Cherie Heilbronn

Trends in amphetamine-related harms in Victoria.

TO THE EDITOR: In the 21 November 2011 issue of the Journal, Sara and colleagues identified 97 000 Australians as heavy stimulant users,1 and McKetin and Lubman detailed the public health importance of heavy stimulant consumption, emphasising impacts of “ice”(crystal methamphetamine).2 In addition, there has been growing concern over rising ice use in Australia and related harms, including psychosis, stroke and cardiac abnormalities.2 In Victoria, there is evidence of significant increases in ice use among people who inject drugs (from 36% in 2010 to 53% in 2011)3 and regular “ecstasy” (methylenedioxymethamphetamine; MDMA) users (from 18% in 2010 to 38% in 2011).4 To examine this issue, we conducted an exploratory study using multiple indicators of amphetamine-related harm from July 2010 to June 2012. Metropolitan Melbourne ambulance attendance data, coded by researchers who are trained to identify alcohol and other drug (AOD) involvement in ambulance presentations,5 are unique in terms of capacity to distinguish use of ice from use of other amphetamines at a population level. Comparing the 2010–11 and 2011–12 financial years, a 318% increase in ice-related attendances (3.4 to 14.2 attendances per 100 000 population) underpinned a substantial rise in all amphetamine-related attendances (11.1 to 21.1 attendances per 100 000 population). The greatest increase occurred among people aged 15–29 years (8.4 to 39.0 attendances per 100 000 population) — an Australian subpopulation with higher rates of heavy stimulant use1 and increased risk of harms.2 Other indicators also suggest an increasing incidence of harms. Comparing 2010–11 and 2011–12, amphetamine-related episodes of care provided by Victorian AOD services increased by 77% (66.2 to 117.2 episodes per 100 000 population), while amphetaminerelated calls to DirectLine, Victoria’s telephone AOD helpline, increased by 194% (1090 to 3210 calls). Compared with our 2011–12 data, all indicators of amphetamine-related harms were lower during the previous peak in ice-related harms (July 2006 to June 2007): 5.1 icerelated ambulance attendances per 100 000 population; 87.3 amphetamine-related episodes of care per 100 000 population; and 2739 amphetamine-related calls to DirectLine. The data presented here were collated for administrative purposes and limitations exist, with increased media interest in drug use possibly contributing to higher reporting of harms.5 However, consistent upward trends across multiple datasets suggest that increasing harms are real and not an artefact of data collection practices. As such, these findings support growing public health concerns regarding increases in amphetamine-related harms.

Trends in quetiapine use and non‐fatal quetiapine‐related ambulance attendances

INTRODUCTION AND AIMS Concern about the non-medical use of quetiapine and related acute harms is growing. Case series cite quetiapine as a potential drug of misuse, while recent research questions its relative safety in comparison with other atypical antipsychotic preparations. This paper explores population-level patterns of quetiapine-related ambulance attendances over time, identifying associated risk factors and potential subpopulations at-risk of acute harms. DESIGN AND METHODS A retrospective analysis of quetiapine-, olanzapine- and risperidone-related ambulance attendances in metropolitan Melbourne and prescription data in Victoria, Australia. Trends in ambulance attendance and prescription rates, attendance characteristics, and associated risk factors were explored from 2001 to 2010. RESULTS Quetiapine was consistently associated with substantially higher rates of ambulance attendances relative to prescription availability than olanzapine or risperidone. Quetiapine prescribing rates increased at a significantly greater magnitude than olanzapine or risperidone, leading to substantial increases in quetiapine attendances by population. Quetiapine-related attendances were associated with concurrent heroin and opioid replacement therapy toxicity, history of heroin and alcohol misuse, mood disorders, low Glasgow Coma Scale and women. DISCUSSION AND CONCLUSIONS Trends in quetiapine-related ambulance attendances indicate rising community-level harms and greater harm relative to other atypical antipsychotics, while prescription patterns suggest increasing quetiapine availability. The association of quetiapine-related attendances with concurrent heroin and opioid replacement therapy toxicity as well as previous heroin and alcohol misuse suggest illicit and poly-drug users are a subpopulation at greater risk of quetiapine-related harms, consistent with emerging evidence of the use, misuse and diversion of quetiapine.

