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Background: The age of people who use illicit opioids has increased, with a clinical picture of accelerated ageing. The study aimed to determine, stratified by age: 1. The circumstances and characteristics of heroin-related toxicity deaths in Australia, 2020-2022; 2. The toxicological profile and autopsy findings; 3. The proportion of cases in which blood 6-acetyl morphine (6AM) was detected, as a measure of survival time., Methods: Retrospective study of 610 cases of fatal heroin-related drug toxicity in Australia, 2020-2022. Cases were stratified as: <30 years, 30-39 years, 40-49 years, ≥50 years., Results: Compared to the youngest group, those aged ≥50 years were more likely to have a history of chronic pain (12.4 v 3.3 %), to have their death attributed to combined drug toxicity/disease (20.1 v 3.3 %), and to have evidence of a sudden collapse (21.3 v 11.1 %). There were no differences in free morphine concentrations or glucuronide concentrations. Compared to the youngest group, however, the two older groups were significantly more likely to have 6AM present in blood, a proxy measure of a shorter survival time (52.0, 55.2 v 34.5 %). Compared to the youngest group, cases aged ≥50 years were more likely to be diagnosed with cardiomegaly (44.0 v 16.7 %), coronary artery disease (46.0 v 15.0 %), emphysema (35.0 v 5.1 %), hepatic steatosis (15.4 v 3.4 %), hepatic fibrosis (17.6 v 3.4 %), and cirrhosis (19.8 v 0.0 %)., Conclusions: Older cases of heroin overdose had more extensive heart, lung, and liver disease, and appeared more likely to have shorter survival times., Competing Interests: The author confirm that there is no financial, or personal interest or belief that could affect their objectivity in the conduct of this study., (© 2024 The Authors.)

