Concerned about your own or
someone else’s drug use?

This symposium presentation introduces a novel internet-based cognitive behavioural therapy (CBT) program developed to support people to change their relationship with methamphetamine, currently in development by NCCRED. The presentation highlights the program aims, the case for iCBT for methamphetamine and product design and development considerations.

Increasingly widespread methamphetamine use disorder globally has generated renewed interest in psychostimulant agonist therapies. Recent meta-analytic data suggest high dose amphetamine or methylphenidate may be promising. We explored lisdexamfetamine – a prodrug of dexamphetamine as an outpatient treatment for methamphetamine use disorder among adults who reported at least 14 days use on the previous 28. 155 people were enrolled at 6 sites across Australia. Participants were commenced on a regimen comprising a one week induction phase of 150mg lisdexamfetamine or placebo daily, followed by a maintenance phase of 250mg lisdexamfetamine or placebo daily for 13 weeks, and a reduction phase of 150mg lisdexamfetamine or placebo daily for one week, then 50mg lisdexamfetamine or placebo daily for one week. All participants were offered cognitive behavioural therapy. There were no serious safety signals and preliminary efficacy results were encouraging for further exploration.

Liam Acheson, Carl I Moller, Krista Siefried, Brendan Clifford, Jonathan Brett, Adrian Dunlop, Paul Haber, Michael Christmass, Nick Lintzeris, Kirsten Morley, Steve Shoptaw, Madhukar Trivedi & Nadine Ezard

Presenter email: liam.acheson@svha.org.au

This open-label pilot study will examine the safety and feasibility of a combination tablet of oral naltrexone 40mg/bupropion 450mg daily over 12 weeks daily over 12 weeks for adults with methamphetamine use disorder, in an outpatient setting. The primary outcomes are safety (assessed by adverse events) and feasibility (medication adherence, retention rate, time taken to recruit entire sample, and proportion of ineligible participants at prescreening and screening stages). Secondary outcomes include changes in psychological wellbeing and quality of life from baseline to primary endpoint, acceptability of the intervention (assessed via qualitative interviews), and changes in methamphetamine use from baseline to primary endpoint.

Psilocybin-assisted Psychotherapy for Methamphetamine use disorder: Recruitment to a novel safety and feasibility trial Elizabeth Knock, Nadine Ezard, Ric Day, Krista J Siefried, Paul Liknaitzky, Marg Ross, Steve Albert, Jonathan Brett

Introduction / Issues: Treatments for Methamphetamine Use Disorder (MAUD) demonstrate modest effectiveness, leaving a requirement for novel, efficacious treatment approaches. Psilocybinassisted psychotherapy (PP) has shown promising initial results in treating a number of substance use disorders (SUD), but has yet to be trialled for MAUD. This pilot study (“PsiMA”) aims to determine if such treatment is safe and feasible for delivery within this population.

Method / Approach: Participants (n=15) will be recruited for this openlabel, single-arm study consisting of three preparatory psychotherapy sessions, one dose day using 25mg of psilocybin, and two integration psychotherapy sessions. Participants must meet criteria for MAUD, consume methamphetamine less than 16 days per month and be otherwise healthy with no history of psychotic disorders. The primary outcomes of safety and feasibility will be measured through clinical observation, monitoring of vital signs, and mental health and wellbeing throughout screening, intervention delivery, and 3-months of follow up assessments.

Results: 55 individuals have been prescreened,16 met eligibility criteria and 13 have been enrolled in the study. 12 participants have completed the intervention protocol and 6 have currently completed the study to 90-day follow up. All those who began the intervention completed it, with no serious adverse events recorded or withdrawals due to adverse events.

Discussions and Conclusions: The PsiMA study will add to the research exploring the use of PP in treatment of SUD, and provide safety and feasibility data for its use within MAUD. Future research will need to consider recruitment issues alongside growing understanding of safety profiles within this population.

