Methamphetamine Presentations to an Emergency Department: Management and Complications

Home , Toxidrome

Isoardi Katherine (Orcid ID: 0000-0002-1176-7923)

Abstract

Objective:

There is little recent published data characterising methamphetamine intoxication.

This study aims to describe the clinical effects, management, complications and

disposition of patients with methamphetamine exposure.

Methods:

This is a retrospective review of patients presenting with methamphetamine

intoxication to an Emergency Department in 2016. All presentations were extracted

from a relational database and each medical record reviewed. Demographics, clinical

features, complications and disposition were extracted.

Results:

There were 378 presentations of 329 patients (234 males [71%]), median age 31 years

(range 16-68 years). The commonest clinical effect was acute behavioural

disturbance, occurring in 295 (78%) presentations. This was successfully managed

with oral sedation alone in 180 (61%) patients with the remainder receiving parenteral

sedation. Other effects included tachycardia in 212 (56%), hypertension in 160 (42%)

and hyperthermia in 17 (4%) presentations. No antihypertensives were given. One

patient was actively cooled. Complications included 21 (30%) presentations with

rhabdomyolysis and 43 (11%) presentations with acute kidney injury. There were two

seizures, three intracranial bleeds and one myocardial infarction. The majority of

This is the author manuscript accepted for publication and has undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/1742-6723.13219

median length of stay was 14 hours. There were 41(11%) mental health admissions.

Two deaths occurred; one following an out of hospital cardiac arrest, the other a

subarachnoid haemorrhage.

Conclusions:

The main toxicity seen with methamphetamines is acute behavioural disturbance,

which is managed well with sedation. Complications, apart from rhabdomyolysis and

acute kidney injury, are rare. Most patients are managed within the Emergency

Department and discharged home.

Introduction

Methamphetamine is a highly addictive methylated derivate of amphetamine.1 It is

available in three main forms of increasing purity; powdered “speed”, a yellow paste

“base” and crystalline “ice”.2 Methamphetamine potentiates the release and blocks the

reuptake of catecholamines, stimulating the sympathetic and central nervous systems.3

Acute poisoning is associated with a sympathomimetic toxidrome, which can vary from mild psychomotor agitation through to severe toxicity with hyperthermic crisis, myocardial ischaemia, arrhythmia and intracerebral haemorrhage.1 Chronic use is

associated with dependence, mental health conditions including anxiety, depression

and psychosis and societal dysfunction. 4

This article is protected by copyright. All rights reserved. Methamphetamine use in South East Queensland, Australia, has increased over the last decade. Wastewater analysis in urban southeast Queensland has demonstrated a five-fold increase in methamphetamine usage over the period of 2009 to 2015.5 This increase in usage, coupled with a shift in the Australian market to a higher purity product,4 has translated into increasing methamphetamine-related hospital presentations and specialist drug treatment episodes.6

There is little published data that characterises methamphetamine intoxication in patients presenting to an emergency department (ED).3, 7, 8 There is even less in the last 10 years, 9, 10 during which time higher purity methamphetamine has dominated.

Most research however, focuses on the severe medical complications of methamphetamine intoxication including myocardial ischaemia,11 stroke

12 and hyperthermic crises.13 These serious complications happen infrequently whereas agitation and aggression (acute behavioural disturbance) appear to be more commonplace.7 A prospective series of 100 methamphetamine intoxicated patients presenting to an Australian inner-city ED in 2006 found acute behavioural disturbance was present in 41% of cases.7 Similarly another Australian prospective case series also found acute behavioural disturbance was the most common presenting complaint in amphetamine related ED presentations.3

There is variation in the management of methamphetamine related acute behavioural disturbance. Chemical restraint using titrated intravenous benzodiazepines is

This article is protected by copyright. All rights reserved. typically recommended.14-16 However antipsychotics, such as droperidol, have been shown to be as effective but safer than benzodiazepines17-19 for the management of all

forms of acute behavioural disturbance including stimulant toxicity. Complications of

chemical restraint include over-sedation, aspiration, respiratory depression and

hypotension. Given the risks of sedation, many departments have protocols to guide

clinicians in the management of acute behavioural disturbance.20-22 The effectiveness

of these guidelines in managing methamphetamine related acute behavioural

disturbance has not been specifically examined.

