In response to the evolving threat of illicit substance use in Australia, public health bodies and advisory committees have called for an enhanced public health response including greater visibility related to community illicit drug use, particularly novel psychoactive substances (NPS). Victorian state government agencies recommended the development of a state-wide illicit drug early warning system (EWS), utilising data-sharing collaborations between emergency physicians, forensic laboratories, researchers, and health services. Current monitoring modalities utilised in Australia, such as surveys, wastewater monitoring and coronial investigations, lack the specificity and/or responsiveness required for an effective EWS. Clinical toxicity observed in patients presenting to emergency departments (EDs) following exposure to an illicit drug provides an objective and timely measure of harm. Although illicit drug EWS exist in other jurisdictions, not all utilise high-quality forensic analysis and instead rely on patient-reported exposure. However, there is evidence demonstrating poor correlation between reported exposure and forensic analytical findings. The Emerging Drugs Network of Australia Victoria (EDNAV) was therefore created to provide a clinical registry collecting high-quality clinical and analytical data from Emergency Department (ED) illicit drug presentations, combined with a multi-disciplinary expert team to analyse registry data and provide intelligence to a state illicit drug EWS.

The EDNAV is a Human Research Ethics Committee (HREC) approved project created in conjunction with a pilot project utilising data from wastewater analysis, syringe residue analysis and ED illicit drug presentations to provide health authorities with intelligence on community drug use. Patients 16years of age or older presenting to one of eleven EDNAV project EDs with reported or suspected illicit drug related toxicity requiring a venipuncture as part of their standard clinical care are eligible for registry inclusion. Blood samples from cases are transferred weekly to the Victorian Institute of Forensic Medicine (VIFM) Toxicology Department. Overnight liquid chromatography-tandem mass spectrometry (LC-MS/MS) screens for 327 common pharmaceuticals and illicit substances (including ∼80 NPS), followed by a secondary NPS specific screen targeting 268 NPS. The NPS specific screen is actively updated based on emerging drug intelligence and literature reports. The HREC approved waiver of patient consent to include deidentified clinical and analytical data into a purpose built secure on-line (REDCap platform) registry. Forensic and clinical toxicologists/emergency physicians produce intelligence reports based on EDNAV registry data, which are provided to department of health policy officers to identify triggers and/or threats that lead to interventions designed to reduce community harm.

There were 700 ED illicit drug presentations included in the EDNAV registry during the period September 2020–February 2022 (71% male, median age 33 years). Eighty-seven percent of patients arrived in ED via ambulance. Overall clinical acuity was high with 22% Australasian triage category 1 (require immediate treatment), and 62% category 2 (require treatment within 10minutes), while 47% of patients were classified as having moderate, and 41% severe clinical toxicity. In additional to traditional illicit substances, novel substance detections included illicit benzodiazepines (n=10), cathinones (n=9), synthetic cannabinoid receptor agonists (n=6), and opioids (n=3).

Forensic analyses revealed that in over 90% of cases there were different and/or additional drugs detected in comparison to the reported exposure, suggesting significant drug adulteration, drug substitution or under-reporting and highlighting the potential limitations of illicit drug EWS that do not utilise high-quality forensic analysis. Three public health alerts have been released in Victoria as the result of EDNAV registry intelligence, involving detections of N-ethylpentylone, 25B-NBOH, and paramethoxymethamphetamine.

The EDNAV registry project has highlighted the critical role of a high-quality forensic analytical service in an illicit drug EWS in the state of Victoria.