Abstract
Background
New psychoactive stimulants and hallucinogens (NPSH) poisonings have generated considerable public health concern in recent years. We aimed to determine: 1. The characteristics, toxicology and major autopsy findings of known cases of NBZD-related poisoning in Australia, 2000–2025; and 2. Changes in characteristics of known cases from 2020 onwards compared to earlier known cases.
Methods
Retrospective study of fatal NPSH-related poisonings in Australia retrieved from the National Coronial Information System.
Results
70 cases were identified, the first occurring in 2007. In 22.9% the decedent appeared unaware they were consuming a NPHS, and in 32.9% the NPSH had been injected. The most commonly observed signs and symptoms of acute NPSH poisoning were intense agitation (22.9%), sudden collapse (22.9%) and hyperthermia (20.0%). There were 31 NPSH identified, of which 13 were first detected in the 2020 s. The most commonly detected NPSH were cathinones (48.6%), most frequently α-pyrrolidinovalerophenone and methylenedioxypyrovalerone. Phenethylamines were present in 38.6%, with paramethoxymethamphetamine and a range of the N-benzylphenethylamine series (NBOMe) the most common. Tryptamines were present in 18.6%, and three cases involved piperazines. In 18 cases (25.7%) multiple NPSH were detected in the blood. 2020 s cases were more likely to have tryptamines detected (36.7 v 5.0%), but less likely to have phenethylamines (23.3 v 50.0%). Psychoactive drugs in addition to NPSH were present in 92.9%, most commonly psychostimulants (68.6%) and hypnosedatives (40.0%).
Conclusions
A wider range of NPHS have been detected in recent fatal poisonings, with tryptamines becoming more common in the 2020 s, and phenethylamines less common.
Keywords: NPS, Psychostimulants, Hallucinogens, Mortality, Toxicology, Toxicity
Highlights
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70 fatal toxicity cases involving new psychoactive stimulants/hallucinogens (NPSH).
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31 NPSH identified, of which 13 were first detected in the 2020 s.
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The most commonly detected NPSH were cathinones (48.6%).
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In 18 cases (25.7%) multiple NPSH were detected in the blood.
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In 16 cases the decedent appeared unaware they were consuming a NPHS.
1. Introduction
New psychoactive substances (NPS) are a wide range of “designer drugs” that have risen to prominence in the 21st century. New psychoactive stimulants and hallucinogens (NPSH) are a class of NPS that have generated considerable public health concern in recent years due to their toxicity (European Union Drugs Agency, 2025, Smith et al., 2025, United Nations Office on Drugs and Crime, 2025). The major categories within the NPSH class are the synthetic cathinones, phenethylamines, synthetic tryptamines and piperazines. A great deal of the public health concern has focused on the cathinones (EUDA, 2025).
Acute toxic responses to NPSH are similar to those of other psychostimulants and hallucinogens and include hyperthermia (Darke et al., 2019, Pullen et al., 2025), cardiovascular effects (hypertension, tachycardia, myocardial infarction) (Darke et al., 2019, Gerostamoulos et al., 2023, Groenewegen et al., 2024, Neumann et al., 2024, Pullen et al., 2025), and neurotoxic effects (seizures, stroke) (Darke et al., 2019, Daziani et al., 2023, Herian et al., 2022, Gerostamoulos et al., 2023, Majrashi et al., 2018). Also, in common with ‘established’ psychostimulants (e.g. methamphetamine) and hallucinogens (e.g. lysergic acid diethylamide, LSD), acute reactions may include delirium, intense agitation, and aggressive behaviour (Darke et al., 2019, Daziani et al., 2023, Gerostamoulos et al., 2023, Logan et al., 2017). Some, particularly phenethylamines such as the N-benzylphenethylamine series (NBOMe) have both stimulant and hallucinogenic effects. Sudden deaths attributed to acute NPHS toxicity have been recorded for all of the major sub-classes: cathinones (Darke et al., 2019, Daziani et al., 2023, Groenewegen et al., 2024, La Maida et al., 2021, Zaami et al., 2018), phenethylamines (Bloomer et al., 2018, Darke et al., 2019, Gerostamoulos et al., 2023, Herian et al., 2022, Karinen and Høiseth, 2017, Kopra et al., 2025), tryptamines (Kopra et al., 2025, Pullen et al., 2025), piperazines (Chatterton et al., 2012, Darke et al., 2019, Majrashi et al., 2018;) and amphetamine analogues (Ellefsen et al., 2017). A common feature of these cases is polypharmacy, with the co-ingestion of other psychostimulants (such as methamphetamine) being prominent (Darke et al., 2019, Gerostamoulos et al., 2023, Groenewegen et al., 2024, Karinen and Høiseth, 2017; Kopra er al., 2025; La Maida et al., 2021). Multiple NPSH have also been documented in fatalities (Gerostamoulos et al., 2023, Groenewegen et al., 2024, Karinen and Høiseth, 2017). The use of multiple psychostimulants places considerable strain upon the cardiovascular system, and increases the risk of acute toxicity with development of cardiac arrhythmias and cardiac arrest.
