The toxicology and characteristics of fatal new psychoactive stimulant and hallucinogen-related poisonings in Australia, 2000–2025

Recent years have seen marked increases in the non-medical use of ketamine. We aimed to determine: (i) the population mortality rates of self-administered fatal ketamine-related poisoning cases in Australia, 2000-2022; (ii) the characteristics, toxicology and major autopsy findings of cases in Australia, 2000-2025; and (iii) changes in case characteristics across the period 2000-2025. Retrospective study of fatal ketamine-related poisoning in Australia retrieved from the National Coronial Information System. 118 cases were identified, 100 (84.7%) of which occurred after 2014. There was a significant upward trend in event rates between 2000 and 2022 (IRR = 1.16). The mean age was 36.2 years and 77.1% were male. The majority (72.9%) of poisonings were unintentional, in 19.5% the final route of ketamine administration was by injection, and a history of substance use problems was documented in 50.8%. There were no significant differences in these case characteristics across the study period. In 14 cases, the decedent was documented as being prescribed take-home ketamine at the time of death and had consumed this medication. The median blood ketamine concentration was 0.20 mg/L (range 0.01-25.0), which did not significantly differ across time. Psychoactive drugs other than ketamine were present in all cases, most frequently hypnosedatives (68.6%) and opioids (62.7%), with a significant difference across time observed in the presence of hypnosedatives (OR 1.45). Cardiomegaly was diagnosed in 13.9% and cardiac fibrosis in 11.1%. There has been a significant increase in self-administered ketamine-related poisoning deaths. Caution should be exercised in prescribing ketamine for self-administration.

Characteristics and circumstances of death related to new psychoactive stimulants and hallucinogens in Australia

Concerns about intentional and unintentional poisoning present a barrier to wider use of clozapine in treatment-resistant schizophrenia. The objective of this study was to investigate decedent demographics and trends in fatal poisonings in Australia involving clozapine. This was a retrospective case series of all fatal drug toxicity reported to an Australian coroner between 1 May 2000 and 31 December 2016 where toxicological analysis detected clozapine. Cases were identified using the National Coronial Information System. Demographics extracted included age and gender of the decedent, year and location of death, cause and manner of death and drugs detected in post-mortem samples. There were 278 poisoning deaths where clozapine was detected in toxicological analyses. Three-quarters of all cases (n = 207) involved men and the median age at death was 38.5 years (interquartile range: 16 years). Three-quarters of the deaths occurred in the home. Overall, 15.8% of deaths were deemed intentional, 57.5% unintentional and 24.5% of unknown intent. While the annual number of intentional self-poisonings remained constant with <5 per year, the overall number of fatalities increased due to an increase in unintentional poisonings. Multiple drug toxicity was reported in 55.0% of cases and clozapine alone in 45.0% of cases. The most common co-reported medications were antidepressants, benzodiazepines and opioids detected in 47.1%, 44.4% and 41.2% of multiple drug toxicities, respectively. This was the first Australia-wide review of all fatal drug poisonings reported to a coroner involving clozapine. Fatalities were most common in men and occurred at home. Multiple drug toxicity generally involved psychotropic, sedative or opioid analgesic medications. Despite increasing clozapine use, rates of intentional poisoning have remained constant and low. Developing a better knowledge of unintentional fatalities presents an opportunity to minimise harm.

Large administrative databases provide powerful opportunities for examining the epidemiology of injury. The National Coronial Information System (NCIS) contains Coronial data from Australia and New Zealand (NZ); however, only closed cases are stored for NZ. This paper examines the completeness of NZ data within the NCIS and its impact upon the validity and utility of this database. A retrospective review of the capture of NZ cases of quad-related fatalities held in the NCIS was undertaken by identifying outstanding Coronial cases held on the NZ Coronial Management System (primary source of NZ Coronial data). NZ data held on the NCIS database were incomplete due to the non-capture of closed cases and the unavailability of open cases. Improvements to the information provided on the NCIS about the completeness of NZ data are needed to improve the validity of NCIS-derived findings and the overall utility of the NCIS for research.

