Objectives With an increasingly dynamic global illicit drug market, including the emergence of novel psychoactive substances, many jurisdictions have moved to establish toxicosurveillance systems to enable timely detection of harmful substances in the community. This paper describes the methodology for the Emerging Drugs Network of Australia – Victoria (EDNAV) project, a clinical registry focused on the collection of high‐quality clinical and analytical data from ED presentations involving illicit drug intoxications. Drug intelligence collected from the project is utilised by local health authorities with the aim to identify patterns of drug use and emerging drugs of concern. Methods The project involves 10 public hospital EDs in Victoria, Australia. Patients 16 years and over, presenting to a network ED with a suspected illicit drug‐related toxicity and a requirement for venepuncture are eligible for inclusion in the study under a waiver of consent. Clinical and demographic parameters are documented by site‐based clinicians and comprehensive toxicological analysis is conducted on patient blood samples via specialised forensic services. All data are then deidentified and compiled in a project specific database. Results Cases are discussed in weekly multidisciplinary team meetings, with a view to identify potentially harmful substances circulating in the community. High‐risk signals are escalated to key stakeholders to produce timely and proportionate public health alerts with a focus on harm minimisation. Conclusions The EDNAV project represents the first centralised system providing near real‐time monitoring of community drug use in Victoria and is fundamental in facilitating evidence‐based public health intervention.

Benzimidazole synthetic opioids are highly potent μ-opioid receptor agonists with heroin-like effects, including dose-dependent respiratory depression and a high risk of abuse and toxicity. Benzimidazoles were first detected in 2019 in Europe and Canada, with analytical confirmation of etodesnitazene, protonitazene and butonitazene in 2021. We report the first detections of these compounds in Australia, in two patients presenting with drug toxicity to Emergency Departments in the state of Victoria. Case 1 was a female in her 20s who rectally administered etodesnitazene and was found unconscious with a respiratory depression and hypotension. Case 2 was a female in her 30s who presented to the ED in a sedated state after taking a formulation of protonitazene which also contained butonitazene, in addition to methylamphetamine. She responded positively to naloxone. Novel synthetic opioids were used with prior experience of the formulations purchased, however the unpredictability of their effects was demonstrated by the acute toxicity experienced with this occasion of use. Toxicosurveillance of Emergency Department presentations with analytical confirmation of drugs is crucial in identifying emerging drugs in the community and informing harm reduction strategies.

Objective A large number of stimulant drug‐associated deaths at music festivals in Australia were reported during the southern hemisphere summer of 2018–2019. This led to the prehospital deployment of healthcare professional‐led critical care response teams. We aimed to describe the characteristics, clinical presentation, management and outcomes of music festival patrons with stimulant drug‐induced serotonin toxicity managed using this model during the study period. Methods We performed a retrospective observational study of patients presenting with stimulant drug‐induced serotonin toxicity and/or drug‐induced hyperthermia who presented between December 2017 and December 2019. Comprehensive follow‐up data were collected for those patients who required hospital admission. Data included demographics, clinical features, management and disposition, hospital outcomes and laboratory data, stratified by severity of presentation. Results Forty‐seven patients were included. Median age was 21.9 years (interquartile range 19.6–22.2). 3,4‐Methylenedioxymetamphetamine was the most frequently reported agent ingested (32/47). After stratification, 13 of 47 patients were classified as mild, 20 of 47 as moderate and 14 of 47 as severe. Median presenting temperature in this latter cohort was 41.1°C (40.5–42.0°C). All severely ill patients required intensive care unit admission, with a median hospital stay of 4.63 days (interquartile range 2.08–8.36). End‐organ complications were reported in 11 of 14 patients. No mortalities were reported. All patients (13/13) from the mild cohort and 15 of 20 patients from the moderate cohort were treated and discharged on‐site. Conclusions Severe illness was associated with a high incidence of end‐organ impairment. A high proportion of patients without severe disease were able to be successfully managed at the event without transport to hospital. No deaths are reported in this series.

Objective: Using a strength-based framework, we aimed to describe and compare First Nations patients who completed care in an ED to those who took their own leave. Methods: Routinely collected adult patient data from a metropolitan ED collected over a 5-year period were analysed. Results: A total of 6446 presentations of First Nations patients occurred from 2016 to 2020, constituting 3% of ED presentations. Of these, 5589 (87%) patients waited to be seen and 857 (13%) took their own leave. Among patients who took their own leave, 624 (73%) left not seen and 233 (27%) left at own risk after starting treatment. Patients who were assigned a triage category of 4-5 were significantly more likely to take their own leave (adjusted odds ratio [OR] 3.17, 95% confidence interval [CI] 2.67-3.77, P < 0.001). Patients were significantly less likely to take their own leave if they were >60 years (adjusted OR 0.69, 95% CI 1.01-1.36, P = 0.014) and had private health insurance (adjusted OR 0.61, 95% CI 0.45-0.84, P < 0.001). Patients were more likely to leave if they were women (adjusted OR 1.17, 95% CI 1.01-1.36, P = 0.04), had an unknown housing status (adjusted OR 1.76, 95% CI 1.44-2.15, P < 0.001), were homeless (adjusted OR 1.50, 95% CI 1.22-1.93, P < 0.001) or had a safety alert (adjusted OR 1.60, 95% CI 1.35-1.90, P < 0.001). Conclusion: A lower triage category is a strong predictor of First Nations patients taking their own leave. It has been documented that First Nations patients are under-triaged. One proposed intervention in the metropolitan setting is to introduce practices which expediate the care of First Nations patients. Further qualitative studies with First Nations patients should be undertaken to determine successful approaches to create equitable access

Novel synthetic opioids (NSOs) are an emerging threat on the global illicit substance market. Although they represent a small proportion of new psychoactive substances (NPS) overall, the number of NPSs with opioid effects reported to the United Nations Office on Drugs and Crime (UNODC) increased significantly in the decade 2009-2019. 1which is used therapeutically in China to treat chronic pain 2 but is not registered in the United States, Europe or Australia (Figure 1). 2-MethylAP-237 was categorised as a NPS when it emerged on the illicit drug market in 2019. It was first identified by a police forensic laboratory in Slovenia in March 2019 3 and reported to the European Union Early Warning System the following month. 4 Shortly after, in June 2019, 2-methyl AP-237 was the first acylpiperazine to be reported in the United States 5 and became the second most encountered non-fentanyl-related opioid in the third quarter of 2021 according to NPS Discovery. 6 Fogarty et al. 5 reported four post mortem cases and one clinical case of 2-methyl AP-237 use between February 2020 and April 2021. Concentrations ranging between 820 and