Finding into death of Mary Veronica Payne

IN THE CORONERS COURT Court Reference: COR 2019 0145

OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: AUDREY JAMIESON, CORONER Deceased: Mary Veronica Payne Date of birth: 22 August 1947 Date of death: Between 7 January 2019 and 8 January 2019 Cause of death: Combined drug toxicity in a woman with emphysema Place of death: 1/37 Wilsons Lane, Sebastopol Victoria 3356 1 of 9

Pursuant to section 67(1) of the Coroners Act 2008, I make findings with respect to the following circumstances:

1. Mary Veronica Payne was a 71-year-old widowed woman who lived alone at 1/37 Wilsons Lane, Sebastopol Victoria 3356.

2. On 8 January 2019, Mrs Payne’s neighbour, Stuart Wells, located Mrs Payne deceased in the living room of her residence.

3. Mrs Payne’s death was reportable pursuant to section 4 of the Coroners Act 2008 (Vic) (the Act), because it occurred in Victoria, and was considered unexpected, unnatural or to have resulted, directly or indirectly, from an accident or injury.

INVESTIGATIONS Forensic pathology investigation

4. Dr Michael Burke, Forensic Pathologist at the Victorian Institute of Forensic Medicine (VIFM), performed an autopsy upon the body of Mrs Payne, reviewed a post mortem computed tomography (CT) scan, medical records from Alfredton Medical Centre and referred to the Victoria Police Report of Death, Form 83.

5. Dr Burke commented that the post mortem examination showed underlying chest disease. There were changes of emphysema and chronic asthma. Microscopic examination of the heart showed mild perivascular fibrosis.

6. Toxicological analysis of post mortem samples detected the presence of methadone1, codeine2, diazepam and its metabolite nordiazepam3, nitrazepam and its metabolite 7aminonitrazepam4, venlafaxine and its metabolite desmethylvenlafaxine5, metoclopramide6 and paracetamol7.

1 Methadone is a synthetic narcotic analgesic available in Australia and used for the treatment of opioid dependency or for the treatment of severe pain.

2 Codeine is a narcotic analgesic related closely to morphine. Other drugs may contribute to the toxic effects of codeine. These include central nervous system depressants, such as alcohol, opioids and benzodiazepines.

3 Diazepam is a sedative/ hypnotic drug of the benzodiazepines class.

4 Nitrazepam is a sedative (hypnotic drug) of the benzodiazepine class.

5 Venlafaxine is indicated for the treatment of depression.

6 Metoclopramide is an anti-emetic drug used for the treatment of nausea and vomiting.

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7. Dr Burke further commented that individuals on long term analgesics and other drugs may develop resistance the therapeutic and side effects of the drugs.

8. There was no current Department of Health and Human Services permit in the name of Mrs Payne for the use of methadone and Dr Burke could not see any reference to the use of methadone for Ms Payne’s chronic pain in her medical records.

9. Dr Burke ascribed the cause of death to combined drug toxicity in a woman with emphysema.

Police investigation

10. Upon attending the Sebastopol residence after Mrs Payne’s death, Mrs Payne’s daughter, Leanne Payne, advised that her mother suffered back pain and took various pain medications. Investigating officers located mirabegron 50 milligrams, tiotropium inhalation capsules 18 mcg, solifenacin 5 milligrams, oxycodone with naloxone CRtablets 12 milligrams- 7.5 milligrams and nitrazepam 5 milligrams. Also located at the residence was Ducolax and Ventolin inhalers.

11. First Constable (FC) Leonie Stizza was the nominated Coroner’s Investigator.8 At my direction, FC Stizza investigated the circumstances surrounding Mrs Payne’s death, including the preparation of the coronial brief. The coronial brief contained, inter alia, statements made by family and treating clinicians.

12. During the investigation, police learned that Mrs Payne attended the Alfredton Medical Centre (the Centre). She consulted on Dr Joanne Love. Dr Love retired at some point prior to Mrs Payne’s death. Subsequently on 3 January 2019, Mrs Payne consulted on Dr James Kieran Lalor. At this consultation, Mrs Payne was prescribed Targin.

13. Dr Lalor detailed that Mrs Payne’s main morbidities for which she consulted on the Centre included chronic back and other pain and depression. Mrs Payne’s grandson, Michael Chew-Payne, stated that for as long as he can recall, he remembers his grandmother being either in pain or unwell and that she was often in bed with many 7 Paracetamol is an analgesic drug.