The aim of this study is to describe the clinical effects of methamphetamine

intoxication in patients presenting to the ED and report its management and

complications, including the treatment of methamphetamine related acute behavioural

disturbance.

Methods

Study Design and Setting

This is a retrospective observational study of patients presenting with

methamphetamine intoxication to the ED at the Princess Alexandra Hospital (PAH) in

Brisbane, Australia. The PAH is a tertiary referral adult (>15 years of age) hospital

sedation in the PAH ED is standardised, following a local area guideline that details

the management of acute behavioural disturbance.20 The Sedation Assessment Tool

(SAT)23 scoring system (Figure 1) is used routinely in the PAH ED to assess the degree of patient agitation. The Clinical Toxicology Unit manages all patients presenting to the PAH with drug intoxication, overdose, poisoning or envenomation.

In 2016 there were 2133 toxicological presentations to the PAH resulting in 1567 inpatient admissions under the Clinical Toxicology Unit. All toxicological presentations are entered into a purpose built relational database by the unit’s medical staff that undergoes weekly audit. The Clinical Toxicology Unit has approval from the Metro South Human Research Ethics Committee to use their database and patient medical records for research.

Patient selection

All patients presenting to the PAH during the 2016 calendar year with an exposure to

methamphetamine were included in the study. This was determined by a patient

admitting to methamphetamine use or when this was not provided, through clinical

examination findings consistent with a sympathomimetic toxidrome and a collateral

history suggestive of methamphetamine exposure. Cases were identified through the

toxicology database using the search term ‘methamphetamine’ with date limits of the

1st January 2016 through to the 31st December 2016.

Methamphetamine presentations were extracted from the toxicology unit’s relational database, and each patient’s electronic medical record was subsequently reviewed. A data collection sheet was designed and piloted by two of the authors (CP and KI) prior to the formal data extraction. The data collection sheet included baseline characteristics (age, sex, ethnicity, employment status), presentation details (arrival method, ingested drug, presenting complaint, intention, co-ingested agents, mental health considerations), clinical features (vital signs, laboratory results, management), complications (rhabdomyolysis, acute kidney injury, seizure, intracranial haemorrhage, myocardial infarction, cardiac arrest) and disposition details (admission location, length of stay, discharge location). Double data extraction (SA and KI) was performed on the first 10% of records extracted, of which there was excellent agreement with only a very small number of discrepancies that were identified and corrected for the remaining extraction. Data extraction was performed on the remaining 90% of cases by a single extractor (SA).

Outcomes

The following outcomes were predefined to describe the clinical effects and complications of methamphetamine intoxication and included tachycardia (heart rate

> 100 beats per minute), hypertension (systolic blood pressure > 140mmHg), severe hypertension (systolic blood pressure >180mmHg), hyperthermia (temperature > 38 degrees Celsius), rhabdomyolysis (creatine kinase [CK] > 1000 IU/L) and acute

Guideline for Acute Kidney Injury.24

Analysis

Continuous variables are reported as medians, interquartile ranges (IQR) and ranges.

All analysis was performed in GraphPad Prism 7.0d for Mac OS X (GraphPad

Software, La Jolla California CA, USA; www.graphpad.com)

Results

Baseline Characteristics

There were 378 presentations of 329 patients (234 males [71%]), median age 31 years

(IQR 25-37 years, range 16-68 years). There were 156 (41%) ambulance presentations, 57 (15%) police presentations, 84 (22%) combined ambulance and police presentations and 81 (22%) self-presentations. The Mental Health Act was enacted in 91 (24%) cases.

Patient social demographics are presented in Table 1. Where stated in the patient record, 242 (80%) patients were unemployed and 172 (70%) patients were receiving some form of social security benefit. Homelessness was present in 62 (21%) patients.