Fatal poisonings in children comprise a small proportion of cases investigated by an Australian coroner; however, they present a major opportunity for death prevention. This study aimed to examine fatal child poisonings in Australia to (1) estimate the rate of acute poisoning deaths in children; (2) describe the key characteristics of the cohort; and (3) describe the outcomes of coronial recommendations made as a death prevention measure. Retrospective case series. The National Coronial Information System (NCIS), a database of cases reported to an Australian coroner. Ninety poisoning deaths reported to an Australian coroner between January 2003 and December 2013 involving children (≤16years of age). Logistic regression, Pearson's correlation coefficient and descriptive statistics were used to examine the significance of associations. The primary outcome measures were poisoning type and cause of death. Covariates included age and mental illness. There were marginally more males (52.2%) [confidence interval (CI)=44.4-45.6] in the cohort and most occurred in the 13-16-year age group (58.9%) (CI=7.5-12.5). Deaths were typically unintentional (61.1%) (CI=17.9-27.1) and occurred in the home (68.9%) (CI=6.8-15.7). The most common form of poisoning was due to opioids (24.4%), followed by carbon monoxide (20%) and volatile substances (18.9%) (CI=18.5-19.6). Males had slightly higher odds of dying from prescription opioids compared with females [odds ratio (OR)=1.9, CI=0.7-5.1], but this was not statistically significant. A recommendation was made by a coroner in 12 cases, 10 of which related to poisons (including drugs). Of these, eight recommendations were implemented. In Australia between 2003 and 2013 there were on average eight acute poisoning deaths in children each year, most commonly involving prescription opioids and adolescents. There has been a downward trend in mortality since 2003. These cases generated more than twice as many recommendations for public safety compared with other Australian coroners' cases.

Deaths due to poisoning involving novel benzodiazepines (NBZDs) are increasing. We aimed to determine: 1. The characteristics, toxicology and major autopsy findings of known cases of NBZD-related poisoning in Australia, 2000-2025; and 2. Changes in characteristics of known cases from 2020 onwards compared to earlier known cases. Retrospective study of fatal NBDZ-related poisoning in Australia retrieved from the National Coronial Information System. 258 cases were identified, the first in 2013 (2013-2019: 33, 2020-2025: 225). The mean age was 31.9 years and 217 were male, which did not change. 2020s cases were more likely to have histories of injecting drug use (52.0v 21.2 %, OR 4.0) and mental health issues (55.1v 30.3 %, OR 2.8). Fifteen NBZDs were detected, nine first detected in the 2020s. The most frequent were etizolam (48.9 %) and bromazolam (38.0 %). Cases in the later period were more likely to have multiple NBZDs detected (39.6v 12.1 %, OR 4.7). The most common other drug classes were opioids (74.8 %) and registered hypnosedatives (62.4 %). There were no differences between cases in the later and earlier periods in the presence of depressants (94.7v 93.9 %), or psychostimulants (52.0v 39.4 %). Acute bronchopneumonia was less common in the later period (18.2v 40.0 %, OR 1.5). The 2020s saw a large increase in poisoning deaths related to NBZDs. As testing varied across time and jurisdiction and new NBZDs are constantly appearing the true extent of NBZD-related poisoning deaths is likely to be higher than those identified.

Quetiapine is an atypical antipsychotic that has been associated with both intentional and unintentional deaths. We aimed to determine, stratified by intentionality: (1) The characteristics and circumstances of adult deaths attributed solely to quetiapine toxicity in Australia, 2000–2024; (2) The blood toxicology of cases for quetiapine and other drugs; and (3) The major autopsy findings for cardiovascular, lung, kidney, and liver disease. All cases of death aged ≥15 years attributed solely to quetiapine toxicity in Australia, 2000–2024, were retrieved from the National Coronial Information System. We identified 136 adult cases attributed solely to quetiapine toxicity. In 64.7% (n = 88), the fatal poisoning was deemed intentional, unintentional in 19.9% (n = 27), and of undetermined intent in 15.4% (n = 21). The mean age was 42.4 years (range 15–69) and 58.1% (n = 79) were male. A history of mental health problems was documented in 92.6% (n = 126). The median quetiapine concentration was 12.0 mg/L (range 1.2–600.0), with that of intentional cases being twice that of unintentional cases (13.0 vs. 6.3 mg/L). Other psychotropic drugs not considered contributory to death were present in 73.0% (n = 92) of cases, most commonly hypnosedatives (34.1%, n = 43) and antidepressants (33.3%, n = 42). Hearts were examined in 87 cases, of which 31.0% (n = 27) were diagnosed with cardiovascular disease. Given these findings, screening patients prescribed quetiapine for suicide histories and ideation is prudent, as is monitoring cardiovascular disease. For forensic pathologists, the extent and nature of cardiovascular disease appear important for the formulation of death, and suicide should be borne in mind.