8 A Coroner’s Investigator is a police officer nominated by the Chief Commissioner of Police or any other person nominated by the Coroner to assist the coroner with his/her investigation into a reportable death. The Coroner’s Investigator receives directions from a Coroner and carries out the role subject to those directions.

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blankets and an electric blanket to keep her warm. He further detailed that she had suffered from emphysema for a long time and was a heavy smoker of approximately 40 cigarettes a day. Mrs Payne had Webster packs for the distribution of her medications.

14. Mrs Payne’s back pain is said to have resulted from a car accident that occurred approximately 23 years prior to her death. Mr Chew-Payne detailed that his grandmother broke her back in this accident that resulted in “life-long problems”.

15. Dr Lalor further stated that Mrs Payne had never been prescribed methadone at the Centre, nor was the Centre aware of her having been prescribed the medication anywhere else.

16. Investigations revealed that Mrs Payne’s daughter, Ms L. Payne, was being treated with methadone through her general practitioner at a separate medical centre. Ms L. Payne had been treated with opiate replacement therapy continuously from the year 2002. In the period proximate to her mother’s death, Ms L. Payne was prescribed 60 milligrams daily of liquid methadone, with which she was allowed up to two takeaway doses with each supervised dose.

17. Mr Chew-Payne detailed that his mother, Ms L. Payne, was Mrs Payne’s “full time carer and would go around every day and stay at least two or three nights a week…” Ms. L.

Payne would take her methadone with her and place it in the fridge when she stayed at her mother’s house.

18. In the year prior to Mrs Payne’s death, Ms L. Payne became increasingly ill and spent a significant amount of time in hospital. Mr Chew-Payne estimated that his mother was taken by ambulance to hospital approximately 20 times. “If Mum was ever taken by ambulance from Nan’s it would remain in the fridge. Nan didn’t like it being there but she knew it was helping Mum.”

19. In the days proximate to Mrs Payne’s death, Ms L. Payne was admitted to hospital.

20. On the evening of 7 January 2019, Mr Chew-Payne’s sister, Sharni Chew-Payne, spoke with their grandmother over the phone. Mrs Payne was concerned about her daughter and grandchildren and expressed being in pain. Ms S. Chew-Payne told her brother that Mrs Payne sounded as though she was struggling to breathe.

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21. The Victoria Police Summary details that at on 8 January 2019 at approximately 3.00pm, Mr Wells entered Mrs Payne residence using a key.

22. Upon entering the residence, he found Mrs Payne slumped on the couch in her living room. Believing her to be deceased, Mr Wells called Ms S. Chew-Payne and emergency services.

23. Ambulance Victoria paramedics arrived shortly after and confirmed Mrs Payne was deceased.

COMMENTS Pursuant to section 67(3) of the Coroners Act 2008 (Vic), I make the following comments connected with the death:

1. Records from the Victorian Department of Health and Human Services did not evidence a permit for the prescribing of methadone to Mrs Payne in the state of Victoria.

2. Medical records and statements obtained throughout the course of the investigation confirm that Mrs Payne’s treating medical practitioner was not providing her with methadone.

3. The Victoria Police Coronial Brief Summary details that Mr Chew-Payne stated that he would be surprised if his grandmother consumed his mother’s methadone because she was against drugs and only accepted the methadone because it was assisting Ms L.

Payne.

4. Despite Mr Chew-Payne’s assertion that he would be surprised if his grandmother had taken his mother’s methadone, in the absence of any evidence that Mrs Payne was prescribed methadone, the likelihood on the balance of probabilities is that she consumed methadone that was diverted from her daughter, Ms L. Payne.

5. I recently asked the Coroners Prevention Unit (CPU)9 to prepare a summary of Victorian overdose deaths for the period 2010-2019 (see Attachment A) whilst investigating the 15 9 The Coroners Prevention Unit is a specialist service created for coroners to strengthen their prevention role and provide them with professional assistance on issues pertaining to public health and safety.

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November 2018 death of Wayne Laurence Marshall10. Given the contribution of methadone in the death of both Mr Marshall and Mrs Payne, I consider it appropriate to refer to this content again.

