those who use opioids and stimulants together, either in combination or alternating between the two, may engage in injection-related practices which potentially place them at greater health risk and could lead to poorer health outcomes. Methods: Participants were recruited nationally through member organizations of the Australian Injecting and Illicit Drug Users League (AIVL); these organizations represent PWID in each Australian state and territory. This study compared a sample of PWID (N = 535) who reported past-month injection of opioids only (N = 173), stimulants only (N = 208), or both (N = 154) on a range of health and wellbeing outcomes. PWID completed a survey assessing drugs injected, frequency of injecting, receptive equipment sharing, psychological distress, self-reported hepatitis C (HCV) status, experienced and internalized stigma, drug use salience, and community attachment. Results: People who injected both opioids and stimulants reported more frequent injecting, more experiences of stigma, and greater reported HCV diagnosis than people who injected stimulants or opioids alone. They also showed greater attachment to a community of PWID and greater salience of drug use to their identity. Conclusions: The findings of increased injecting and broader harms associated with injecting both stimulants and opioids are important for tailoring harm reduction and intervention designs for people who use both opioid and stimulant drugs, including prioritizing peer-based approaches

Inpatient GHB withdrawal management in an inner-city hospital in Sydney, Australia: a retrospective medical record review

Rationale: Regular consumption of gamma-hydroxybutyrate (GHB) may result in a dependence syndrome that can lead to withdrawal symptoms. There are limited data on medications to manage GHB withdrawal. Objectives: To examine characteristics associated with delirium and discharge against medical advice (DAMA), in the context of implementing a GHB withdrawal management protocol at an inner-city hospital in 2020. Methods: We retrospectively reviewed records (01 January 2017–31 March 2021), and included admissions that were ≥ 18 years of age, admitted for GHB withdrawal, and with documented recent GHB use. Admissions were assessed for demographics, medications administered, features of delirium, ICU admission, and DAMA. Exploratory analyses were conducted to examine factors associated (p < 0.2) with features of delirium and DAMA. Results: We identified 135 admissions amongst 91 patients. Medications administered included diazepam (133 admissions, 98.5%), antipsychotics (olanzapine [70 admissions, 51.9%]), baclofen (114 admissions, 84%), and phenobarbital (8 admissions, 5.9%). Features of delirium were diagnosed in 21 (16%) admissions. Delirium was associated with higher daily GHB consumption prior to admission, while duration of GHB use, time from presentation to first dose of diazepam, and concomitant methamphetamine use were inversely associated with delirium. DAMA occurred amongst 41 (30%) admissions, and was associated with a longer time from presentation to first dose of baclofen, while being female and receiving a loading dose of diazepam were inversely associated. Conclusions: This study adds to the literature in support of the safety and feasibility of diazepam and baclofen for the management of GHB withdrawal. Prospective, randomised trials are required

Estimating the functional form for the density dependence from life history data

Two contrasting approaches to the analysis of population dynamics are currently popular: demographic approaches where the associations between demographic rates and statistics summarizing the population dynamics are identified; and time series approaches where the associations between population dynamics, population density, and environmental covariates are investigated. In this paper, we develop an approach to combine these methods and apply it to detailed data from Soay sheep (Ovis aries). We examine how density dependence and climate contribute to fluctuations in population size via age- and sex-specific demographic rates, and how fluctuations in demographic structure influence population dynamics. Density dependence contributes most, followed by climatic variation, age structure fluctuations and interactions between density and climate. We then simplify the density-dependent, stochastic, age-structured demographic model and derive a new phenomenological time series which captures the dynamics better than previously selected functions. The simple method we develop has potential to provide substantial insight into the relative contributions of population and individual-level processes to the dynamics of populations in stochastic environments

[Accepted Manuscript] A Systematic Review on Harmful Alcohol Use Among Civilian Populations Affected by Armed Conflict in Low- and Middle-Income Countries.

There are currently over 55 million refugees and internally displaced persons due to armed conflict. In addition, there are around 150 million more conflict-affected residents who remain in their home communities. Armed conflict poses a number of potential risks for harmful alcohol use. The objective of the study was to systematically examine evidence on harmful alcohol use among conflict-affected populations in low- and middle-income countries. A systematic review methodology was used following PRISMA guidelines. Quantitative studies were selected with outcomes relating to harmful alcohol use among conflict-affected populations in low- and middle-income countries. Seven bibliographic databases and a range of gray literature sources were searched. Descriptive analysis was applied and a quality assessment conducted using the Newcastle-Ottawa Quality Assessment Scale. The search yielded 10,037 references of which 22 studies met inclusion criteria. Twenty-one of the studies used a cross-sectional design, and 1 used a case series design. Evidence on risk factors for harmful alcohol use was weak overall. Factors associated with harmful alcohol use were male gender, older age, cumulative trauma event exposure, and depression. There were no studies on the effectiveness of interventions for harmful alcohol use. The strength of evidence was also limited by the generally moderate quality of the studies. Substantially more evidence is required to understand the scale of conflict-associated harmful alcohol use, key risk factors, association of alcohol use with physical and mental disorders, and effectiveness of interventions to address harmful alcohol use in conflict-affected populations