Introduction: The study aimed to determine: 1. The characteristics of all recorded cases of fatal drug poisoning involving 'novel' benzodiazepines (NBZDs) in Australia; 2. The toxicology of cases; and 3. The major autopsy findings., Methods: Retrospective study of all deaths due to drug toxicity in Australia in which NBZDs were present in blood toxicology, retrieved from the National Coronial Information System (2000-2021). Information was collected on case characteristics, toxicology and major organ pathology., Results: A total of 40 cases were identified, the first occurring in 2015, with a median age of 26.5 years and 87.5% being male. Death was due to accidental toxicity in 92.5% of cases. There were extensive histories of substance use problems (80.0%) and mental health problems (32.5%). Etizolam was the most common NBZD (87.5%), followed by flubromazolam (15.0%), with other NBZDs detected in 20.0% (delorazepam, diclazepam, flualprazolam, flubromazepam, lormetazepam). Multiple NBZDs were present in 27.5%. Other drugs were present in 97.5%, most commonly opioids (70.0%), registered benzodiazepines (62.5%), psychostimulants (45.0%) and gabapentinoids (32.5%). A CNS depressant other than a NBZD was detected in 95.0% (n = 38). Autopsies were conducted and available for 30 cases, with pulmonary oedema (76.7%, n = 23), aspiration of vomitus (46.7%, n = 14) and acute bronchopneumonia (36.7%, n = 11) the most common diagnoses., Conclusions: The 'typical' NBZD-related death was a young male who died due to accidental toxicity. Deaths most frequently involved etizolam and multiple substances, particularly depressants., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Introduction: Opioid dependence is a global health priority, currently making the biggest contribution to drug-related deaths. The chronic, long-term persistence of heroin dependence over the life course requires investigation in prospective longitudinal studies, to better understand patterns and predictors of remission and relapse, as well as the impact of changes in substance use on a range of physical and mental health outcomes. Such knowledge is critical in order to identify modifiable risk factors that can be targeted for intervention. Crucial unanswered questions include the following: What are the long-term rates of mortality? What are the long-term patterns and predictors of heroin use, remission, psychiatric health and health service use? What are the long-term physical health consequences of heroin use?, Methods and Analysis: The 18-20-year follow-up of the Australian Treatment Outcome Study (ATOS) cohort will examine the natural history of heroin dependence of an existing cohort of 615 people with heroin dependence, who were recruited into the study in 2001-2002. Five waves of follow-up interviews have since been completed, at 3-month, 1-year, 2-year, 3-year and 10-11-year post-baseline. At the 18-20-year follow-up, the ATOS cohort is (on average) approaching their 50s and an average of 30 years have passed since they first used heroin. The 18-20-year follow-up will consist of: (1) a structured interview; (2) physical health assessment; and (3) data linkage. The results of this follow-up will improve our understanding and management of age-related disorders in this population, which if not addressed in the immediate future, has the capacity to overwhelm treatment centres and aged care facilities., Ethics and Dissemination: Ethical approval has been granted for the study (Sydney Local Health District Royal Prince Alfred Zone, Human Research Ethics Committee X18-0512 & HREC/18/RPAH/733). The results of the study will be disseminated through published manuscripts, bulletins and technical reports, as well as conference, seminars, webinar and workshop presentations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Novel Psychoactive Substances (NPS), especially Synthetic Cannabinoid Receptor Agonists (SCRAs), pose a substantial challenge to health and the security of the prison environment. This study analyses the phenomenon from the perspective of people in prison and that of professionals working with them., Methods: A phenomenological qualitative approach was used to analyze self-reported experiences with 'Spice' (NPS) among users in prison. A semi-structured questionnaire was also disseminated among professionals working in these settings to better understand (a) the impact of NPS on their work; (b) perceived issues on safety in their working environment; (c) approaches used to tackle the phenomenon and best practices., Results: Psychotic events resulting from the collected Spice accounts (5) were marked by hallucinations, depression, self-harm, and suicidal ideations. Other emerging elements included fear, paranoia, inability to be with others, mistrust, breakdown and other risky behaviors. Overall, 186 responses from prison staff were collected across the country. 67% claimed NPS to have had a deep impact on their work as they commonly witnessed espisodes involving outbursts of anger, slurred speech, hallucinations, psychosis, and significant mental deterioration among those in prison. Some 91% have witnessed aggression at least once, with 53% experiencing direct harm. Suggested interventions included enhanced training and education (84%), improved detection (92%) and treatment and support services (93%)., Conclusions: Findings highlight the urgent need for joint multi-disciplinary efforts to tackle the exponential escalation of NPS in prisons as well as to facilitate the recovery and societal reintegration of those affected. Phenomenology can be recommended as a valuable methods to study drug induced experiences., (Copyright © 2020 Corazza, Coloccini, Marrinan, Vigar, Watkins, Zene, Negri, Aresti, Darke, Rinaldi, Metastasio and Bersani.)

Background: Heroin is currently contributing to the worst drug addiction epidemic in United States history; recent rates of use, dependence and death have also increased dramatically in parts of Europe. An improved understanding of the long-term relationship between heroin use and treatment utilisation is essential to inform both clinical and public health responses. We aimed to identify i) joint trajectories of heroin use and treatment utilisation, ii) predictors of joint group membership, and iii) outcomes associated with joint group membership; over 10-11 years among a cohort of Australians with heroin dependence., Methods: A total of 615 people with heroin dependence were recruited as part of a prospective longitudinal cohort study between 2001 and 02. This analysis focuses on 428 participants (70.1% of the original cohort) for whom complete data were available over 10-11 years., Findings: Five joint trajectory groups were identified: i) 'long-term stable' (17%: decrease in probability of heroin use alongside high treatment utilisation); ii) 'long-term success' (13%: decrease in heroin use alongside decreased treatment utilisation, until there was maintained abstinence from heroin with no treatment utilisation); iii) 'treatment failure' (12%: no decrease in heroin use alongside high treatment utilisation); iv) 'late success' (9%: gradual decrease in heroin use alongside increased treatment utilisation); and v) 'relapsed' (9%: relapse in heroin use alongside an increase and decrease in treatment utilisation). Few variables were found to predict joint group membership, but group membership was predictive of demographic, substance use and physical and mental health outcomes at 10-11 years., Interpretation: The role of treatment in recovery from heroin dependence is undeniable; however, a considerable proportion of people are able achieve and maintain abstinence without the need for ongoing treatment. An equally significant proportion will continue to use heroin despite being in long-term treatment., Funding: Australian National Health and Medical Research Council., (© 2019 Published by Elsevier Ltd.)