6. This summary shows (in table 5) that over the past decade methadone has consistently been one of the most frequent contributors to overdose death in Victoria, playing a role in more fatal overdoses than drugs that attract far more public attention, such as methamphetamine and oxycodone and codeine and alprazolam.

7. The deaths reflect the significant risks that methadone consumption entails, even for people who are otherwise experienced opioid users. Methadone has a particularly long period of action; its effects on individuals are highly variable; it can continue to have a respiratory depressant effect after its subjective effects are no longer experienced; and it interacts with many other drugs. All these properties heighten the risk of overdose in users.

8. Consumption of diverted methadone, as occurred in the death of Mrs Payne, is a common theme Victorian coroners encounter in their investigations. The CPU analysis showed that in 2019, the year Mrs Payne died, the evidence suggested methadone diversion amounted to 19 deaths (table 6) for a single year, which is a substantial number.

9. Reducing methadone diversion and non-clinical use of methadone is essential to reducing Victoria's overdose death toll, and coroners have repeatedly made recommendations aimed at addressing this.

10. For example and as appears to be the case with Mrs Payne, in many Victorian deaths a person has been prescribed methadone to treat opioid dependence (methadone maintenance therapy) and given the methadone in takeaway doses for unsupervised consumption at home, but does not store the methadone safely and securely, leading to another person (usually a co-resident) accessing the drug and overdosing. In response, coroners have made multiple recommendations that the Victorian Department of Health and Human Services (which is responsible for opioid pharmacotherapy policy) improve policy and education pertaining to methadone safe storage.

10 MARSHALL Wayne Laurence, COR2018 5754 6 of 9

11. Another common scenario is where a person has been dispensed unsupervised methadone for opioid dependence and sells, trades or gifts the methadone to another person who fatally overdoses. Coroners have, again, made multiple recommendations that this issue be addressed through the Victorian Department of Health and Human Services tightening access to unsupervised methadone dosing and doctors conducting better assessment of patient suitability for unsupervised methadone dosing.

12. For this reason, I have included the Victorian Department of Health and Human Services in the distribution list of this Finding. I would encourage the Medicines and Poisons Regulation Unit within the Department to consider the circumstances of the death in light of their current Policy for Maintenance Pharmacotherapy for Opioid Dependence, and whether there are any safeguards for unsupervised methadone dosing not described in the Policy which might reasonably have prevented this death from occurring.

STANDARD OF PROOF

1. All coronial findings must be made based on proof of relevant facts on the balance of probabilities. In determining whether a matter is proven to that standard, I should give effect to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336.

These principles state that in deciding whether a matter is proven on the balance of probabilities, in considering the weight of the evidence, I should bear in mind: a) the nature and consequence of the facts to be proved; b) the seriousness of any allegations made; c) the inherent unlikelihood of the occurrence alleged; d) the gravity of the consequences flowing from an adverse finding; and e) if the allegation involves conduct of a criminal nature, weight must be given to the presumption of innocence, and the court should not be satisfied by inexact proofs, indefinite testimony or indirect inferences.

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2. The effect of the authorities is that coroners should not make adverse findings against or comments about individuals, unless the evidence provides a comfortable level of satisfaction that they caused or contributed to the death.

3. There is no presumption for or against a finding of suicide. Nevertheless, a finding that a person has deliberately taken his or her life can have long lasting ramifications for families and friends of that person. Therefore, a coroner should only make this finding when they are satisfied to the abovementioned standard. In this matter, I am not satisfied to the requisite standard that Mary Vernonia Payne intended to end her own life.

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FINDINGS

1. I find that Mary Veronica Payne, born 22 August 1947, died between 7 January 2019 and 8 January 2019 at 1/37 Wilsons Lane, Sebastopol Victoria 3356.

2. I accept and adopt the cause of death ascribed by Dr Michael Burke and I find that Mary Veronica Payne, a woman with emphysema, has died from combined drug toxicity in circumstances where I find she ingested her daughter’s methadone.

Pursuant to section 73(1A) of the Coroners Act 2008 (Vic), I order that this Finding be published on the internet.