To examine deaths associated with methadone and buprenorphine in order to identify opportunities to improve clinical practice for opioid agonist treatment. A retrospective cohort study of methadone and buprenorphine toxicity-related deaths over a 13-year period between the 1st of January 2009 and the 31st of December 2021 in the state of Victoria, Australia. Case details were extracted from the National Coronial Information System, including treatment permit information, as well as detailed toxicological and autopsy findings. 446 fatal methadone-toxicity cases and 131 fatal buprenorphine-toxicity cases were identified over the study period. Drug diversion-related deaths accounted for almost half (46.2 %, n = 206) of the fatal methadone toxicity cases, and 41.2 % (n = 54) of fatal buprenorphine toxicity cases over the study period. For people in current treatment, high risk prescription and illicit drug combinations were commonly seen in unintentional fatal drug toxicity cases. For buprenorphine-related deaths this included 75 % (n = 38) of cases that involved other opioids, 77 % (n = 39) that involved CNS depressants, and 61 % (n = 31) with a combination of other opioids, benzodiazepines and buprenorphine. Similarly, 43 % (n = 94) of methadone-related deaths also involved other opioids, with 88 % (n = 191) involving CNS depressants, including benzodiazepines in 83 % (n = 180) of cases. Almost all (96 %) unintentional drug toxicity deaths for people in treatment with methadone or buprenorphine occurred with the concomitant use of other opioid drugs or CNS depressants. Drug diversion-related deaths were also identified as an important public health issue that requires appropriate consideration to balance treatment accessibility with the drug diversion problem.

Toxicological analyses are often performed in drug-facilitated sexual assaults (DFSA), when the victim shows or reports impaired consciousness and reduced ability. However, in other crimes or fatalities, especially in cases of concurrent natural disease or when another likely cause of death has been established, the involvement of drugs can be overlooked. The aim of this study is to report a series of cases of (i) victims of drug-facilitated crimes (DFC) other than DFSA and (ii) victims of acute intoxications, in which "licit" psychoactive drugs were found in blood samples, with the aim of understanding in which circumstances and to what extent prescription drugs have been used for non-medical purposes in recent Italian casuistry. Circumstantial, autopsy, and toxicological data were collected through a retrospective analysis performed between 2013 and 2017 in the Forensic Toxicology Unit of the University of Bologna. Cases of "DFC other than DFSA" and "Acute Intoxication" in which "psychoactive drugs" or "prescription drugs" or "licit drugs" were found in the blood samples of the victims were included in the study. Nine cases of DFC other than DFSA, and 11 cases of acute intoxication, were identified. Different categories of "licit" psychoactive drugs (e.g. hypnotics, antipsychotics, antidepressants, anticonvulsants) had been used to facilitate diverse types of crime (homicide, robberies, elder abuse, fatal poisoning) or acute intoxication (suicide, attempted suicide, accidental death). The circumstances of these cases, as well as toxicological findings in blood samples and other relevant forensic elements, are reported, summarized and discussed in this paper. The non-medical use of pharmaceuticals has been identified by recent forensic literature and the present study as a significant and growing phenomenon, and its implication in fatalities should be taken into consideration and accurately investigated through appropriate toxicological analysis. Our study presents an overview of the circumstances of non-medical use of prescription drugs, usually considered "safe drugs", and their involvement in cases of DFC, suicides and accidental intoxication. In order to estimate the real incidence of these medications in DFC and acute intoxication, and thus collect more analytical and contextual data, further studies are needed, along with effective cooperation among police officers, clinicians, forensic pathologists, and toxicologists.