In 2019 we reported on the characteristics of all-cause NPSH-related deaths in Australia, the most recent cases being from 2017 (Darke et al., 2019). Seventeen different NPSH were detected in that case series, with poisoning by far the major contributor. The NPSH market, typical of all NPS markets, is dynamic with new drugs constantly emerging. Indeed, in 2023 alone seven new cathinones were detected in Europe (EUDA, 2025). Toxicity remains the major concern. Whether the range of NPHS seen in poisoning deaths has changed since 2017 is unknown, and of clear public health significance. Given this concern, the current study focused solely on deaths attributed to drug toxicity in which NPHS were present in blood toxicology. We aimed to provide a comprehensive clinical profile of a national case series of the circumstances, characteristics and toxicology of such deaths, to determine the NPSH detected, and to determine whether case characteristics have changed. Specifically, the study aimed to determine:
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1.
The characteristics, toxicology and major autopsy findings of known cases of NBZD-related poisoning in Australia, 2000–2025; and
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2.
Changes in characteristics of known cases from 2020 onwards compared to earlier known cases.
2. Methods
2.1. National coronial information system
The Department of Justice and Community Safety (Victoria) is the organisational source of the NCIS. The NCIS is a national database of medicolegal death investigation records provided by the coroners’ courts in each Australian and New Zealand jurisdiction, commencing in July 2000 for Australia (January 2001 for Queensland) and July 2007 for New Zealand. Only Australian cases were accessed in this study. Throughout Australia, all cases of suspected drug overdose are required to be reported to the coroner for investigation of the death. A complete NCIS case file includes demographic information, a police narrative of circumstances, autopsy reports and toxicology reports (where these processes were conducted), and the coronial finding. Cause of death is ascertained by a forensic pathologist and documented on the autopsy and in the coroner’s report. The forensic pathologist may report on: i. the direct cause of death, ii. the antecedent cause, and iii. other significant conditions associated with the death. This advice is provided to the coroner, who makes a formal determination of the cause of death.
2.2. Case identification
All closed cases (i.e. the Coronial investigation had been completed) that occurred between 1 July 2000 and the final search (31 December 2025) in which a NPSH (‘synthetic cathinones’, ‘synthetic phenethylamines’, ‘piperazines’, ‘synthetic tryptamines’) was coded in the NCIS Drug Coding fields set as contributory to death were identified and inspected by the authors. A search was also conducted using the code ‘other novel psychoactive substances’. The series included only cases where death was attributed to drug toxicity, and the presence of a NPSH was confirmed by blood toxicology.
Ethical approval for the study was received from the Justice Human Research Ethics Committee (CF/18/22484), and the University of New South Wales Human Research Ethics Committee (HC220754).
2.3. Measures
Data were retrieved from police narratives, autopsy reports, toxicology reports and coronial findings. Information was collected on demographics, employment (from the code field in the NCIS case details), circumstances of death, a documented history of substance use-related issues (e.g. a history of enrolent in a drug treatment programme), a documented history of injecting drug use, and a history of mental health issues (diagnosis documented, history of treatment noted, mention in any document of known issues). Suicidal intent for included cases was determined by the NCIS codes for ‘IntentCompletion’ (codes include ‘Intentional self-harm’, ‘Unintentional’, ‘Undetermined intent’).