I direct that a copy of this finding be provided to the following: Michael Chew-Payne Danielle Wooltorton, Department of Health and Human Services First Constable Leonie Stizza Signature:

AUDREY JAMIESON CORONER Date: 28 September 2020 9 of 9

VP 1050 Coroners Court of Victoria

COR 2019 0145 CORONIAL FINDING INTO THE DEATH OF MARY VERONICA PAYNE ATTACHMENT A Data Summary: Overdose Deaths, Victoria 2010-2019 Coroners Court of Victoria 65 Kavanagh Street, Southbank Tel: (03) 8688 0700 Email: courtadmin@coronerscourt.vic.gov.au

Coroners Prevention Unit Data Summary Subject: Overdose deaths, Victoria 2010-2019 Date: 20 August 2020

1. Background The Coroners Prevention Unit (CPU) prepared this data summary at the direction of the Coroner to assist the Coroner's death investigation.

2. Data source The data source for this data summary was the CPU's Victorian Overdose Deaths Register (‘the Register’).1 To prepare the summary, on 17 August 2020 the Register was used to identify all Victorian overdose deaths reported to the CCOV between 2010 and 2019, and to extract data on the individual drugs that contributed to each death.

The contents of the Register are regularly revised and updated as coronial investigations progress.

Through the coroner’s investigation, an overdose death initially characterised as involving one drug might be determined to have involved two other drugs; or a death initially thought to be unrelated to drug consumption might be found to be a fatal overdose. Therefore, data reported from the Register about Victorian overdose deaths occurring in any given period can change over time.

3. Overdose deaths, Victoria 2010-2019 The 18 August 2020 data extract included 4365 overdose deaths investigated by Victorian coroners between 2010 and 2019. The following tables describe the patterns of drug contribution over time in the deaths.

3.1 Annual frequency of Victorian overdose deaths Table 1 shows the annual frequency of overdose deaths in Victoria for the period 2010-2019, and the frequency and proportion of overdose deaths each year which were due to the toxic effects of a single drug versus multiple drugs.

The annual frequency of Victorian overdose deaths fell in 2019, after a decade of consistent year-onyear increases. While the magnitude of the decrease was not particularly substantial (from 542 deaths in 2018 to 516 deaths in 2019, a decline of 26 deaths or 4.8%) it occurred against a backdrop of Victoria's continually growing population. Figure 1 shows that Victoria's crude overdose death rate per 100,000 population,2 declined quite notably in 2019 for the first time in a decade.

1 For the Register design, definitions, case inclusion criteria and coding process see Dwyer J, Ogeil O, Bugeja L, Heilbronn C, Lloyd B, Victorian Overdose Deaths: The Role of Pharmaceutical Drugs and Drug Combinations, Richmond: Turning Point, February 2017.

2 Crude rates were calculated by dividing the annual overdose death frequency by the estimated resident population of Victoria at June each year for 2010-2019 (the latter is published in Australian Bureau of Statistics Catalogue 3101.0).

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Table 1: Annual frequency and proportion of single- and multiple-drug overdose deaths, Victoria 2010-2019 Overdose deaths 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Overall frequency 341 362 366 380 387 454 494 523 542 516 Single drug 123 134 115 119 101 131 137 123 133 129 Multiple drug 218 228 251 261 286 323 357 400 409 387 Overall proportion 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Single drug 36.1 37.0 31.4 31.3 26.1 28.9 27.7 23.5 24.5 25.0 Multiple drug 63.9 63.0 68.6 68.7 73.9 71.1 72.3 76.5 75.5 75.0 Figure 1: Annual crude overdose death rate per 100,000 population, Victoria 2010-2019 The proportion of Victorian overdose deaths involving multiple drugs increased across the period, from 63.9% of deaths (218 of 341) in 2010 to 75.0% of deaths (387 of 516) in 2019. This underscores the importance of focusing on combinations of drugs used in harm reduction education and other overdose prevention initiatives.

3.2. Overdose deaths by contributing drug types Contributing drugs across all Victorian overdose deaths were classified into three main types: pharmaceutical, illegal and alcohol. Table 2 shows the annual frequency of Victorian overdose deaths involving each of these three contributing drug types. Most overdose deaths were from combined (multiple) drug toxicity, which is why the annual frequencies for each drug type in Table 2 sum to greater than the overall annual frequency.