Trial protocol of an open label pilot study of lisdexamfetamine for the treatment of acute methamphetamine withdrawal

Introduction Methamphetamine (MA) use disorder is an important public health concern. MA withdrawal is often the first step in ceasing or reducing use. There are no evidence-based withdrawal treatments, and no medication is approved for the treatment of MA withdrawal. Lisdexamfetamine (LDX) dimesilate, used in the treatment of attention deficit hyperactivity disorder and binge eating disorder has the potential as an agonist therapy to ameliorate withdrawal symptoms, and improve outcomes for patients. Methods A single arm, open-label pilot study to test the safety and feasibility of LDX for the treatment of MA withdrawal. Participants will be inpatients in a drug and alcohol withdrawal unit, and will receive a tapering dose of LDX over five days: 250mg LDX on Day 1, reducing by 50mg per day to 50mg on Day 5. Optional inpatient Days 6 and 7 will allow for participants to transition to ongoing treatment. Participants will be followed-up on Days 14, 21 and 28. All participants will also receive standard inpatient withdrawal care. The primary outcomes are safety (measured by adverse events, changes in vital signs, changes in suicidality and psychosis) and feasibility (the time taken to enrol the sample, proportion of screen / pre-screen failures). Secondary outcomes are acceptability (treatment satisfaction questionnaire, medication adherence, concomitant medications, qualitative interviews), retention to protocol (proportion retained to primary and secondary endpoints), changes in withdrawal symptoms (Amphetamine Withdrawal Questionnaire) and craving for MA (visual analogue scale), and sleep outcomes (continuous actigraphy and daily sleep diary). Discussion This is the first study to assess lisdexamfetamine for the treatment of acute MA withdrawal. If safe and feasible results will go to informing the development of multi-centre randomised controlled trials to determine the efficacy of the intervention

LiMA: A study protocol for a randomised, double-blind, placebo controlled trial of lisdexamfetamine for the treatment of methamphetamine dependence

© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. Introduction Methamphetamine dependence is a growing public health concern. There is currently no pharmacotherapy approved for methamphetamine dependence. Lisdexamfetamine (LDX) dimesylate, used in the treatment of attention-deficit hyperactivity disorder and binge eating disorder, has potential as an agonist therapy for methamphetamine dependence, and possible benefits of reduced risk of aberrant use due to its novel formulation. Methods and analysis A double-blind randomised controlled trial will be used to evaluate the efficacy of LDX in reducing methamphetamine use. The target sample is 180 participants with methamphetamine dependence of =2 years, using =14 days out of the previous 28, who have previously attempted but not responded to treatment for methamphetamine use. Participants will be randomly assigned to receive either a 15-week intervention consisting of induction (1 week of 150 mg LDX or placebo), maintenance (12 weeks of 250 mg LDX or placebo) and reduction (1 week of 150 mg LDX or placebo and 1 week of 50 mg LDX or placebo). All participants will be given access to four sessions of cognitive-behavioural therapy as treatment as usual and receive a 4-week follow-up appointment. The primary outcomes are efficacy (change from baseline in days of methamphetamine use by self-report for the last 28 days at week 13 and urinalyses confirmation of methamphetamine use) and safety (treatment-related adverse events). Secondary outcomes are total number of days of self-report methamphetamine use over the 12-week active treatment, longest period of abstinence during treatment period, percentage of achieving =21 days abstinence, craving, withdrawal, dependence, retention, bloodborne virus transmission risk behaviour, criminal behaviour, as well measures of abuse liability, physical and mental health, other substance use, cognitive performance, psychosocial functioning, treatment retention and satisfaction. Additionally, the study will assess the cost-effectiveness of LDX relative to the placebo control. Ethics and dissemination The study has been approved by the Human Research Ethics Committee of St. Vincent's Hospital, Sydney, Australia (HREC/16/SVH/222). Contact the corresponding author for the full trial protocol. Trial registration number ACTRN12617000657325; Pre-results

'The Drug Survey App': a protocol for developing and validating an interactive population survey tool for drug use among Aboriginal and Torres Strait Islander Australians.

BACKGROUND: Disadvantage and transgenerational trauma contribute to Aboriginal and Torres Strait Islander (Indigenous) Australians being more likely to experience adverse health consequences from alcohol and other drug use than non-Indigenous peoples. Addressing these health inequities requires local monitoring of alcohol and other drug use. While culturally appropriate methods for measuring drinking patterns among Indigenous Australians have been established, no similar methods are available for measuring other drug use patterns (amount and frequency of consumption). This paper describes a protocol for creating and validating a tablet-based survey for alcohol and other drugs ("The Drug Survey App"). METHODS: The Drug Survey App will be co-designed with stakeholders including Indigenous Australian health professionals, addiction specialists, community leaders, and researchers. The App will allow participants to describe their drug use flexibly with an interactive, visual interface. The validity of estimated consumption patterns, and risk assessments will be tested against those made in clinical interviews conducted by Indigenous Australian health professionals. We will then trial the App as a population survey tool by using the App to determine the prevalence of substance use in two Indigenous communities. DISCUSSION: The App could empower Indigenous Australian communities to conduct independent research that informs local prevention and treatment efforts