Toxicological testing was conducted according to local protocols. In all cases of suspected drug toxicity drug identification is performed. In cases of hospitalisation prior to death, antemortem blood samples taken on or near admission to hospital were reported, and drugs administered by medical staff excluded. Results from blood toxicology samples were reported for NPSH and other substances that were detected: alcohol, antidepressants, antipsychotics, cannabis (Δ-9-THC), gabapentinoids, GHB, hallucinogens, hypnosedatives, ketamine/ketamine analogues, opioids, and psychostimulants. All samples were tested using a range of methodologies specific to that laboratory, including immunoassay, gas chromatography, high-performance liquid chromatography (HPLC) and liquid chromatography-quadrupole time-of-flight mass spectrometry (LC-QTOF-MS) for common drugs and selected therapeutic substances. While the time between sampling and testing was not known, all specimens were preserved and stored at 4°C prior to testing.
Major pathology diagnosed at autopsy was reported for the following systems: pulmonary, cardiovascular, hepatic, renal. Cardiomegaly was diagnosed by heart weight exceeding the 90th percentile of normal weight ranges (Bell et al., 2022), and severe coronary artery atherosclerosis as ≥ 75% cross-sectional area stenosis or where described by the autopsy pathologist as severe.
2.4. Statistical analyses
For normally distributed variables, means, standard deviations (SD) and ranges were presented and t-tests conducted for group comparisons. For the purposes of analysing changes in case characteristics in the 2020 s, cases were categorised as those that occurred in the 2020 s (‘later’ period) and those that occurred prior to 2020 (‘earlier’ period). Analyses of changes in characteristics of categorical variables were conducted using logistic regressions with Odds Ratios (OR) and 95% confidence intervals (CI) reported. All analyses were conducted using IBM SPSS Statistics v. 29.0 (IBM inc, 2024). For low frequency cells, where case identification may pose a risk, the frequency was reported as n < 5. All analyses were conducted using IBM SPSS Statistics v. 29.0 (IBM, 2024).
3. Results
3.1. Case characteristics
We identified 70 cases of death in which the cause of death was drug toxicity and NPSH were present in blood, the first occurring in 2007, with 30 cases identified in the 2020 s (Table 1). In 11 cases the direct cause of death was attributed solely to NPHS toxicity, the remaining 59 being due to multiple drug toxicity. The annual number of deaths varied in a narrow band from 0 (2008) to 9 (2014, 2021), with a median of 4.5. The mean age was 32.8 years (SD 10.8, 18–62) with 82.9% being male. Approximately half were unemployed at the time of death. In 16 cases (22.9%) people present at the decedent’s final NPHS consumption stated that the decedent had commented to them that they were consuming methylenedioxymethamphetamine (MDMA), methamphetamine or LSD, and did not mention a NPHS. In a third of cases bystanders who witnessed the fatal event stated that that the NPSH had been injected.
Table 1.
Case characteristics of fatal cases of new psychoactive stimulant/hallucinogen-related toxicity.