Table 2: Annual frequency and proportion of overdose deaths by contributing drug types, Victoria 2010-2019 Overdose deaths 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Overall frequency 341 362 366 380 387 454 494 523 542 516 Pharmaceutical 263 274 302 312 316 356 383 414 424 405 Illegal 146 150 130 163 164 227 265 271 263 270 Alcohol 85 89 80 95 94 106 124 151 161 145 Overall proportion 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Pharmaceutical 77.1 75.7 82.5 82.1 81.7 78.4 77.5 79.2 78.2 78.5 Illegal 42.8 41.4 35.5 42.9 42.4 50.0 53.6 51.8 48.5 52.3 Alcohol 24.9 24.6 21.9 25.0 24.3 23.3 25.1 28.9 29.7 28.1 The decline in the frequency of Victorian overdose deaths between 2018 and 2019 appears to be driven largely by a decline in the number of fatal overdoses involving pharmaceutical drugs (from 424 CPU Overdose deaths 2010-2019 Page 2 of 7

deaths in 2018 to 405 in 2019) and alcohol (from 161 deaths in 2018 to 145 in 2019), but not illegal drugs (which rose from 263 deaths in 2018 to 270 deaths in 2019).

The 2019 increase in overdose deaths involving illegal drugs, in the context of a slight drop in the overall frequency of overdose deaths, is consistent with a broader five-year pattern. Between 2010 and 2014, the annual proportion of Victorian overdose deaths involving illegal drugs average 41.0%, but then increased suddenly to 50.0% of overdose deaths in 2015 and contributed in an average 51.3% of overdose deaths per year through to 2019.

3.3. Overdose deaths by combinations of contributing drug types To explore further how pharmaceutical drugs, illegal drugs and alcohol interacted with one another, each death was classified according to the combination of drug types that contributed to the fatal overdose. The seven mutually exclusive combinations were:  Pharmaceutical drugs only (no contributing illegal drugs or alcohol).

 Pharmaceutical and illegal drugs (no alcohol).

 Illegal drugs only (no pharmaceutical drugs or alcohol).

 Pharmaceutical drugs and alcohol (no illegal drugs).

 Pharmaceutical and illegal drugs and alcohol.

 Alcohol only (no contributing pharmaceutical or illegal drugs).

 Illegal drugs and alcohol (no contributing pharmaceutical or illegal drugs).

Table 3 shows the annual frequency and proportion of Victorian overdose deaths for each combination of contributing drugs.

Table 3: Annual frequency and proportion of overdose deaths by combinations of contributing drug types, Victoria 2010-2019 Combination of 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 drug types Overall frequency 341 362 366 380 387 454 494 523 542 516 Pharma only 141 148 170 148 160 153 153 165 173 154 Pharma + illegal 64 63 74 82 91 125 146 139 134 155 Illegal only 51 62 42 55 42 70 71 68 73 62 Pharma + alc 33 45 47 57 45 52 47 61 72 56 Pharma + ill + alc 25 18 11 25 20 26 37 49 45 40 Alcohol only 21 19 19 12 18 22 29 26 34 36 Illegal + alcohol 6 7 3 1 11 6 11 15 11 13 Overall proportion 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Pharma only 41.3 40.9 46.4 38.9 41.3 33.7 31.0 31.5 31.9 29.8 Pharma + illegal 18.8 17.4 20.2 21.6 23.5 27.5 29.6 26.6 24.7 30.0 Illegal only 15.0 17.1 11.5 14.5 10.9 15.4 14.4 13.0 13.5 12.0 Pharma + alc 9.7 12.4 12.8 15.0 11.6 11.5 9.5 11.7 13.3 10.9 Pharma + ill + alc 7.3 5.0 3.0 6.6 5.2 5.7 7.5 9.4 8.3 7.8 Alcohol only 6.2 5.2 5.2 3.2 4.7 4.8 5.9 5.0 6.3 7.0 Illegal + alcohol 1.8 1.9 0.8 0.3 2.8 1.3 2.2 2.9 2.0 2.5 Pharmaceutical drug only overdose deaths were consistently the most frequent type of Victorian overdose death between 2010 and 2018. However, over time there was a decline in the proportion of pharmaceutical drug only overdose deaths, and a shift towards overdose deaths involving pharmaceutical drugs in combination with illegal drugs; in 2019 for the first time this combination CPU Overdose deaths 2010-2019 Page 3 of 7

contributed in more overdose deaths than the pharmaceutical only group. The other notable trend over time has been the increase in alcohol-only overdose deaths (deaths from the acute toxic effects of alcohol), which nearly doubled over the decade.

