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.

Objective To illustrate the toxicosurveillance role of the Emerging Drugs Network of Australia – Victoria (EDNAV) project in informing timely harm minimisation interventions. Methods Utilisation of an ethics approved clinical registry storing de‐identified clinical and analytical data on Victorian ED illicit drug‐related presentations. Results In April 2022, six adults presented to hospital with varying levels of sedation, following the use of counterfeit benzodiazepines. Comprehensive toxicological analysis identified five separate novel benzodiazepines within blood samples from each patient. A public ‘Drug Alert’ was subsequently issued, and local emergency physicians were notified. Conclusion Toxicosurveillance projects, such as EDNAV, are critical to the continued monitoring and reporting of illicit substance use in the community.

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.

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

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