| n = 70 | |
|---|---|
| Characteristics | |
| Year of occurrence n (%) | |
| 2006–2019 | 40 (57.1%) |
| 2020–2025 | 30 (42.9%) |
| Sex n (%) | |
| Male | 58 (82.9 |
| Female | 12 (17.1) |
| Age | |
| Mean years (SD, range) | 32.8 (10.8, 18–62) |
| Employment n (%) | |
| Unemployed | 34 (48.6) |
| Employed/Student | 30 (42.9) |
| Retired/Pensioner | < 5 |
| Unknown | < 5 |
| Documented history of: n (%) | |
| Substance use issues | 38 (53.3) |
| Injecting drug use | 29 (41.4) |
| Mental health issues | 24 (34.3) |
| Circumstance of death | |
| Intention n (%) | |
| Unintentional | 65 (92.9) |
| Intentional | 0 (0.0) |
| Undetermined | 5 (7.1) |
| Route of final administration n (%) | |
| Inject | 23 (32.9) |
| Swallow/Snort/Smoke | 24 (34.3) |
| Unknown | 23 (32.9) |
| Decedent apparently unaware they were consuming a new psychoactive stimulant/hallucinogen n (%) | 16 (22.9) |
| Location of fatal incident (private setting) n (%) | 57 (81.4) |
| Others in immediate vicinity n (%) | 49 (70.0) |
| Medical intervention n (%) | 36 (51.4) |
| Signs and symptoms at fatal incident n (%) | |
| Intense agitation | 16 (22.9) |
| Sudden collapse | 16 (22.9) |
| Hyperthermia | 14 (20.0) |
| Seizure | 13 (18.6) |
| Delirium | 12 (17.1) |
| Respiratory distress | 7 (10.0) |
| Vomiting | 6 (8.6) |
| Number of signs and symptoms | |
| 0 | 29 (41.4) |
| 1 | 18 (25.7) |
| 2 | 9 (12.9) |
| 3 | 9 (12.9) |
| 4–5 | 5 (7.1) |
⁎ Overall case closure statistics for all deaths recorded in NCIS: 2000–2022 (>90.0%), 2023 (65.9%), 2024 (42.9%), 2025 (16.2%) (National Coronial Information System, 2025)
A history of substance use issues was documented in over half, and of injecting drug use in 41.4%. A history of mental health issues was documented in a third (affective disorders n = 15, psychotic disorders n = 9). No case was coded as intentional self-poisoning. The majority of fatal incidents occurred in private settings, such as a house, with fewer than five cases occurring at a music festival. In half there was medical intervention by ambulance personnel and/or doctors prior to death.
Signs and symptoms of acute NPSH poisoning were reported in 41 cases (58.6%), ranging to five. The most commonly observed signs and symptoms of acute NPSH poisoning were intense agitation (22.9%), sudden collapse (22.9%), hyperthermia (20.0%), seizure (18.6%) and delirium (17.1%). The most common co-occurring signs and symptoms were: intense agitation/delirium (11), intense agitation/hyperthermia (8), intense agitation/seizure (7), hyperthermia/seizure (7).
3.2. Toxicology
A total of 31 NPSH were identified in blood toxicology, 13 of which were first detected in the 2020 s (Table 2). Cathinones were the most commonly detected NPSH, present in 34 cases (48.6%), most frequently α-pyrrolidinovalerophenone (α-PVP) and methylenedioxypyrovalerone (MDPV). Phenethylamines were present in 27 cases (38.6%), with paramethoxymethamphetamine (PMMA) and a range of NBOMe the most common. Tryptamines were present in 18.6%, most commonly N,N-dimethyltryptamine (DMT)/5-MeO-DMT. Few cases involved piperazines. Where quantitated, median blood concentration for the main types of NPHS were: cathinones (n = 11, 0.100 mg/L, range 0.002–1.000), phenethylamines (n = 17, 0.402 mg/L, range 0.010–38.000), tryptamines (n = 6, 0.011 mg/L, range 0.002–0.250), piperazines (n = 1, 0.01 mg/L).
Table 2.
New psychoactive stimulants detected in blood toxicology of fatal cases of new psychoactive stimulant/hallucinogen-related toxicity.
