Ecstasy and related drug presentations at two hospital emergency departments:

Melbourne, 2008-2010Danielle Horyniak, De Villiers Smit, Venita Munir,

Louisa Degenhardt, Jennifer Johnston, Craig Fry, Paul Dietze

APSAD 2012

Prevalence of use & related harms• Lifetime use (NDSHS, 2011):

– Ecstasy: 10%– GHB: 1%

• Around ¼ REU use at least weekly (EDRS, 2012)• Polydrug use common – amphetamines, cocaine, cannabis• Varied harms:

– Ecstasy: heart palpitations, loss of consciousness, dizziness– GHB: respiratory depression, hypothermia, death

ERDs and the ED• 700-800 ecstasy/GHB ambulance attendances per million

population annually in 2008-2010• Majority result in transport to hospital• 6% of REU used an ED in the last 6mths (EDRS, 2012)• Few studies of ERDs in Australian EDS:

– GHB (n=1), Amphetamines (n=2), All illicit drugs (n=1)– Different jurisdictions/time periods– Small sample sizes– Data collection limitations

Study aims• Describe three-year trends in ERD-related presentations• Compare socio-demographic & clinical characteristics

across ERD types• Identify correlates of repeat ERD-related ED presentation

Methods• Retrospective audit, Jan 2008 – Dec 2010• 2 major inner-city EDs (~97,000 patients annually)• Electronic searching of triage notes/discharge diagnosis:

– Drug names, street drug names, additional terms• Data extracted from medical records:

– Demographic characteristics– Medical history– Pre-hospital clinical characteristics– In-hospital clinical characteristics

Presentation Characteristics• Total of 1347 presentations• Commonly occur on weekends (60%), 12pm-6am (41%)• Median length of stay: 3.0hrs (IQR: 1.8-4.8)• Treatment generally limited to patient observation/monitoring• 149 (14%) hospital admissions• 1 fatality

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Attendance Date

Site 1 Site 2

Number of presentations over time

Patient Characteristics• 64% male, 90% Australian-born• Median age (female): 24.1yrs (IQR: 21.2-27.6)• Median age (male): 25.9yrs (IQR: 22.4-31.7)• 36% recorded history of substance use• Last recorded location: public place (42%), private residence

(26%), licensed premises (21%), dance party/music fest (7%)

Main drug implicated

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q42008 2009 2010

01020304050607080

Ecstasy/MDA Amphetamines GHB/GBL/1,4B Other ERDsMultiple ERDs

Attendance date

Num

ber o

f pre

sent

ation

s

GHB-related presentationsVariable N=480

n (%)

Male 305 (64)

Median age (IQR) 23.9yrs (21.0-27.8)

Substance use history 119 (25)

Psychiatric illness history 45 (10)

Arrived by ambulance 408 (86)

Presenting complaint Altered conscious state Psych/behavioural Vomiting/nausea

429 (89)43 (9)40 (8)

Triage Category 1 206 (46)

Hospital arrival GCS ≤8 245 (55)

Intubated in ED 80 (17)

Admitted to hospital 39 (8)

Median LOS (IQR) 2.9hrs (1.9-4.3)

Alcohol implicated 158 (35)

Ecstasy-related presentationsVariable N=236

n (%) OR relative to GHB (95% CI)

Male 142 (60) 0.87 (0.63-1.19)

Median age (IQR) 24.9yrs (21.7-28.7) 1.01 (0.99-1.04)

Substance use history 61 (27) 1.08 (0.75-1.54)

Psychiatric illness history 32 (14) 1.54 (0.95-2.50)

Arrived by ambulance 141 (62) 0.26 (0.18-0.38)

Presenting complaint Altered conscious state Psych/behavioural Vomiting/nausea

61 (26)61 (26)45 (19)

0.04 (0.03-0.06)3.56 (2.32-5.47)2.61 (1.65-4.12)

Triage Category 1 8 (3) 0.04 (0.02-0.09)Hospital arrival GCS ≤8 11 (6) 0.05 (0.03-0.10)

Intubated in ED 2 (<1) 0.04 (0.01-0.18)

Admitted to hospital 32 (14) 1.77 (1.08-2.91)

Median LOS (IQR) 3.0hrs (1.7-4.9) 1.02 (0.98-1.05)Alcohol implicated 173 (75) 5.55 (3.89-7.91)

Amphetamine-related presentationsVariable N=236

n (%) OR relative to GHB (95% CI)

Male 163 (64) 1.02 (0.74-1.39)

Median age (IQR) 28.4yrs (24.1-34.8) 1.09 (1.07-1.12)

Substance use history 158 (62) 4.85 (3.50-6.74)

Psychiatric illness history 105 (41) 6.64 (4.47-9.87)

Arrived by ambulance 140 (56) 0.21 (0.15-0.30)

Presenting complaint Altered conscious state Psych/behavioural Vomiting/nausea

35 (14)99 (39)25 (10)

0.02 (0.01-0.03)6.53 (4.37-9.77)1.21 (0.71-2.04)

Triage Category 1 9 (4) 0.05 (0.02-0.09)Hospital arrival GCS ≤8 11 (6) 0.05 (0.03-0.10)Intubated in ED 3 (1) 0.06 (0.02-0.19)Admitted to hospital 55 (22) 3.11 (2.00-4.84)

Median LOS (IQR) 3.3hrs (1.9-5.9) 1.06 (1.02-1.10)

Alcohol implicated 101 (40) 1.26 (0.92-1.73)

Correlates of repeat presentationVariable Repeat

N=57Non-repeat

N=1,215 OR (95% CI) AOR (95% CI)

Presentation year 2008 2009 2010

16 (28)24 (42)17 (30)

372 (31)428 (35)412 (34)

11.30 (0.68-2.49)0.96 (0.48-1.93)

---

Sex Male Female

37 (65)20 (35)

770 (63)445 (37)

10.93 (0.53-1.63)

--

Age (median, IQR) 24.6 (21.4-30.8) 25.3 (21.8-30.3) 1.00 (0.96-1.04) -GHB main drug implicated No Yes

26 (46)31 (54)

805 (66)410 (34)

12.34 (1.37-4.00)

13.54 (1.99-6.31)

AOD history No Yes

15 (28)39 (72)

809 (68)389 (32)

15.41 (2.94-9.93)

17.23 (3.84-13.58)

Altered Conscious State No Yes

27 (47)30 (53)

670 (55)542 (45)

11.37 (0.81-2.34)

--

Alcohol involved No Yes

37 (66)19 (34)

576 (49)603 (51)

10.49 (0.29-0.86)

--

Key findings• Decrease in ecstasy presentations over study period• Drug-related harms occur across a variety of settings• Characteristics of presentations vary by drug type• Most presentations relatively minor• Majority of patients treated & discharged within 4-hour

recommended limit• Presentations at peak times to place a burden on the ED

Recommendations• In the ED:

– Separate management strategies for amphetamine-related presentations

• In the community:– Harm reduction/prevention messages within licensed venues– Enhance capacity of venues/patrons to self-manage minor

adverse events– Party planning guides for private settings– Education around risks of alcohol & ecstasy

Acknowledgements• Project management: Anita Feigin• Site management: Tracey Weiland, Sue Cowling, Nathan Farrow,

Chris Batey, Catherine Walker• Data extraction/entry: Graham Bushnell, Alice Voskoboynik, Eve

Urban, Lauren Booth, Natalie Green, Carlo Di Bella, Jennifer Taylor, Katherine Hall, Emily Hadgkiss, Claudia Marck, Ellaine Boo, Angela Weber, Elizabeth White, Claire Doherty, Andrew Waugh • Funding: NHMRC