Overdose data highlight need for drug checking services

ON 29 July 2021, the Coroner’s Court of Victoria released a report presenting statistics related to drug overdose deaths for the period 2011–2020.

The report states that it is the first in a series of regular public reports on this type of data and is aimed at “supporting drug harm reduction initiatives in the community”.

Australia has a number of surveys and data systems which provide us with a good snapshot of trends in substance use and harm, which includes population monitoring through the 3-yearly National Drug Strategy Household Survey, as well as strategic warning systems, such as the annual Illicit Drug Reporting System and Ecstasy and Related Drugs Reporting System. Other data sources, such as the number of drugs seized at the Australian border, the number of people arrested for possession or use, the number of people seeking treatment, and the number of people obtaining sterile injecting equipment, further round out this picture. It is in this latter category that the Coroner’s report can be added, and it is a welcome addition.

The report includes deaths (in Victoria) where experts determined that acute toxic effects of drugs contributed to the death (excludes behavioural effects or chronic effects). Drug types included were pharmaceutical, alcohol and illegal drugs (including novel and new substances).

There were 4551 overdose deaths in Victoria between 2011 and 2020, with that number steadily increasing between 2011 and 2018 (543 in 2018), before a slight decline in 2019 (516) and 2020 (526). Over the decade, there has been a gradual increase in the rate of overdoses per 100 000 population for males and females, across urban and rural populations. Males consistently accounted for two-thirds of overdose deaths throughout the period.

Some findings that are most relevant to medication practitioners include:

• The proportion of overdoses that included multiple drugs has increased from 63% (2011) to 74% (2020). In 2020, pharmaceuticals contributed to 76% of deaths, illegal drugs to 51% and alcohol to 29% — 2020 was similar to previous years.
• Benzodiazepines (mainly diazepam) contributed to 53% of all overdose deaths in 2020, with this rate remaining unchanged from previous years. Prescription opioids (mainly methadone and oxycodone) contributed to 36% of deaths in 2020.
• Illegal drugs contributed 270 of the 526 total deaths in 2020 and included heroin (187), methamphetamine (111), novel psychoactive substances [NPS] (33), cocaine (27), gamma hydroxybutyrate [GHB] (18), and 3,4-methylenedioxymethamphetamine [MDMA] (17).
• Heroin-related deaths peaked in 2017 (220) and have since declined to 187 deaths in 2020, while methamphetamine deaths peaked in 2016 (120) and were 111 in 2019 and 2020.
• Heroin deaths in the City of Yarra, where the Richmond medically supervised injecting room is situated, decreased from 26 in 2018 (the injecting room opened in July 2018) to nine in 2020. All overdose deaths in Yarra also decreased from 32 (2018) to 25 (2019) to 17 (2020).
• Between 2019 and 2020, GHB overdoses doubled, while cocaine and MDMA also increased. Causes of these changes are unclear, but could be related to disruptions in drug markets during the COVID-19 pandemic. Small variances in GHB dose can result in overdose; for more detailed information regarding deaths related to GHB, we recommend this article by Professor Shane Darke and colleagues.
• Increased deaths from cocaine and MDMA use seems to conflict with the strong signals from surveys in 2020 suggesting that many people had decreased or stopped their use due to a lack of access to club, festival and party settings. The Global Drug Survey’s COVID-19 special edition provides some more detailed information, and we direct interested readers to that report;
• Unlike in North America, fentanyl was only detected in five deaths in 2020 in Victoria, its lowest incidence across this decade. Opioids in the NPS category, including butyl fentanyl and ocfentanil, were detected in only two deaths over the 10-year period.
• The anticonvulsant pregabalin featured in 69 deaths in 2020 and shows a consistent increasing trend across the 10-year period. This trend matches other Australian data, including from New South Wales, which can be found here.
• The COVID-19 pandemic led to increased “unsupervised” doses of methadone in 2020, but this policy change did not lead to increased overdose deaths. Indeed, there was a reduction in overdose deaths involving diverted methadone. One explanation is that lockdowns reduced opportunities for diversion.
• NPS overdose deaths have shot up from eight (2018) to 17 (2019) to 33 (2020). This could be because toxicologists are better at finding them. It is also likely that NPS were more prevalent in the illegal drug market during the COVID-19 pandemic. Novel benzodiazepines are the main driver of these trends – they were involved in 28 deaths in 2020, up from ten in 2019 and one in 2018. This category includes etizolam, which was the focus of a recent rapid review.
• NPS empathogens appeared in 2020 for the first time (n = 5). These include ethylone and eutylone. These drugs have been detected in substances sold as MDMA in New Zealand by their drug checking service KnowYourStuffNZ, and perhaps a similar substitution is also occurring here.
• There were 15 deaths associated with synthetic cannabinoid receptor agonists (SCRAs) over the decade, with most occurring in 2018–2019. Drugs detected included: 5F-Cumyl-P7AICA, 5F-Cumyl-PINACA, 5F-MDMB-PICA, AB-CHMINACA, Cumyl-PeGACLONE, and WIN55212-2. Victoria toughened its legislation on NPS in 2017. The SCRA death trends here support the concern that while blanket ban legislation may reduce overall prevalence and harm rates, it may also result in more dangerous NPS appearing on the market.

Information is power, but only if it reaches the people who need it most. Some of the data contained in the Coroner’s Court of Victoria report only serve to highlight the problem with a market that operates with no oversight – what people purchase to consume may not be what they intend to consume. Without our own drug checking service in Victoria, we lack the capacity to rapidly warn the community about what new substances and combinations are emerging.

These data show that drug checking – “an accessible service where people can get advice on how to reduce the risks associated with drug use, informed by chemical analyses of the substances they are considering taking” – is needed more than ever, as drug markets are more unpredictable and complex.

We also need to remember that every number represents a person; each number is a life lost. While the safest option when it comes to substance use is to not use them, the reality is that thousands of people continue to do so. Australia was once leading the world in reducing harms related to substance use, but there is still a lot more we could be doing to prevent overdose deaths.

Dr Monica Barratt is a Senior Research Fellow at RMIT University and a Visiting Fellow at the National Drug and Alcohol Research Centre, UNSW Sydney. She leads research activities at Global Drug Survey, The Loop Australia and Bluelight.org.

Dr Matthew Dunn is a Senior Lecturer in Public Health and a member of the Institute for Health Transformation at Deakin University. He is a member of The Loop Australia. 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.