| Drug (Year of first case) | n = 70 n (%) |
|---|---|
| Cathinones | 34 (48.6) |
| α-Pyrrolidinovalerophenone (α-PVP) (2012) | 11 (15.7) |
| Methylenedioxypyrovalerone (MDPV) (2012) | 11 (14.7) |
| Pentylones: N-ethylpentylone (2020), N,N-dimethylpentylone (2023) | 6 (8.6) |
| Methylone (2023)/N-cyclohexylmethylone (2020) | < 5 |
| Eutylone (2020) | < 5 |
| Ethylone (2015)⁎ | < 5 |
| Mephedrone (2020) | < 5 |
| Methcathinone (2015) | < 5 |
| N-ethylheptedrone (2020) | < 5 |
| N-ethylhexedrone (2020) | < 5 |
| Phenethylamines | 27 (38.6) |
| Paramethoxymethamphetamine (PMMA) (2007) | 10 (14.3) |
| N-benzylphenethylamines (NBOMe): 25B (2012), 25 C (2014), 25 H (2014), 25I (2014) | 9 (12.9) |
| 4-fluoroamphetamine (2016) | 7 (12.9) |
| Ethylone (2015)⁎ | < 5 |
| 6-(2-aminopropyl)benzofuran (6-APB) (2020) | < 5 |
| 4-bromo-2,5-dimethoxy-phenethylamine (2-CB) (2021) | < 5 |
| β-phenethylamine (2014) | < 5 |
| Dimethoxyamphetamine (DMA) (2016) | < 5 |
| 1,3-dimethylamylamine (DMAA) (2012) | < 5 |
| Chloroamphetamine (2015) | < 5 |
| Methiopropamine (2014) | < 5 |
| Tryptamines | 13 (18.6) |
| N,N-dimethyltryptamine (DMT) (2011)/5-MeO-DMT (2020) | 9 (12.9) |
| Bufotenine (2021) | < 5 |
| Piperazines | 3 (4.3) |
| 3-Trifluoromethylphenylpiperazine (TFMPP) (2015) | < 5 |
| Benzylpiperazine (BZP) (2009) | < 5 |
| Other | |
| Phenmetrazine (2021) | < 5 |
Ethylone is both a cathinone and a phenethylamine
In 18 cases (25.7%) multiple NPSH were detected in the blood. These most commonly involved multiple phenethylamines (9) and multiple cathinones (6). Five cases had more than one NPHS class detected.
Psychoactive drugs in addition to NPSH were present in 92.9%, most commonly psychostimulants (68.6%) and hypnosedatives (40.0%) (Table 3). Overall, 53 cases (75.7%) had multiple stimulants/hallucinogens (NPHS, other psychostimulants, hallucinogens) in their blood.
Table 3.
Other drugs detected in blood toxicology of fatal cases of new psychoactive stimulant/hallucinogen-related toxicity.
| Drug class | n = 70 n (%) |
|---|---|
| Other psychoactive drugs present | 65 (92.9) |
| Psychostimulants | 48 (68.6) |
| Hypnosedatives | 28 (40.0) |
| Opioids | 25 (35.7) |
| Alcohol | 20 (28.6) |
| Cannabis | 13 (18.6) |
| Antidepressants | 11 (15.7) |
| Antipsychotics | 11 (15.7) |
| Ketamine/Ketamine analogue (2-fluoro-2-oxo-PCE) | 5 (7.1) |
| Other (Gabapentinoids, Hallucinogens, Gamma-hydroxybutyrate GHB) | 9 (12.9%) |
3.3. Major autopsy findings
Forensic pathology reports were available for inspection in all but 6 cases (in which the report was not attached to the NCIS files). An internal examination was conducted in 53 cases, an external examination with full body post-mortem CT scan in seven, and an external only examination in four. Acute bronchopneumonia in nine (15.0%). Cardiomegaly (enlarged heart) was diagnosed in seven cases (11.7%), severe coronary artery disease in six (10.0%) and replacement fibrosis (indicative of previous myocardial ischaemia) in six (10.0%).
3.4. Comparison of major characteristics of later and earlier period cases
There was no difference between cases from the 2020 s and those that occurred earlier in sex, employment, documented substance use issues, a history of injecting drug use or mental health issues (Table 4). Cases in the later period were, however, older. There was no difference between the later and earlier periods in the proportions of unintentional deaths.
Table 4.
Comparison of major characteristics of later and earlier period cases of of fatal new psychoactive stimulant and hallucinogen-related poisonings in Australia, 2000–2025.