There were 48 (15%) patients who stated they were of Aboriginal and/or Torres Strait

Islander heritage, compared to 2.4% of the local population who identify as

Aboriginal and/or Torres Strait Islander.25

In 367 (97%) cases the patient admitted to taking methamphetamine, with 331 (86%) of these also provided details as to route of delivery. Ice, or crystal methamphetamine accounted for 357 (94%) exposures with the remainder being speed. Co-ingestants were taken in 191 (51%) presentations with alcohol being the most common (67/191,

recreational (352/378, [93%]) with the remainder being deliberate self-poisonings

(Table 1).

Clinical Features & Management

The most common clinical toxicity was acute behavioural disturbance, occurring in

295 (78%) presentations. This was successfully managed with oral and/or parenteral sedation in 290 (98%) cases (Figure 2). Oral sedating agents in the form of diazepam and/or olanzapine were given to 226 patients (Figure 3). Successful sedation was achieved in 180 (80%) patients. Sedation rates did not increase with the addition of oral olanzapine to diazepam (50 of 65 [77%]) compared to diazepam alone (125 of

154 [81%]). Only seven patients received oral olanzapine without diazepam. There were 115 (46 failed oral sedation and 69 presentations with SAT 2 or 3) patients who received parenteral sedation either prehospital (8) or in the ED (107). Sedation was not achieved in five patients (2%). Four of these patients settled following the administration of physical restraints. The other patient was intubated at a rural centre to facilitate their helicopter retrieval to the PAH.

Other clinical features included tachycardia in 212 (56%) presentations and hypertension in 160 (42%) presentations. Severe hypertension was present in only 8

(2%) presentations and no patients received antihypertensives. Hyperthermia was present in 17 (5%) presentations, but only one patient with a temperature of 38.9oC

A urine drug screen was performed on 39 (10%) patients and was positive for

amphetamine related substances in 37 (95%) of these samples.

Complications

Rhabdomyolysis occurred in 21 (30%) patients where a CK was requested. The median peak CK concentration was 3890 (IQR 1480 to 5040, range 1100 to 14300).

A creatinine was performed in 321 (85%) presentations. AKI was present in 41 (13%) presentations, with a median peak creatinine concentration of 128 μmol/L (IQR 117

to 142, range 111 to 277). All episodes of AKI resolved with supportive care

including intravenous rehydration. Concurrent rhabdomyolysis occurred in 23 (56%)

with AKI. There were two seizures, three intracranial bleeds and two myocardial

infarctions.

Disposition

The majority of patients (317 [84%]) were managed solely within the emergency

department, including 241 Short Stay Unit admissions. The median length of stay

was 14 hours (IQR 8 to 22 hours). Five patients were admitted to the surgical ward.

Four of these had traumatic injuries and the other had a quinsy. Six patients were

admitted to the medical ward for the management of angina, diabetic ketoacidosis or

infectious complications. Nine patients (2%) were admitted to the intensive care or

This article is protected by copyright. All rights reserved. coronary care units (Table 2). There were two deaths in this series; one following an out of hospital cardiac arrest, the other following a subarachnoid haemorrhage. There were 41 (11%) mental health admissions. Of these 23 (6%) were for ongoing assessment and management of psychosis. The remaining mental health admissions

(18 [5%]) were for suicidality, depressive symptoms and situational crisis.

Discussion

Our study has shown that methamphetamine intoxication is largely characterised by acute behavioural disturbance that is well managed within the ED. Severe sympathomimetic toxicity and critical care interventions are rare. Rhabdomyolysis and AKI occur commonly but resolve with supportive care. The majority of presentations are managed within the ED and most patients are discharged home.

Similar to previous studies,3, 7, 10 this study confirms that presentations relating to methamphetamine intoxication are resource intensive; with a high utilisation of

This article is protected by copyright. All rights reserved. ambulance and police services as well as departmental resources, such as a resuscitation area and staffing to manage acute behavioural disturbance.

