NCCRED

Peita Ava-Jones

National Cent r.- fer Cl inico l Research on Emerg i ng Drugs

Inquest, Inquiries and Representations Office of the General Counsel Department of Justice Level 4, Henry Deane Building 20 Lee Street Sydney NSW 2000

Friday 31 May 2019

Dear Ms. Ava-Jones

Nadine Ezard National Centre for Clincial Research in Emerging Drugs C/0 National Drug and Alcohol Research Centre UNSW 22-32 King St, Randwick NSW 2031

I wish to thank the Deputy State Coroner for this invitation to provide my expert opinion for her consideration in the conduct of a joint inquest into the deaths of seven young people arising at music festivals between 2015-2019. I understand that the current evidence suggests the deaths may be drug­induced, either MOMA or methylene.

Please find attached my report including answers to questions you have requested of me in your letter of 6 May 2019, along with my CV.

Kind regards ,

Prof Nadine Ezard Director, National Centre for Clinical Research on Emerging Drugs Conjoint Professor, UNSW

(02) 8382 1663 infoDnccred . org . au

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Inquest into deaths arising at music festivals, 2019 NSW

Report for the Deputy State Coroner Grahame

I, Nadine Ezard, acknowledge for the purposes of Rule 31.23 of the Uniform Civil Procedure Rules 2005 that I have read the expert witness code of conduct in Schedule 7 to the said rules and agree to be bound by it.

1. Outline your current role and research interest

I am currently the inaugural Director of the National Centre for Clinical Research on Emerging Drugs (NCCRED) and Conjoint Professor, UNSW, a role I took up in 2018. I am also the Clinical Director of the Alcohol and Drug Service at St Vincent's Hospital, Sydney Australia, a role I have held since 2012. A Fellow of the Australasian Chapter of Addiction Medicine (Royal Australasian College of Physicians), I have a Bachelor of Medicine and Surgery from the University of Melbourne, a Masters of Public Health from the Harvard School of Public Health and Doctor of Philosophy in Public Health from London School of Hygiene and Tropical Medicine.

My research involves building the evidence base for improved health interventions for substance related harm. My current research interests include working with people who use stimulants to develop new and effective interventions, including a clinical trial of a novel stimulant drug in the treatment of methamphetamine dependence and a trial of a smart phone application to promote behaviour change for people who use methamphetamine. Other research interests include the Managed Alcohol Program for chronic severe alcohol dependence, systems change interventions to improve offer and uptake of earlier intervention, and community development approaches to reducing acute harms from drug use such as GHB overdose. I am particularly interested in testing the effectiveness of a new system for rapid detection and communication of emerging harm to clinicians and people who use drugs, the Prompt Response Network.

2. Please explain the Prompt Response Network being developed to be an early warning system for drugs in Australia.

Australia has a strong history of monitoring illicit drug trends over time (such as the Drug Trends, program). However, there is no national system using event­level data to rapidly identify and communicate clinical events of concern

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related to drug use. The Australian Federal Police Drug Monitoring System collates and shares information on new psychoactive substances (NPS), yet this service is only for registered personnel and is largely focused on analytical information identifying new substances.

Given the delays in detecting and responding to emerging drug related harm from methamphetamine, NCCRED was established as part of the National Ice Action Strategy. Funded by the Commonwealth Department of Health, NCCRED was formed as a consortium of four partners: The National Centre for Education and Training on Addiction (NCET A, Flinders University); The National Drug Research Institute (NORI, Curtin University); The National Drug and Alcohol Research Centre (NDARC, The University of New South Wales, lead agency); and St Vincent's Health Australia.

A key activity of NCCRED is to build and test a collaborative and interactive network for information sharing, known as the Prompt Response Network (PRN). The Network aims to allow for rapid, flexible and collaborative responses to emerging substances that are having prevalent, persistent and harmful health and community impacts.

The primary intention of the PRN is to collect real time event data on newly identified harmful and potentially hazardous illicit substances that have emerged in the Australian community and provide this information back to people who use drugs to promote change in behaviour to avoid harm related to the use of these drugs, as well as to clinicians and other health care professionals to enable prompt and effective clinical responses.

The focus of the PRN is on clinical and public health responses with an aim to fill the gap between surveillance programs, drug testing and the clinical and public health need for immediate knowledge of current threats. The Network is a collaboration between actors, and plans to develop a system for event-based detection and response through:

a) Real-time reporting of emerging or unusual drug related events from a range of public and closed network sources

b) Timely moderation of these reports to assess validity and risk c) Dissemination of information and alerts to drug user groups, health care

providers and the general public on newly identified or emerging drugs of concern

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3. Please explain any limitation and/or room for improvement in the Prompt Response Network being developed to be an early warning system for drugs in Australia.