3.4. Overdose deaths by contributing pharmaceutical drug groups Pharmaceutical drugs were disaggregated into drug groups for more detailed analysis. Table 4 shows the annual frequency of Victorian overdose deaths 2010-2019 involving each of the major contributing pharmaceutical drug groups, with illegal drugs and alcohol included for context. Most overdose deaths were from combined drug toxicity, which is why the annual frequencies for each drug group in Table 4 sum to greater than the overall annual frequency.

Table 4: Annual frequency and proportion of contribution to overdose deaths, among major contributing pharmaceutical drug groups plus alcohol and illegal drugs, Victoria 2010-2019. (^ Non-benzodiazepine anxiolytics; * Non-opioid analgesics.) Drug groups 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Overall frequency 341 362 366 380 387 454 494 523 542 516 Benzodiazepines 168 180 199 212 215 238 263 303 305 288 Illegal drugs 146 150 130 163 164 227 265 271 263 270 Pharma opioids 127 165 188 175 182 185 183 198 207 207 Antidepressants 105 101 141 134 144 161 165 196 195 171 Alcohol 85 89 80 95 94 106 124 151 161 145 Antipsychotics 64 65 78 75 81 91 107 136 108 103 Anticonvulsants 14 13 10 37 45 51 54 75 87 85 Non-benzo anx.^ 28 33 38 56 48 60 40 56 47 54 Non-opioid anlg.* 25 30 44 39 49 46 35 38 40 50 Overall proportion 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Benzodiazepines 49.3 49.7 54.4 55.8 55.6 52.4 53.2 57.9 56.3 55.8 Illegal drugs 42.8 41.4 35.5 42.9 42.4 50.0 53.6 51.8 48.5 52.3 Pharma opioids 37.2 45.6 51.4 46.1 47.0 40.7 37.0 37.9 38.2 40.1 Antidepressants 30.8 27.9 38.5 35.3 37.2 35.5 33.4 37.5 36.0 33.1 Alcohol 24.9 24.6 21.9 25.0 24.3 23.3 25.1 28.9 29.7 28.1 Antipsychotics 18.8 18.0 21.3 19.7 20.9 20.0 21.7 26.0 19.9 20.0 Anticonvulsants 4.1 3.6 2.7 9.7 11.6 11.2 10.9 14.3 16.1 16.5 Non-benzo anx.^ 8.2 9.1 10.4 14.7 12.4 13.2 8.1 10.7 8.7 10.5 Non-opioid anlg.* 7.3 8.3 12.0 10.3 12.7 10.1 7.1 7.3 7.4 9.7 Benzodiazepines were the most frequent contributing pharmaceutical drug group, playing a role in an average 54.3% of overdose deaths annually across the period. The next most frequent pharmaceutical drug groups were opioids (an average 41.6% of overdose deaths each year), antidepressants (annual average 34.7%) and antipsychotics (annual average 20.8%). Notable trends in the data included the gradual increase over time in antidepressant and anticonvulsant involvement in overdose deaths.

3.5. Overdose deaths by individual contributing drugs Table 5 shows the annual frequency of overdose deaths, Victoria 2010-2019, involving the most frequent contributing individual drugs. The individual drugs are tabulated by the major drug groups to which they belong.

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Table 5: Annual frequency and proportion of contribution to overdose deaths, among major contributing pharmaceutical drug groups plus alcohol and illegal drugs, Victoria 2010-2019. (^ Non-benzodiazepine anxiolytics; * Non-opioid analgesics.) Individual drugs 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Benzodiazepines 168 180 199 212 215 238 263 303 305 288 Diazepam 109 124 133 164 169 192 204 242 235 232 Alprazolam 56 43 57 45 28 23 23 27 31 28 Oxazepam 19 44 40 17 19 34 27 23 35 28 Temazepam 22 48 34 22 20 25 26 32 29 20 Clonazepam 8 14 18 19 25 33 31 48 40 35 Nitrazepam 15 11 24 26 13 17 22 11 16 13 Lorazepam 0 3 1 4 6 2 7 7 6 9 Etizolam 0 0 0 0 0 1 0 0 1 10 Illegal drugs 146 150 130 163 164 227 265 271 263 270 Heroin 136 125 107 128 136 171 191 220 202 212 Methamphetamine 14 29 34 51 53 72 120 93 95 111 Cocaine 1 2 4 5 7 15 11 10 17 20 Amphetamine 4 19 10 10 8 9 1 3 5 3