Methamphetamine intoxicated patients were socially disadvantaged with high rates of unemployment, reliance on social security and homelessness. People of Aboriginal and/or Torres Strait Islander heritage were also overrepresented. These findings are consistent with a recent Australian Government report on the social burden of methamphetamine misuse,26 which found that methamphetamine users were more likely to have worse employment, education, housing and health outcomes than those who used other illicit drugs. This was more pronounced for crystal methamphetamine users.26

The rate of acute behavioural disturbance in this series is higher than previously reported.3 A study by Gray et al of 156 amphetamine-related presentations over a three-month period reported 50 (32%) of patients required sedation. It is likely that the increased rate of acute behavioural disturbance requiring sedation in our series reflects the increasing use of the more potent crystal methamphetamine.

Acute behavioural disturbance was effectively managed with chemical sedation. Oral agents alone achieved sedation in almost two thirds of patients. Diazepam was an effective oral sedative. The addition of olanzapine to diazepam in our series, did not improve sedation rates. A recent review of 26 Australian and New Zealand hospital protocols for the management of acute behavioural disturbance found

This article is protected by copyright. All rights reserved. recommendations for oral benzodiazepine and antipsychotic combination therapy were common in the first line management of agitation, with olanzapine being the commonest antipsychotic recommended.27 However the use of combination therapy exposes the patient potentially to more adverse effects without necessarily providing any additional benefit.28

When a parenteral agent was required, droperidol was effective and failure to achieve sedation was rare. Intramuscular droperidol is used at the PAH in keeping with the local area and Queensland state management guidelines that standardise the approach of chemical restraint in the ED for acute behavioural disturbance. These guidelines, suggest using oral diazepam and/or olanzapine for the first line management of mild to moderate (SAT 1) agitation and intramuscular droperidol as first line management of severe (SAT 2 and 3) agitation. Intramuscular ketamine, at the senior doctor’s discretion, is often used as a second line agent should there be ongoing agitation following droperidol. The effectiveness of droperidol for the management of severe agitation in this series is consistent with previous studies that reported the use of droperidol in all causes of ED acute behavioural disturbance.18

Once the effects of sedation pass, ongoing behavioural disturbance is uncommon with the majority of patients being discharged home within 24 hours. Similarly, most psychotic symptoms resolve with the resolution of methamphetamine toxicity, with a low rate of psychiatric admissions for ongoing drug induced psychosis.

Significant medical complications of methamphetamine intoxication, such as sympathomimetic crisis, were rare. Similarly ICU admission was uncommon. The commonest medical complications were rhabdomyolysis and AKI, both of which resolved with supportive management. Rhabdomyolysis occurred in approximately one third of patients that had a CK performed. An association between methamphetamine use and rhabdomyolysis has been previously reported8 and routine measurement of CK has been suggested in this population.8 It is thought methamphetamine intoxicated patients are more susceptible to rhabdomyolysis given excessive isometric motor activity due to agitation and subsequent efforts of physical restraint.8 Although common, rhabdomyolysis in this series was mild and posed few complications.

The rate of AKI in this series was unexpected and is not an association that has previously been reported. It is likely the cause of this creatinine rise is multifactorial, with dehydration and rhabdomyolysis both being potential causes as neither methamphetamine nor its metabolite have been shown to cause direct renal tubular injury.29 All cases of AKI resolved promptly in this series with supportive care including fluid rehydration. It is increasingly being recognised that episodes of AKI predispose to the development of chronic renal failure.30 Potentially this group may pose a significant burden on the health system in the future.

Limitations

intoxication may have been missed if the history was not forthcoming and the treating

clinician did not consider stimulant toxicity in their differential. In a previous study

only 50% of patients with methamphetamine positive urine drug screens self-reported

methamphetamine use in a retrospective review of patients presenting to an

emergency department with chest pain.31 Furthermore, there was no routinely

performed confirmatory test to analytically confirm methamphetamine exposure.