| Later period | Earlier period | Comparisons | |
|---|---|---|---|
| (2020–2025) | (2007–2019) | ||
| n = 30 | n = 40 | ||
| Case Characteristics | |||
| Age (Years) | 34.7 | 31.2 | t68= 1.2, p = .2 |
| Male n (%) | 28 (93.3) | 30 (75.0) | OR 4.7 CI 0.9–23.2 |
| Employed n (%) | 12 (40.0) | 18 (47.4) | OR 0.7 CI 0.3–2.0 |
| Substance use issues n (%) | 18 (60.0) | 20 (50.0) | OR 1.5 CI 0.6–3.9 |
| Injecting drug use n (%) | 15 (50.0) | 14 (35.0) | OR 1.9 CI 0–7–4.9 |
| Mental health issues n (%) | 14 (46.7) | 10 (25.0) | OR 2.6 CI 1.0–7.2 |
| Unintentional death n (%) | 28 (93.3) | 37 (92.5) | OR 1.1 CI 0.2–7.3 |
| Toxicology n (%) | |||
| Cathinones | 15 (50.0) | 19 (47.5) | OR 1.1 CI 0.4–2.9 |
| Phenethylamines | 7 (23.3) | 20 (50.0) | OR 0.3 CI 0.1–0.9 |
| Tryptamines | 11(36.7) | 2 (5.0) | OR 11.0 CI 2.2–54.7 |
| Piperazines | 0 (0.0) | 3 (7.5) | OR 0.2 CI 0.0–3.5 |
| Multiple NPHS | 5 (16.7) | 13 (32.5) | OR 0.4 CI 0.1–1.3 |
| Other novel psychoactive substances | 17 (56.7) | 3 (7.5) | OR 16.1 CI 4.1–64.1 |
| Other psychostimulants | 22 (73.3) | 26 (65.0) | OR 1.5 CI 0.5–4.2 |
| Major autopsy findings n (%) | n = 27 | n = 33 | |
| Acute bronchopneumonia | 5 (18.5) | 4 (12.1) | OR 1.6 CI 0.4–6.9 |
| Cardiomegaly | 5 (18.5) | < 5 | OR 3.5 CI 0.6–19.8 |
⁎Odds Ratio, Confidence Interval. Referent group for ORs=Earlier period
Cases in the later period were more likely to have tryptamines detected, and less likely to have phenethylamines detected. There were no differences in the detection of cathinones or piperazines. Cases in the later period were 16.1 times more likely to have another type of NPS detected. There were no differences between cases in the 2020 s and the earlier period in detections multiple NPHS or other psychostimulants.
Acute bronchopneumonia and cardiomegaly did not differ between the later and earlier periods.
4. Discussion
We identified 70 cases of fatal poisoning involving a NPSH, confirmed by blood toxicology, 30 of which occurred in the 2020 s. These figures are, in all probability conservative, given lower numbers of case closures in recent years (National Coronial Information System, 2025). The predominance of males is consistent with other case reports and series (Chatterton et al., 2012, Darke et al., 2019, Ellefsen et al., 2017, Gerostamoulos et al., 2023, Groenewegen et al., 2024, Kopra et al., 2025, La Maida et al., 2021, Pullen et al., 2025). The increase in average age of 3.5 years age of cases was notable, with ages extending into the 60 s. While the average age remains relatively young, deaths amongst older people involving NPHS have been reported previously (Gerostamoulos et al., 2023, Groenewegen et al., 2024, Kopra et al., 2025, La Maida et al., 2021, Pullen et al., 2025). We should not assume this is an issue restricted to the young. In terms of other characteristics, clinical histories and circumstances of death, case presentations remained similar.
Consistent with previous research (Darke et al., 2019, Daziani et al., 2023, Gerostamoulos et al., 2023, Groenewegen et al., 2024, Herian et al., 2022, Logan et al., 2017, Majrashi et al., 2018, Neumann et al., 2024, Pullen et al., 2025) the most common clinical presentations preceding death were intense agitation, sudden collapse, hyperthermia, seizure and delirium. It was notable that in a third of cases the NPSH had been injected, a practice likely to have increased the risk of acute toxicity through a rapidly delivered bolus. It was also notable that most fatal incidents occurred in home environs, with few occurring at music festivals.