Methamphetamine use typically starts in adolescence, and early onset is associated with worse outcomes. Yet, health, functional, and cognitive outcomes associated with methamphetamine use in young people are not well understood. The aim of this study was to comprehensively assess the evidence on health, functional, and cognitive outcomes in young people (10–25 years-old) who use methamphetamine. Sixty-six studies were included. The strongest association observed was with conduct disorder, with young people who use methamphetamine some 13 times more likely to meet conduct disorder criteria than controls. They were also more likely to have justice system involvement and to perpetrate violence against others. Educational problems were consistently associated with youth methamphetamine use. The cognitive domain most reliably implicated was inhibitory control. Key limitations in the literature were identified, including heterogenous measurement of exposure and outcomes, lack of adequate controls, and limited longitudinal evidence. Outcomes identified in the present review – suggesting complex and clinically significant behavioural issues in this population are informative for the development of future research and targeted treatments.

Tayla J. Degan T, Poshan Thapa, Natalia Uthurralt, Alessandra Bo, Louisa Degenhardt, Michael Farrell, Jane Mounteney, Paul Griffiths, & Rebecca McKetin.

Background: Finding evidence to support interventions for illicit substance use often requires extensive reviewing of the literature. Although such evidence is often found in systematic reviews of randomised controlled trials (RCTs), compiling this information from often disparate sources is still required. This study aimed to conduct an overview of systematic reviews on the best available evidence to support interventions for illicit substance use. Evidence statements on cannabis, opioid and stimulant use disorders were compiled along with their evidence quality.

Methods: Systematic reviews and meta-analyses on evidence relating to interventions for illicit substance use were searched using Pubmed from 2010 to March 2021. Data were extracted on the evidence for interventions from these reviews (referred to as “evidence statements”) and each was provided with a GRADE quality rating.

Results: A total of 47 evidence statements were extracted. These statements pertained to 3 topics: interventions for cannabis use disorder (n= 8), opioid use disorder (n= 27), and stimulant use disorder (n= 12). Interventions for opioid use disorder (specifically opioid agonist therapy and withdrawal management) and stimulant use disorder (psychosocial interventions) provided moderate to high quality evidence (n= 13). Within this, there was good evidence of benefits for opioid agonist treatment, medically supported opioid withdrawal, and psychosocial interventions for stimulant use disorders.

Conclusion: Although there is good evidence to support several currently used approaches for illicit substance use, much of the best available evidence is of low quality e.g., interventions to address cannabis use disorder, pharmacotherapies for stimulant use disorder, and alternatives to opioid agonist treatment. This overview of reviews provides policymakers and practitioners with a synthesis of the best available evidence for illicit substance use interventions. In addition, a website summarising the evidence statements and their quality ratings was developed to disseminate these findings in a timely, convenient, and accessible manner.

Akhurst J, Pierce A, Volpe I, Harrod M E, Sutherland R, Bruno R, Barratt M J, Sumnall H, Page R, Brown J, Keygan J, Hill P, Ezard N, Peacock A

Introduction: In Australia, drug warnings (‘drug alerts’) are released to inform people about circulating higher risk substances and promote harm reduction behaviours. This study aimed to examine awareness of, and responses to, drug alerts among people who use drugs, and identify their preferences for communication of alerts.

Methods: Australians aged ≥18 years who had used illegal/non-prescribed drugs in the past 12 months were recruited via social media, web forums, posters and word of mouth to complete the online survey between June-September 2023 (n=575).

Results: Participants (49% woman/female; 46% male/men; 5% other gender identity; median age 36 years) typically reported monthly or less frequent drug use (43%) and use of methamphetamine, cocaine and ecstasy (49%, 42%, and 41%, respectively) in the past 12 months.

More than three in four had seen a drug alert in the past five years (77%). When asked about the last alert, the most common drug types mentioned in the alert were MDMA (30%), methamphetamine (18%) and cocaine (14%). Over half shared information from the alert with someone else (58%), and 65% wanted to know more information after learning about the alert. Over half changed their use of the drug type mentioned, by stopping using the drug entirely (18%), avoiding using drugs matching the alert (20%) or changing their use behaviours (18%; most commonly by practicing safer dosing). Of those who used the drug as usual (44%), 53% said they were already using harm reduction strategies. Almost four in five participants (78%) said alerts should be triggered by clusters of overdose events; 51% said by peer reports of adverse events. The most trusted sources for issuing of drug alerts were drug checking services and harm reduction/peer-based organisations.

Conclusions: Participants demonstrated high engagement with drug alerts and a broad interest in receiving more information on circulating higher-risk substances. Communication via harm reduction services and peer-based organisations was viewed as particularly important. Findings highlight the role of drug alerts in empowering people to make informed decisions around their drug use.