Absence of Detectable Influenza RNA Transmitted via Aerosol during Various Human Respiratory Activities – Experiments from Singapore and Hong Kong

Two independent studies by two separate research teams (from Hong Kong and Singapore) failed to detect any influenza RNA landing on, or inhaled by, a life-like, human manikin target, after exposure to naturally influenza-infected volunteers. For the Hong Kong experiments, 9 influenza-infected volunteers were recruited to breathe, talk/count and cough, from 0.1 m and 0.5 m distance, onto a mouth-breathing manikin. Aerosolised droplets exhaled from the volunteers and entering the manikin’s mouth were collected with PTFE filters and an aerosol sampler, in separate experiments. Virus detection was performed using an in-house influenza RNA reverse-transcription polymerase chain reaction (RT-PCR) assay. No influenza RNA was detected from any of the PTFE filters or air samples. For the Singapore experiments, 6 influenza-infected volunteers were asked to breathe (nasal/mouth breathing), talk (counting in English/second language), cough (from 1 m/0.1 m away) and laugh, onto a thermal, breathing manikin. The manikin’s face was swabbed at specific points (around both eyes, the nostrils and the mouth) before and after exposure to each of these respiratory activities, and was cleaned between each activity with medical grade alcohol swabs. Shadowgraph imaging was used to record the generation of these respiratory aerosols from the infected volunteers and their impact onto the target manikin. No influenza RNA was detected from any of these swabs with either team’s in-house diagnostic influenza assays. All the influenza-infected volunteers had diagnostic swabs taken at recruitment that confirmed influenza (A/H1, A/H3 or B) infection with high viral loads, ranging from 105-108 copies/mL (Hong Kong volunteers/assay) and 104–107 copies/mL influenza viral RNA (Singapore volunteers/assay). These findings suggest that influenza RNA may not be readily transmitted from naturally-infected human source to susceptible recipients via these natural respiratory activities, within these exposure time-frames. Various reasons are discussed in an attempt to explain these findings.

Timeliness of Salmonella Typhimurium notifications after the introduction of routine MLVA typing in NSW.

Salmonella Typhimurium is the most common bacterial cause of gastrointestinal disease in NSW. Regular review of surveillance procedures ensures system objectives are met and informs improvements in system utility and efficiency. This paper assesses the timeliness and data completeness of NSW Salmonella Typhimurium surveillance after the routine introduction of multilocus variable repeat analysis (MLVA), a rapid sub-typing technique. MLVA results were available significantly earlier than alternate sub-typing techniques over the 2 years of this review. Accordingly, from a timeliness perspective, MLVA offers a favourable Salmonella Typhimurium sub-typing option in NSW. Further opportunities to improve timeliness and data completeness are identified. This paper was produced as part of a review of Salmonella Typhimurium surveillance in NSW for the period 2008-2009 by members of OzFoodNet based at Hunter New England Population Health. OzFoodNet is a national network established by the then Commonwealth Department of Health and Ageing in 2000 to enhance foodborne disease surveillance in Australia.

Pharmaceutical opioid overdose deaths and the presence of witnesses

BACKGROUND In the past two decades, rates of pharmaceutical opioid use and harms resulting from their use (including death) have risen. The present study identified a series of fatal opioid overdoses where there was evidence that witnesses had noted symptoms consistent with overdose, and examined associated contextual factors. METHODS A retrospective review was undertaken utilising the Coroners Court of Victorias Overdose Deaths Register for pharmaceutical opioid overdose deaths between 2011 and 2013. Information on the source of pharmaceutical opioids, co-contributing drugs, history of drug dependence, and mental illness was extracted and coded. RESULTS Pharmaceutical opioids were involved in 587 deaths, and within these, 125 cases (21%) were witnessed. The majority of these witnessed deaths (77.6%) occurred at the deceaseds residence, with the witness being a partner or unrelated acquaintance who did not realise the significance of what they were witnessing. The most common contributing pharmaceutical opioids were methadone (49.6%), codeine (32.0%), and oxycodone (19.2%), with the source more often prescribed than diverted. Co-contributing drugs were involved in 110 cases, with the most common being benzodiazepines. Evidence of current dependence and mental illness was found in 53.6% of cases. CONCLUSION Most pharmaceutical opioid overdose deaths with a witness present occurred in the deceaseds home, with symptoms of overdose being noted, but not acted upon. These findings support the trialling of education and/or naloxone to partners and family members of people who use pharmaceutical opioids in order to reduce overdose deaths.