The extent and dynamic nature of the NPHS market is illustrated by the 31 different NPHS detected in blood toxicology, 13 of which were first detected in the 2020 s. The continuing emergence of new preparations observed in these deaths is consistent with Australian and international trends in drug markets (EUDA, 2025; Smith et al., 2025; United Nations Office on Drugs and Crime, 2025). Consistent with international concern (EUDA, 2025), cathinones were the most commonly detected NPHS in both the 2020 s and earlier. The balance of NPHS detected had, however, changed in the 2020 s, with these cases 11 times more likely to have tryptamines detected but far less likely to have phenethylamines detected. Indeed, almost all deaths involving tryptamines occurred in the 2020 s. Few cases involved piperazines. The median cathinone concentration was similar to that reported in our earlier study (Darke et al., 2019). Like that study, phenethylamine concentrations were higher than those observed for cathinones, and were also higher than observed in the 2019 series (0.402 v 0.250 mg/L). It was notable that a quarter of cases had consumed multiple NPHS, a risky use pattern that has been reported elsewhere (Gerostamoulos et al., 2023, Groenewegen et al., 2024, Karinen and Høiseth, 2017). Moreover, consistent with earlier studies, (Darke et al., 2019, Gerostamoulos et al., 2023, Groenewegen et al., 2024, Karinen and Høiseth, 2017, Kopra et al., 2025, La Maida et al., 2021), psychostimulants in addition to NPHS were highly prominent. Overall, three quarters of cases had multiple stimulants/hallucinogens in their blood at the time of the fatal incident, a scenario likely to increase the risk of cardiovascular events and neurotoxicity. The fact that seven cases had enlarged hearts may possibly have added to the cardiovascular risk, although we cannot say this for certain.
The current study has clinical and public health implications. People who use NPHS need to be aware of the cardiovascular and neurotoxic effects of these drugs and that death can, and does, occur. The dangers of their use with other psychostimulants and hallucinogens needs to be emphasised. Those around people who use these drugs should be aware that signs of overdose, such as intense agitation, hyperthermia, and seizure are cause for medical intervention, as is a sudden collapse. Aspiration bronchopneumonia takes time to develop, with prolonged inertia increasing the risk of it developing. The few cases diagnosed suggests that most deaths were relatively rapid, emphasing the need for prompt medical attention. NPSH should be also included in toxicology screens in hospital accident and emergency departments in cases of suspected drug poisoning. Buyers of such drugs would be prudent to use a drug checking service if one is available, particularly considering that almost a quarter of cases in this series were apparently unaware they were consuming a NPHS.
As in all studies, caveats must be considered. The current study reports on data extracted from NCIS,and did not involve primary data collection by the authors. This series of NPHS deaths was restricted to closed cases, and in recent years there will be cases in which the coronial process was still underway (National Coronial Information System, 2025). As new NPSH are constantly appearing on the market, there may be cases of poisoning involving NPSH that were not detected, so the number of cases identified is likely to be conservative. This is thus a study of the characteristics of known cases, rather than a study of epidemiological trends. It should be noted that storage and testing protocols and capabilities between toxicological laboratories is not uniform across jurisdictions. The series was also restricted to deaths attributed to poisoning and does not include cases of death due to traumatic injury or disease that may have been attributable to NPHS use. We also restricted this case series to poisonings that were confirmed by the presence of NPHS in blood toxicology. As in all cases of multiple drug toxicity, it is not possible to determine the exact relative contributions of various substances to individual deaths, but in all cases the cause of death was drug toxicity in which NPHS was coded in NCIS as contributory. Details of clinical histories and the circumstances of death were restricted to those documented in case files, and autopsy data were restricted to those cases in which the procedure was conducted and available for inspection. In all studies of mortality, the attribution of suicidal intent is problematic. In this series, suicidal intent was based upon the NCIS code for ‘Intentional self-harm’, which derives from the case circumstances and the conclusions of the coroner.
In summary, a wider the range of NPHS have been detected in fatal poisonings in recent years. While cathinones remain the most common NPHS detected in these deaths, tryptamines became more common in the 2020 s, and phenethylamines less common.
CRediT authorship contribution statement
Amy Peacock: Writing – original draft, Conceptualization. Julia Lappin: Writing – original draft, Conceptualization. Michael Farrell: Writing – original draft, Conceptualization. Johan Duflou: Writing – original draft, Methodology, Investigation, Conceptualization. Shane Darke: Writing – original draft, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization.
Declaration of Competing Interest
The National Drug & Alcohol Research Centre at the University of NSW is supported by funding from the Australian Government. Associate Professor Peacock is supported by a National Health and Medical Research Council Investigator Fellowship (#1174630).
Acknowledgements
The authors acknowledge the Victorian Department of Justice and Community Safety as the source organisation for the data presented here, and the National Coronial Information System as the data source. We would like to thank the staff at the National Coronial Information System.
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