Coordinated information exchange is key to responding to emerging drugs and drug trends. The Know Community professional online platform was launched in December 2022. The platform currently connects 176 people across Australia, with representation from all Australian States and Territories and a mix of professional groups, including front-line harm reduction, emergency and other health service, policy-makers, toxicologists and other analysts allowing information exchange for drug alerts at a national level. Since December 2022, there have been eleven public drug alerts issued by Australian government departments. The majority (n=6) have been related to the potent novel synthetic opioid nitazine family (including metonitazene, protonitazene and isotonitazene). Two have been related to cathinones, and three have been related to high dose MDMA. The implications of these emerging drugs will be discussed from a front line peer-based service provider perspective and the potential of realtime collaboration in enhancing prompt responses explored.

Monica J. Barratt, Matthew Ball, Gabriel T.W. Wong & Angus Quinton

Introduction: Prohibited drugs in unregulated markets are often adulterated, resulting in increased risks for consumers. This study investigated levels of adulteration and substitution in drugs purchased by Australians from cryptomarkets.

Method: Data were collected from the Dread subforum /d/Test4Pay (1/9/2022–23/8/2023). Posts were included if they reported the results of drug samples submitted to the Get Your Drugs Tested service, which uses Fourier-transform infrared spectroscopy (FTIR) with immunoassay strip tests (fentanyl and benzodiazepines).

Results: Typically, reports were made by community members funded by Test4Pay to “make undercover purchases for the purpose of lab testing”. 67% of 103 samples contained only the advertised substance, 14% contained the advertised substance in combination with other psychoactive and/or potentially harmful substances, and for 19%, the advertised substance was absent.

MDMA, methamphetamine and heroin were consistently found to contain only the advertised substance, while 2C-B, alprazolam and ketamine were the most likely to be completely substituted. Cocaine was the least likely to contain solely the advertised substance (21%), with 68% of the samples containing cocaine with adulterants like lidocaine, creatine, levamisole, and boric acid. All fentanyl tests were negative. A variety of novel dissociatives and novel benzodiazepines were detected, as well as a novel nitazene compound.

Discussions and Conclusions: Drug markets under prohibition continue to contain numerous unexpected substances, some of which elevate risk of harm dramatically for consumers. Cryptomarkets are not immune to this problem, despite review systems which should in theory make vendors more accountable for the quality of their stock.

Implications for Practice or Policy: Test4Pay demonstrates community desire to protect its members from adulteration and substitution of unregulated drugs. Legalised supply would resolve these issues, but in the context of prohibition, a local postal laboratory testing service with publicly accessible individual results would increase the effectiveness of these efforts.

Jennifer L. Smith, Courtney Weber, Francois Oosthuizen, Paul Sakrajda, Jessamine Soderstrom, Daniel Fatovich, Sam Alfred, Peter Stockham, Emma Partridge, Jennifer Schumann, Rebekka Syrjanen Katherine Isoardi, Natalie MacCormick, Amanda Thompson, Andrew Griffiths, Viet Tran, Craig Gardner & Shaun Greene

Background: Timely access to comprehensive toxicology testing of emergency department (ED) presentations is critical for identifying novel psychoactive drugs (NPS) and associated harms. The Emerging Drugs Network of Australia (EDNA) is a national toxicosurveillance system of illicit and emerging drugs presenting to sentinel EDs across Australia.

Methods: We extracted laboratory confirmed analytical data from the EDNA national clinical registry (April 2020-Oct 2023) to identify the type and frequency of traditional illicit drugs and NPS detections to date. All case biofluid samples (blood) underwent comprehensive toxicology analysis for a broad range of pharmaceutical and traditional illicit drugs and NPS by state forensic laboratories.

Results: Five states and 14 hospitals are now contributing to EDNA’s national toxicosurveillance system. Clinical and toxicological data are available on over 2,400 ED presentations. The most frequently detected traditional illicit drugs were methylamphetamine (n=1,301, 53%) and gamma-hydroxybutyrate (n=608, 25%).

A total of 298 NPS detections across 206 NPS positive cases were identified, including 39 unique types. Novel benzodiazepines comprised three-quarters of all NPS detections (n=220, 74%). Other NPS classes included designer stimulants (n=48, 16%), novel opioids (n=11, 4%), synthetic cannabinoid receptor agonists (n=11, 4%) and hallucinogens/psychedelics (n=5, 2%).