Urine drug screening, which can qualitatively confirm amphetamine-related substance exposure, was performed on a minority of patients. Additionally, it is possible that the history of methamphetamine use was unknowingly inaccurate with the patient actually taking a different stimulant under the impression that it was methamphetamine. Finally, this was a retrospective analysis of data recorded in patient medical records that were subsequently extracted. Poorly classified, missing or inaccurate data could have occurred that a prospectively designed study with specific hypotheses may have avoided.

Conclusions

The main toxicity seen with methamphetamine exposure prompting ED presentation

is acute behavioural disturbance. This is managed effectively with oral sedation and

intramuscular droperidol. Complications include rhabdomyolysis and acute kidney

injury. Severe complications i.e. hypertension, cardiac ischemia and intracranial

pathology are rare. Most patients are managed entirely within the emergency

Acknowledgements

Colin Page is supported by a research fellowship from the Emergency Medicine

Foundation.

References:

1. Schep, L.J., R.J. Slaughter, and D.M. Beasley, The clinical toxicology of metamfetamine. Clin Toxicol (Phila), 2010. 48(7): p. 675-94. 2. Jones, R., C. Woods, and K. Usher, Rates and features of methamphetamine- related presentations to emergency departments: An integrative literature review. J Clin Nurs, 2018. 27(13-14): p. 2569-2582. 3. Gray, S.D., et al., Amphetamine-related presentations to an inner-city tertiary emergency department: a prospective evaluation. Med J Aust, 2007. 186(7): p. 336-9. 4. Degenhardt, L., et al., Crystalline methamphetamine use and methamphetamine-related harms in Australia. Drug Alcohol Rev, 2017. 36(2): p. 160-170. 5. Lai, F.Y., et al., Cocaine, MDMA and methamphetamine residues in wastewater: Consumption trends (2009-2015) in South East Queensland, Australia. Sci Total Environ, 2016. 568: p. 803-809. 6. Roche, A., et al., Methamphetamine Use in Australia. 2015, NCETA, Flinders University. 7. Bunting, P.J., G.W. Fulde, and S.L. Forster, Comparison of crystalline methamphetamine ("ice") users and other patients with toxicology-related problems presenting to a hospital emergency department. Med J Aust, 2007. 187(10): p. 564-6.

This article is protected by copyright. All rights reserved. 8. Richards, J.R., et al., Methamphetamine abuse and emergency department utilization. West J Med, 1999. 170(4): p. 198-202. 9. Liakoni, E., et al., Presentations to an urban emergency department in Bern, Switzerland associated with acute recreational drug toxicity. Scand J Trauma Resusc Emerg Med, 2017. 25(1): p. 26. 10. Richards, J.R., et al., Methamphetamine Use and Emergency Department Utilization: 20 Years Later. J Addict, 2017. 2017: p. 4050932. 11. Hawley, L.A., et al., Cardiac complications of adult methamphetamine exposures. J Emerg Med, 2013. 45(6): p. 821-7. 12. Perez, J.A., Jr., E.L. Arsura, and S. Strategos, Methamphetamine-related stroke: four cases. J Emerg Med, 1999. 17(3): p. 469-71. 13. Matsumoto, R.R., et al., Methamphetamine-induced toxicity: an updated review on issues related to hyperthermia. Pharmacol Ther, 2014. 144(1): p. 28-40. 14. Richards, J.R., et al., Treatment of toxicity from amphetamines, related derivatives, and analogues: a systematic clinical review. Drug Alcohol Depend, 2015. 150: p. 1-13. 15. Wodarz, N., et al., Evidence-Based Guidelines for the Pharmacological Management of Acute Methamphetamine-Related Disorders and Toxicity. Pharmacopsychiatry, 2017. 50(3): p. 87-95. 16. Greene, S.L., F. Kerr, and G. Braitberg, Review article: amphetamines and related drugs of abuse. Emerg Med Australas, 2008. 20(5): p. 391-402. 17. Isbister, G.K., et al., Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study. Ann Emerg Med, 2010. 56(4): p. 392-401.e1. 18. Calver, L., et al., The Safety and Effectiveness of Droperidol for Sedation of Acute Behavioral Disturbance in the Emergency Department. Ann Emerg Med, 2015. 66(3): p. 230-238.e1.