MDMA 1 1 1 3 4 5 12 7 4 13 Pharma opioids 127 165 188 175 182 185 183 198 207 207 Methadone 55 72 75 70 67 67 72 71 72 74 Oxycodone 38 46 46 60 46 58 54 66 62 59 Codeine 32 38 55 46 47 48 46 37 34 42 Tramadol 9 15 18 23 23 32 26 32 35 37 Morphine 12 12 13 9 12 9 13 18 19 18 Fentanyl 2 5 17 11 11 23 13 14 18 5 Buprenorphine 4 14 4 3 7 4 2 8 20 11 Tapentadol 0 0 0 0 0 0 0 1 9 13 Antidepressants 105 101 141 134 144 161 165 196 195 171 Mirtazapine 21 23 26 30 29 50 25 42 59 45 Amitriptyline 26 22 32 25 41 28 34 47 40 41 Citalopram 22 21 25 24 25 26 28 35 25 26 Venlafaxine 12 16 15 20 19 10 22 27 18 20 Duloxetine 5 7 14 11 12 12 15 12 19 20 Sertraline 6 4 12 13 9 12 11 18 19 20 Fluoxetine 9 8 13 10 7 12 16 10 12 12 Desvenlafaxine 1 3 6 8 11 15 19 15 18 12 Alcohol 85 89 80 95 94 106 124 151 161 145 Antipsychotics 64 65 78 75 81 91 107 136 108 103 Quetiapine 36 34 41 41 48 49 57 74 52 50 Olanzapine 18 17 22 15 21 30 36 41 42 33 Risperidone 3 11 8 10 7 9 14 9 13 10 Zuclopenthixol 4 4 6 3 3 5 4 14 4 7 Chlorpromazine 2 4 10 6 3 5 5 5 4 5 Clozapine 6 0 4 6 2 4 5 3 3 3 Anticonvulsants 14 13 10 37 45 51 54 75 87 85 Pregabalin 0 0 0 17 27 34 34 52 69 66 Sodium valproate 9 5 6 13 9 9 6 7 5 7 Lamotrigine 2 1 2 2 2 2 3 6 10 7 Table 5 continued over page CPU Overdose deaths 2010-2019 Page 5 of 7

Table 5 continued from previous page Individual drugs 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Non-benzo anx. 28 33 38 56 48 60 40 56 47 54 Doxylamine 16 11 21 23 13 14 13 18 18 16 Zopiclone 3 6 13 14 11 17 13 17 13 22 Pentobarbitone3 5 11 1 8 15 18 9 10 6 9 Zolpidem 3 5 5 4 6 11 6 8 6 8 Diphenhydramine 1 4 2 7 5 5 4 6 6 7 Non-opioid anlg. 25 30 44 39 49 46 35 38 40 50 Paracetamol 21 24 42 37 37 42 30 32 32 47 Ibuprofen 5 4 5 2 7 5 4 1 7 4 Antihistamines 11 11 10 11 14 14 14 21 33 27 Promethazine 10 8 8 6 11 11 11 16 27 18 Pheniramine 0 1 1 3 3 3 2 4 4 4 The following is a brief description of some notable findings in table 5:  The frequency of Victorian overdose deaths involving benzodiazepine contribution declined for the first time in a decade. Antidepressant and antipsychotic involvement also declined slightly from 2017-2018 peaks. While it is not possible to confirm the reasons why this occurred, two major initiatives focused on improving appropriate prescribing may have had an influence. The first is the Victorian Department of Health and Human Services (DHHS) SafeScript real-time prescription monitoring program, which became available for all medical practices and pharmacies in October 2018. The second is the Royal Australian College of General Practitioners suite of clinical resources, Prescribing Drugs of Dependence in Clinical Practice, which have been progressively developed and disseminated over the past five years.

 The frequency of overdose deaths involving illegal drugs heroin and methamphetamine has increased again in 2019 after a 2018 decline that gave some hope that drug harm reduction strategies that target injecting drug users might be having a positive impact. In addition, overdose deaths involving cocaine and MDMA reached 10-year highs.