Background and Purpose- Fatal stroke during pregnancy and the puerperium is rare. Pregnancy-related hypertension and vascular abnormalities underlie significant proportions of pregnancy-related stroke, but up to one-quarter are of no known cause. Methods- Case series of fatal pregnancy-related stroke. All cases where the cause of death was attributed to stroke during pregnancy/postpartum were retrieved from the National Coronial Information System database (January 1, 2009 to December 31, 2016). Results- Fourteen fatal strokes were identified, all hemorrhagic in origin. Underlying causes included pregnancy-related hypertension, rupture of vascular malformations, vasculitis, and cardiomyopathy. Conclusions- Fatal pregnancy-related stroke occurred secondary to hemorrhages of heterogeneous causes, including pregnancy-related hypertension and previously undiagnosed risk factors.

Background: The cardiovascular impact of cocaine use in otherwise healthy individuals who consider themselves 'social' users is not well established., Methods/results: Twenty regular cocaine users and 20 control subjects were recruited by word-of-mouth. Cardiovascular magnetic resonance was performed to assess cardiac and vascular structure and function. Cocaine users had higher systolic blood pressure compared to non-users (134±11 vs 126±11 mmHg, p = 0.036), a finding independent of age, body surface area, smoking and alcohol consumption. Cocaine use was associated with increased arterial stiffness - reflected by reduced aortic compliance (1.3±0.2 vs 1.7±0.5 cm2×10-2.mmHg-1, p = 0.004), decreased distensibility (3.8±0.9 vs 5.1±1.4 mmHg-1.10-3, p = 0.001), increased stiffness index (2.6±0.6 vs 2.1±0.6, p = 0.005), and higher pulse wave velocity (5.1±0.6 vs 4.4±0.6 m.s-1, p = 0.001). This change in aortic stiffness was independent of vessel wall thickness. Left ventricular mass was 18% higher in cocaine users (124±25 vs 105±16 g, p = 0.01), a finding that was independent of body surface area, and left atrial diameter was larger in the user group than controls (3.8±0.6 vs 3.5±0.3 cm, p = 0.04). The increased left ventricular mass, systolic blood pressure and vascular stiffness measures were all associated with duration and/or frequency of cocaine use. No late gadolinium enhancement or segmental wall motion abnormalities were seen in any of the subjects., Conclusions: Compared with the non-user control cohort, cocaine users had increased aortic stiffness and systolic blood pressure, associated with greater left ventricular mass. These measures are all well known risk factors for premature cardiovascular events, highlighting the dangers of cocaine use, even in a 'social' setting, and have important public health implications.

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.

To determine annual patterns and correlates of nonfatal heroin overdose across 3 years, data were analyzed on 387 heroin users recruited for the Australian Treatment Outcome Study (ATOS), interviewed at 12, 24, and 36 months. A heroin overdose across follow-up was reported by 18.6%, and naloxone had been administered to 11.9%. Annual rates of overdose declined between baseline and 12 months and then remained stable. Previous overdose experience was strongly related to subsequent overdose. Those with a history of overdose before ATOS were significantly more likely to overdose during the study period. In particular, there was a strong association between overdose experience in any 1 year and increased overdose risk in the subsequent year. This is the first study to examine long-term annual trends in nonfatal heroin overdose. While overdose rates declined after extensive treatment, substantial proportions continued to overdose in each year, and this was strongly associated with overdose history.