This article is protected by copyright. All rights reserved. 19. Page, C.B., et al., A Prospective Before and After Study of Droperidol for Prehospital Acute Behavioral Disturbance. Prehosp Emerg Care, 2018: p. 1- 9. 20. Adult - Acute Behavioural Disturbance Management in the Emergency Department, M.S. Health, Editor. 2018: Brisbane, Australia. 21. Management of Patients with Acute Severe Behavioural Disturbance in Emergency Departments, N. Health, Editor. 2015: Sydney, Australia. 22. Management of Patients with Acute Severe Behavioural Disturbance in Emergency Departments, Q. Health, Editor. 2017: Brisbane, Australia. 23. Calver, L.A., B. Stokes, and G.K. Isbister, Sedation assessment tool to score acute behavioural disturbance in the emergency department. Emerg Med Australas, 2011. 23(6): p. 732-40. 24. KDIGO Clinical Practie Guideline for Acute Kidney Injury. Kidney Int, 2012. 2(Suppl): p. 1-138. 25. Demographic and Health Status Profile; 2016 Update., E.a.R.U. Metro South Health Planning, Editor. 2016: Brisbane, Australia. 26. Goldsmid, S., et al., Australian Methamphetamine User Outcome, A.I.o. Criminology, Editor. 2017. 27. O'Connor, N. and J. Corish, Pharmacological management of acute severe behavioural disturbance: a survey of current protocols. Australas Psychiatry, 2017. 25(4): p. 395-398. 28. Isbister, G.K., Droperidol or Olanzapine, Intramuscularly or Intravenously, Monotherapy or Combination Therapy for Sedating Acute Behavioral Disturbance. Ann Emerg Med, 2017. 69(3): p. 337-339. 29. Luciano, R.L. and M.A. Perazella, Nephrotoxic effects of designer drugs: synthetic is not better! Nat Rev Nephrol, 2014. 10(6): p. 314-24. 30. Chawla, L.S. and P.L. Kimmel, Acute kidney injury and chronic kidney disease: an integrated clinical syndrome. Kidney Int, 2012. 82(5): p. 516- 24.

This article is protected by copyright. All rights reserved. 31. Lee, M.O., P.M. Vivier, and D.B. Diercks, Is the self-report of recent cocaine or methamphetamine use reliable in illicit stimulant drug users who present to the Emergency Department with chest pain? J Emerg Med, 2009. 37(2): p. 237-41.

Score Responsiveness Speech ______

3 Combative, violent, out of control Continual loud outbursts

2 Very anxious and agitated Loud outbursts

1 Anxious/restless Normal/talkative

0 Awake and calm/cooperative Speaks normally

-1 Asleep but rouses if name is called Slurring or prominent slowing

-2 Responds to physical stimulation Few recognizable words

-3 No response to stimulation None

Acute Behavioural Disturbance (295)

Initial SAT score Initial SAT score

of 1(226) of 2 or 3 (69)

Successful sedation (290) 98.3%

180 Oral sedation provided (226) Parenteral sedation provided

(115) Ineffective (46)

110

Inadequate sedation (5)

1.7%

SAT = Sedation Assessment Tool

Pre-hospital Received oral parenteral Successful sedation sedation in ED sedation received (14) (226) 125 (290) 98%

Diazepam (154) Ineffective Received sedation* (46) Diazepam & 50 parenteral 20% Olanzapine sedation in ED (65) (107) 5 Olanzapine (7) Droperidol 10mg (107) 87

Droperidol 9 10mg (20)

Ketamine (11) 6

Ineffective sedation* (5) ED = Emergency Department

*Ineffective sedation is defined as SAT > 1 following chemical sedation This article is protected by copyright. All rights reserved. METHAMPHETAMINE PRESENTATIONS TO AN EMERGENCY DEPARTMENT: MANAGEMENT AND COMPLICATIONS

Isoardi Katherine Z,1,2, Ayles Sarah F2, Harris Keith1,2, Finch Clare J,1 Page Colin B1,2,3 1Clinical Toxicology Unit and Emergency Department and, Princess Alexandra Hospital, Brisbane, Australia. 2Faculty of Medicine, University of Queensland, Brisbane, Australia. 3Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia.