Conclusion: Early results from EDNA demonstrate a toxicosurveillance system with sufficient sensitivity to detect NPS in ED presentations across multiple jurisdictions. Data generated by EDNA and shared within jurisdictional early response networks aligns with the underpinning strategic principles of the National Drug Strategy 2017–2026, including: partnerships; coordination and collaboration; national direction, jurisdictional implementation; and evidence-informed responses.

Peter Stockham, Sam Alfred, Shaune Greene, Chris Kostakis, Francois Oosthuizen, Emma Partridge, Jennifer Schuman, Jennifer Smith, Jessamine Soderstrom, Rebekka Syrjanen, Courtney Weber & Daniel Fatovich

Background and aim: Gamma-hydroxybutyrate (GHB) is a potent sedative drug with a narrow dose window and short analytical detection time. It is a drug of abuse taken in the form of GHB itself or as 1,4-butanediol or gammabutyrolactone (GBL), which are industrial solvents that are readily converted to GHB after ingestion. The Emerging Drugs Network of Australia (EDNA) is a national toxico-surveillance initiative, collecting clinical and analytical data from emergency department (ED) illicit drug intoxications. Drawing on results from three states and 13 EDs across Australia, this study examined the demographic and ED presentation characteristics of GHB positive cases, and extent of co-detected methamphetamine (MA). Methods: Blood samples from ED patients experiencing suspected illicit drug toxicity were collected and submitted to the respective state forensic toxicology facility for comprehensive toxicological testing using locally validated protocols. De-identified demographic and toxicology data were extracted from the EDNA clinical registry.

Results: The GHB postive cohort (n=170 samples) constituted 20% of samples entered in the registry (September 2020 to September 2022 , n=862). MA was the most common codetected drug (91%, n=154). A higher proportion of the GHB positive patients were female (n=87, 51%) compared to the overall cohort (n=325, 38%). Severe, acute toxicity in GHB patients was indicated by the high proportion of ambulance arrivals (n=151, 89%) and the Australasian Triage Scores (ATS) allocated, with 105 (62%) requiring immediate care (ATS 1) and 57 (34%) requiring care within 10 minutes (ATS 2). Twenty-percent (n=35) were admitted to the intensive care unit. The median GHB concentration was 120mg/L (IQR 82-150mg/L, range 5.6-570mg/L) and the median MA concentration was 0.28mg/L (IQR 0.11-0.40mg/L, range 0.01-2.1mg/L).

Conclusions: The high co-detection rate of MA in GHB positive patients and higher than expected rates of female GHB positivity are key outcomes of this tri-state study, and are consistent with data from recent, more localised studies. Reasons behind both the high prevalence of GHB and the practice of co-use of MA with GHB in this study requires further exploration, but it may indicate a wider use of GHB as a drug of abuse than is often considered.

Background:  To support responses to harm relating to emerging drugs in Australia, the National Centre for Clinical Research on Emerging Drugs (NCCRED) engaged existing jurisdictional networks, clinicians, toxicologists, policymakers and peer organisations to develop the Prompt Response Network (PRN). A collaborative codesign process identified a series of interventions to support the Network, including a public-facing website publishing drug alerts from across Australian states and territories.

Description of intervention: Theknow.org.au is a new website developed by NCCRED as part of the PRN. It publishes drug alerts from the four Australian jurisdictions (ACT, NSW, SA, Vic) that currently issue public-facing alerts. The website was designed and developed with external agencies and supported by design activities including feedback sessions and card sorting to determine how to display and structure the alerts on a new website.

Implementation: Specifically, we designed a high-fidelity prototype of the website and conducted feedback sessions with consumer representatives and representatives of agencies issuing the alerts. These sessions informed the design of the website’s home page, landing pages and alert pages, as well as the use of visual elements and imagery. We also recruited members of the public to perform a card sorting exercise, a common design method to determine website information architecture and categories.

Conclusion and Next Steps: After conducting the activities described above, we launched a website acceptable to both jurisdictional agencies and consumer representatives. However, as the landscape of emerging drugs and alerts develops over time, the website should be seen as an iterative product designed to evolve over time. Areas to be addressed in the future include the publishing of alerts from a broader range of sources, the creation of supporting content to provide context to drug alerts, and a more effective dissemination of theknow.org.au to the audiences that need it.