 Pregabalin continued to be a substantial contributor to Victorian overdose deaths in 2019. In deaths investigated by Victorian coroners, doctors have been found to prescribe it widely without regard to its risk of misuse and abuse. Despite this, the Victorian Department of Health and Human Services has on multiple occasions refused to add pregabalin to the list of drugs monitored in the SafeScript system.4  Methadone remained the most frequent contributing opioid to Victorian overdose deaths in 2019, and opioid involvement in Victorian overdose deaths generally remained at its highest level in a decade despite several interventions such as the implementation of SafeScript, rescheduling of codeine, and oxycodone reformulation.

 The benzodiazepine etizolam contributed in 10 deaths in 2019, having not appeared more than once in previous years. Etizolam is not approved by the Therapeutic Goods Administration for prescription in Australia but can be purchased via the internet and imported.

3 Pentobarbitone prescribing to humans is not permitted in Australia, and the drug could be alternatively classified as illegal.

4 For the most recent example of DHHS refusal to monitor pregabalin, see Coroner Sarah Gebert's finding in the death of Mr A (case reference COR 2016 4886 delivered 18 October 2019) and the DHHS response, which can be accessed on the Coroners Court of Victoria website at <https://www.coroners court.vic.gov.au/inquests-findings/findings>.

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 The opioid tapentadol contributed in 13 deaths in 2019, up from nine in 2018 and one in 2017.

Tapentadol is widely promoted for its improved safety profile compared to other opioids.

4. Methadone overdose deaths and permits As table 5 shows, opioids were one group of pharmaceutical drugs for which involvement in Victorian overdose deaths did not decline; and among them, methadone remained (for the tenth straight year) the most frequent contributor to overdose deaths.

This finding is consistent with the risk profile of the drugs. Opioids generally present a risk of misuse, addiction and other harms (including fatal overdose), and methadone is associated with a particularly elevated overdose risk because it has a long half-life of action; there is wide variation in how it affects individuals; its respiratory depressant effects can last well beyond the experience of its subjective (analgesic and euphoric) effects; and its respiratory depressant effects are additive with the effects of most other central nervous system depressants.

Methadone access is tightly regulated in Victoria. Except for certain specific circumstances (such as treatment in palliative settings; treatment of cancer pain; and treatment in prisons, hospitals and aged care facilities), a doctor prescribing methadone to a patient must have applied to the Victorian Department of Health and Human Services (DHHS) for a permit to do so. The purpose of the permit system is to assist in managing the risk of misuse and addiction and harm in patients prescribed methadone.

Each year Victorian coroners investigate several overdose deaths involving methadone for which the DHHS has no record of a permit application to prescribe to the deceased. In most of these cases, if the source of contributing methadone can be identified it has been diverted: that is, gifted or sold to the deceased by another person, or accessed by the deceased without the knowledge of the person to whom it was originally prescribed and dispensed. The permit status of a person who died from a methadone-involved overdose, is a generally reliable heuristic indicator of whether the contributing methadone was dispensed to the deceased (permit held) or diverted (no permit held).

Table 6 shows the annual frequency and proportion of methadone-involved overdose deaths in Victoria, disaggregated by whether there was evidence a doctor held a permit to prescribe methadone to the deceased.

Table 6: Annual frequency and proportion of methadone-involved overdose deaths by permit status of deceased, Victoria 2010-2019 Overdose deaths 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Overall frequency 55 72 75 70 67 67 72 71 72 74 Permit 21 33 40 28 45 45 50 47 48 55 No permit 31 38 35 41 22 22 22 24 24 19 Unknown 3 1 0 1 0 0 0 0 0 0 Overall proportion 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Permit 38.2 45.8 53.3 40.0 67.2 67.2 69.4 66.2 66.7 74.3 No permit 56.4 52.8 46.7 58.6 32.8 32.8 30.6 33.8 33.3 25.7 Unknown 5.5 1.4 0.0 1.4 0.0 0.0 0.0 0.0 0.0 0.0 In 2010 a clinician held a permit to prescribe methadone to the deceased in only 38.2% of fatal Victorian methadone-involved overdose. This proportion increased over time, and by 2019 there was evidence of a permit held in 74.3% of deaths. This suggests the frequency and proportion of overdose deaths involving methadone decreased over time, with most deaths now occurring among people who were prescribed the drug.

CPU Overdose deaths 2010-2019 Page 7 of 7