Commentary on Meng et al. (2014): Diverging alcohol consumption across populations—issues for policy and intervention

Meng and colleagues [1] provide a detailed exploration of alcohol consumption trends in the British general population over a 25-year period, taking into account gender differences in age, period and cohort effects. Using time–series modelling to understand drinking patterns more clearly is essential in identifying risky alcohol consumption, and also anticipating and responding to changing patterns of acute and chronic alcohol-related harms over time. In developed countries, alcohol-related harms are increasing in the context of apparently stable alcohol consumption levels within the general population [2–5]. There are several potential explanations for these divergent trends. Alcohol consumption surveys are limited by poor response rates, meaning that inherent differences between participants and those who decline can mask the true consumption patterns within the community [6]. Also, routine data collection practices, using home telephones and home drop-and-collect methodology, are barriers to recruitment of hard-to-reach populations, such as homeless and institutionalized people, culturally and linguistically diverse populations and other disadvantaged groups [6]. We must also acknowledge that national consumption surveys underestimate true alcohol consumption by as much as 30–70% when compared with sales or taxation data [7]. Under-reporting is grounded in participant provision of estimates lower than actual consumption, poor recruitment of high alcohol consumers in hard-toreach populations and the reluctance of high alcohol consumers to consent to participate [6]. However, the approach used by Meng and colleagues—time–series analysis using data collected consistently over an extended period—allows trend comparison over time. Expressly, if under-reporting or under-sampling of highrisk populations resulted in consumption underestimation, such limitations are likely to have occurred consistently across the data collection years. Rising consumption among specific subpopulations, while masked by overall survey results, may be driving the growth in alcohol-related harm [8]. Polarization of alcohol consumption patterns is an increasingly evident cross-country trend, with higher abstention rates occurring in tandem with increasing very high-risk alcohol consumption (for example, more than 20 drinks in a single occasion) among different populations [9,10]. Such trends reflect shifting population characteristics and cultural norms regarding alcohol consumption, simultaneously posing new challenges and opportunities in alcohol-related harm reduction efforts. Meng’s work provides important insights into changes in genderspecific consumption in the context of age, period and cohort effects. However, other factors influencing the polarization of alcohol consumption must also be examined, such as the role of social determinants of health and accompanying differential levels of risk of acute and chronic harm [11,12]. Tailored surveillance models for sensitive reporting of alcohol consumption within and across subpopulations, rather than assuming a homogeneous general population, is vital. Refocusing research to the subpopulation level enhances evidence for targeted prevention and intervention as well as the means to evaluate such activities. Meng et al. provide a sound example of the usefulness of such refined subpopulation evidence. Changing consumption patterns identified within the younger and older populations represent important opportunities for policymakers and health service providers. Historically, there has been a strong focus on risky drinking and acute harm among younger people [13]. However, increasing abstention and reducing consumption in Meng’s youngest cohort indicates a credible opportunity to promote drinking culture change, particularly regarding the perceived acceptability of drinking and drunkenness. Conversely, higher consumption levels in older cohorts represent new challenges and more complex issues in terms of acute and chronic harm prevention, intervention and treatment. Responding to this changing trend requires a shift in thinking. Specifically, older people may need to be considered an at-risk population before appropriate priorities and approaches to alcohol-related harm prevention and treatment can be implemented. The sensitive and more sophisticated alcohol consumption surveillance technique employed by Meng and colleagues—which could be extrapolated to other populations, particularly high-risk groups—can inform innovative prevention and treatment options in the future.