Objective: This study examined the costs and outcomes of treatment for opiate dependence associated with posttraumatic stress disorder (PTSD)., Methods: Data were collected on the use of opiate treatment over a 12-month period for a cohort of 495 individuals, of whom 42 percent had PTSD. Total treatment costs were calculated as the sum of the time spent in each treatment modality multiplied by the appropriate unit cost. Outcome measures included occupational functioning, use of heroin and other drugs, and physical and mental health., Results: No significant difference was noted in the cost of treatment over the 12-month period for persons with and without PTSD (5,394+/-5,136 and 4,821+/-5,144 [Australian dollars], respectively). However, persons with PTSD had poorer treatment outcomes in terms of occupational functioning, overdose, and physical and mental health., Conclusions: Although the same resources were invested in opiate treatment for persons with and without PTSD, PTSD continued to be associated with poorer functioning in a number of domains at 12-month follow-up. A well-designed intervention targeting both heroin dependence and PTSD may help to improve the outcomes of persons with PTSD.

A sample of 183 current cocaine users, 120 primary injecting cocaine users (ICUs), and 63 primary noninjecting cocaine users (NICUs) were administered a structured interview to ascertain attempted suicide histories, methods used, and factors associated with suicide attempts. All respondents were volunteers and current cocaine users recruited through a wide range of sources. The mean age of participants was 30.1 years, and 65% were male. The ICUs were older (32.3 vs. 26.7 years, respectively), more likely to be male (72% vs. 54%, respectively), to be unemployed (84% vs. 23%, respectively) and to have a prison history (53% vs. 1%, respectively) compared to NICUs. Of the sample, 31% had attempted suicide, 18% had done so on more than one occasion, and 8% had made an attempt in the preceding 12 months. Overall, 28% of the sample had been treated by a medical practitioner after an attempt. ICUs (38%) were significantly more likely than NICUs (10%) to have attempted suicide and to have done so on more than one occasion (23% vs. 3%, respectively). The most common method used among both groups was self-poisoning (ICUs 28%, NICUs 8%), primarily by drug overdose. Violent methods had been used by 22% of ICUs and 3% of NICUs. Multivariate analyses revealed that injecting, female gender, and more extensive polydrug use were independent predictors of a suicide attempt. The prevalence of suicide in this study indicates that it represents a major clinical issue among ICUs and to a lesser extent among noninjectors of the drug. Those treating cocaine users for drug dependence need to be aware of the salience of suicide as a problem, among injectors in particular.

Drug overdose is a major cause of premature death and morbidity among heroin users. This article examines recent research into heroin overdose to inform interventions that will reduce the rate of overdose death. The demographic characteristics of overdose cases are discussed, including factors associated with overdose: polydrug use, drug purity, drug tolerance, routes of administration, and suicide. Responses by heroin users at overdoses are also examined. Potential interventions to reduce the rate of overdose and overdose-related morbidity are examined in light of the emerging data in this field.

Objectives: To determine the clinical outcome of subintimal angioplasty (SA) and to assess impact on surgical workload., Design: Retrospective review of a single radiologist's case series., Materials: One hundred and twenty two patients with critical limb ischaemia and 26 with claudication., Methods: One hundred and fifty eight limbs treated by SA., Main Outcome Measures: Technical success and complications; cumulative patency, limb salvage and survival; affect of SA on vascular workload., Results: The technical success rate was 85%. There were 26 procedural complications (16%) but no patient required emergency surgery; 30-day mortality was 3%. Primary and secondary 12-month patency rates were 27 and 33%. Limb salvage rate was 88% at 12 months. SA initially reduced the number of patients needing arterial surgery, although this then increased due to late failure of SA and an increase in de novo bypass., Conclusions: SA carries a low risk of major complications and high immediate technical success. Poor long-term patency suggests that SA is not as durable as bypass surgery. However, failed SA did not compromise subsequent surgery, which only became necessary in a proportion of patients. Our data suggests that there is little to be lost by using SA as first-line treatment for patients with limb-threatening ischaemia who are poor operative risks or who have no autologous vein available.