To (i) assess the population mortality rates of cocaine-related deaths in Australia, 2000 to 2021; (ii) determine the circumstances of death and case characteristics; and (iii) determine their toxicological profile. Retrospective study of cocaine-related deaths in Australia, 2000 to 2021, retrieved from the National Coronial Information System. Australia-wide. A total of 884 cases, mean age = 33.8 (SD, 10.0) years and 86.5% (n = 765) male. Information was collected on characteristics, manner of death and toxicology. Only cases in which the presence of blood cocaine and/or metabolites were included. Population rates did not significantly increase during 2001-2011 (annual percentage change [APC] = 1.5; CI, -3.2, 6.5), but from 2012, there was a marked acceleration (APC = 20.0, 95% CI, 15.5, 25.3). Circumstances of death were unintentional drug toxicity (70.7%, n = 625), intentional self-harm (17.8%, n = 157), traumatic accident (11.5%, n = 102). The proportion of cases constituted by unintentional toxicity declined across the study period (APC = -2.6; CI, -3.1, -2.1). There was a substantial decline in the proportion of cases with a history of injecting drug use (APC = -5.7; CI, -6.5, -4.9) and with a history of substance use problems (APC = -3.2; CI, -3.9, -2.5). Both cocaine (0.100 vs 0.050 mg/L, P < 0.001) and benzoylecgonine (0.590 vs 0.240 mg/L, P < 0.001) concentrations were higher amongst toxicity cases than in cases of death from traumatic injury. Cocaethylene was present in 26.4% (n = 233), levamisole in 18.6% (n = 164) and lignocaine in 11.5% (n = 102). Psychoactive drugs in addition to cocaine were present in 92.9% (n = 821), most commonly opioids (50.5%, n = 446), alcohol (47.1%, n = 416), hypnosedatives (43.2%, n = 382) and psychostimulants (30.3%, n = 268). There was a steady decline in the proportion of opioid positive cases (APC = -5.4; CI, -6.3, -4.5). There was a large increase in cocaine-related deaths across Australia from 2000 to 2021. This was accompanied by changes in case profiles, with histories of injecting drug use and substance use problems, as well as recent opioid use, becoming less prominent.

Differences in combinations and concentrations of drugs of abuse in fatal intoxication and driving under the influence cases

Characteristics of fatal ‘novel’ synthetic opioid toxicity in Australia

The National Coronial Information System (NCIS) is the world's first national Internet-based database of coronial information. It was established in Australia following the recognition by coroners that their mandate for public health and safety could be improved if they could identify previous similar deaths. The NCIS is funded from state, territory, and commonwealth government agencies and overseen by the NCIS Board of Management. A team of ten staff manage the day-to-day operation of the system. The NCIS enables the rapid identification of up-to-date information on deaths investigated by the coroners' jurisdictions in Australia (from July 2000) and New Zealand (from July 2007). It is accessible to death investigators (coroners; forensic, medical, and scientific staff; and police) to assist with death investigation and approved third parties (e.g., researchers). The NCIS contains demographic information about the deceased, contextual information about the circumstances in which the death occurred, the cause and manner of death, and four full text reports generated during the investigation. The NCIS contains information on over 328 000 completed coroners' death investigations across Australia and New Zealand. Approximately 350 death investigators are registered to access the data for their ongoing death investigations, and 235 third party users are registered to utilize the data set in their research. In addition to the utility of the NCIS, this paper describes the rationale and governance structure of the NCIS, the information technology infrastructure, data set, quality assurance framework, and contribution to death and injury prevention.

Suicide decline in Australia: where did the cases go?

Suicides are likely to be underreported. In Australia, the National Coronial Information System (NCIS) provides information about suicide deaths reported to coroners. The NCIS represents the findings on the intent of the deceased as determined by coroners. We used the Queensland Suicide Register (QSR) to assess the direction, magnitude, and predictors of any differences in the reporting of suicide in Queensland. Therefore, we conducted a consecutive case series study to assess agreement and variation between linked data from the NCIS and QSR determinations of suicide for all suicide deaths (N = 9520) in the QSR from 2001 to 2015 recorded from routinely collected coronial data. The rate of concordance between the QSR and NCIS for cases of intentional self-harm was 92.7%. There was disagreement between the findings in the data, since 6.3% (n = 597) were considered as intentional self-harm in the QSR but not in the NCIS, and, less commonly, 0.9% (n = 87) were considered intentional self-harm in the NCIS but not in the QSR. Overall, the QSR reported 510 more suicides than the NCIS in 15 years. These findings indicate that using suicide mortality data from suicide registers may not underreport suicide as often.