Running Title: Methamphetamine presentations to an ED

Competing Interest: Nil

Declaration of Sources of Funding: Colin Page is supported by a research fellowship

from the Emergency Medicine Foundation.

Authors:

Dr Katherine Z Isoardi B.Medicine, FACEM, GradDip ClinTox Dr Sarah F Ayles MBBS Dr Keith Harris MB BCh BSc, FACEM Dr Clare J Finch MBBS, FACEM Dr Colin B Page MBChB, FACEM, MMedSci(Clin Epid)

Author contributions:

CP, KI & CF conceived study & design, SA and KI acquired data, KI, KH & CP analysed data and KI & CP developed manuscript. All authors reviewed and approved manuscript

Corresponding Author: Katherine Isoardi [email protected]

Clinical Toxicology Unit Princess Alexandra Hospital Ipswich Rd Woolloongabba Q 4102 Ph +617 3176 2111

Word count: 2443 words

Keywords: acute behavioural disturbance, acute kidney injury, methamphetamine,

rhabdomyolysis

______

Total number of patients (329)

Age, median (range), years 31 (range 16-68) Male 234 (71%) Patients with multiple presentations 34 (10%) Median representations per patient 1 (range 1-7)

†Unemployed 242 (80% of 301) †Receiving any form of social security 172 (70% of 245) †Receiving Disability Support Pension 78 (32% of 245) †Homeless 62 (21% of 301) †Aboriginal and/or Torres Strait Islander 48 (15% of 325)

Total number of presentations (378)

Mental Health Act enacted 91 (24%)

Methamphetamine exposure: Ice 357 (94%) Speed 21 (6%)

†,‡ Route of administration: Intravenous 231 (70% of 331) Inhalational 103 (31% of 331) Oral 20 (6% of 331)

Coingestions: 191 (51%) Alcohol 67 (18%) Cannabis 57 (15%) Benzodiazepines 31 (8%) Heroin 24 (6%) MDMA 14 (4%)

Intent: Recreational 352 (93%) Deliberate self-poisoning 26 (7%)

† Where information was available ‡ Some patients used more than one route MDMA = 3,4-Methylenedioxymethamphetamine

Age Sex Presenting complaint Co-ingestants Complications Admission LOS Discharge location location

42 M Chest pain Nil MI, AKI, CCU 9.0 Home rhabdomyolysis

43 M Dyspnoea; Presumed septic shock Alcohol MI, AKI, ICU 4.3 Home

53 M Acute behavioural disturbance; Heroin Aspiration, AKI ICU 2.6 Home Altered level of consciousness

52 M Acute behavioural disturbance; Diazepam Nil ICU 1.8 Home Altered level of consciousness

39 F Sedation following deliberate self Morphine, Nil ICU 1.8 Home poisoning buprenorphine, cannabis 36 M Acute behavioural disturbance, Nil Nil ICU 2.2 Psychiatric intubated for helicopter retrieval unit

45 M Chest pain, out of hospital cardiac Nil MI, Hypoxic ICU 4.5 Died in arrest with prolonged downtime brain injury, hospital Death 45 F Seizure, catastrophic subarachnoid Unknown ICH, Death ICU 1.1 Died in haemorrhage from cerebral hospital aneurysm 28 M Collapse; respiratory arrest Alcohol, Aspiration ICU 1.5 Home Fentanyl, Diazepam

M= Male, F=Female, MI = myocardial infarction, AKI = acute kidney injury, CCU = Coronary Care Unit, ICU= Intensive Care Unit, ICH = Intracranial haemorrhage, LOS = length of stay (days)