The Prompt Response Network is in the process of being established. The extent of information sharing capacity between various stakeholders, and effectiveness of communication to clinicians and consumers, is yet to be tested. The Network itself has limited resources and will rely on developing trust and engagement of stakeholders. Laboratory confirmatory capacity is anticipated to be one key limitation of the system. Local reliable data are expected to be limited, in particular by the absence of a system of formal public drug checking.

4. How does Australia work with the international community in developing and maintaining the Prompt Response Network?

Local event reporting will be triangulated with available data from outside Australia, such as from the network of fixed drug checking facilities that form the real-time Drug Information and Monitoring System (DIMS) in the Netherlands. Ongoing routine information will be derived from active and regular monitoring of international networks (such as the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), United Nations Office on Drugs and Crime (UNODC), National Drug Early Warning System (NDEWS), Drug Information Management System (DIMS), Public Health England Illicit Drug Data Report (PHE IDDR). The Network proposes to extend existing relationships to maintain regular communication internationally. The Network's experience and research findings will be communicated through formal and informal means, including at scientific meetings.

5. Your opinion as to appropriate harm reduction strategies at music festivals.

There are a range of strategies for which there is growing experience although formal scientific evidence of effectiveness in reducing drug related harm is limited. In my opinion, ready provision of non-judgemental advice may provide information on known effects of substances, and easily accessible treatment may prevent deaths which have occurred in people who have not sought health care promptly, at the first signs of illness. Promoting an environment of caring for each other and adequate levels of community levels of drug literacy are thought to contribute to a health promoting festival environment. Active and

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attentive mobile health and social support from nominated peers/health workers can assist in early identification and prompt response to people experiencing harm from drug and alcohol use in festival settings. Attention to the physical context, such as temperature, crowding, availability of safe and quiet spaces and drinking water, can support a health promoting environment. This will usually require good planning, coordination and communication between promoters, organisers, police, and health. Care must be taken to avoid policing strategies that inadvertently encourage consumption of drugs to avoid detection with resultant risk of overdose. Given the presence of consumption of unknown substances of variable dose there is growing experience from large multi-day festivals in Europe of the use of on-site laboratories for penalty-free drug checking. Recent conference reports from Vienna 1 and Switzerland2 describe evidence of acceptability of these services and behaviour change following receipt of results, including discarding of drugs when the result is not as expected. Further, these on-site facilities provide an opportunity for delivery health promotion messaging.

6. Any other matters you think may be of assistance to the Coroner

The statements above are my general opinion. Without the clinical case notes it is difficult for me to give an opinion on opportunities to prevent the deaths being examined by the coroner. For example, it would be of interest to understand if there was evidence of deliberate consumption of ethylone , or if this drug was mis-sold as another substance such as MOMA. Further, given the variability in tablets/capsules from 0mg to a potentially lethal dose, it would be of interest to know if the individuals had inadvertently consumed a high dose tableUcapsule.

7. Within the area of your expertise, please provide any other opinion and/or research that you consider will be relevant to the Coroner in

1 Alexandra Karden, checkit! - Suchthilfe, Wien Austria, The c(o)urse of ecstasy - a substance in the spotlight: 20 years of drug checking data analysed by checkit! in Vienna, paper presented at 11th International Conference on Nightlife, Substance Use and Related Health Issues, Amsterdam, 15-17 May 2019 2 Hans-Joerg Helmlin, Health & Social Welfare Department, State of Berne Switzerland, 20 years of drug checking with a mobile high-tech lab at parties and in stationary settings in Switzerland, paper presented at 11th International Conference on Nightlife, Substance Use and Related Health Issues, Amsterdam, 15-17 May 2019

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her inquest into the deaths of seven young adults at music festivals from illicit drug use.

Deaths related to substance use may involve multiple substances, including alcohol. There is growing concern around the use of the short acting sedative, gamma-hydroxybutyric acid (GHB) and its precursors gammabutyrolactone (GBL) and 1,4-butanediol (1,4-BD) and its inherent overdose risk. It is unknown to what extent this drug is used in festival settings in NSW, and there is a lack of evidence around effective overdose prevention strategies for this drug.

8. Please reference and/or include any articles you have authored or co-authored that may be of relevance to the Coroner.

Barratt M, Bruno R, Ezard N, Ritter A. Pill testing or drug checking in Australia: Acceptability of service design features. Drug and Alcohol Review 2018; 37(2) :226-236.

Butterfield R, Ezard N, Barratt M, Day R. Drug checking to improve the monitoring of new psychoactive substances in Australia. Medical Journal of Australia 2016,204 (4), 144-145

Barratt M, Ezard N. Drug checking interventions can track the nature and size of the discrepancy between self-report and actual drugs consumed Addiction 2016, 111 (3):558-559

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