NDARC Technical Report No. 213 (2005)
EXECUTIVE SUMMARY
Demographic characteristics of injecting drug users (IDU)
One hundred and one IDU participated in the 2004 IDRS. The median age of the sample was 32 years and 61% of participants were male. Almost two-thirds (63%) of the sample was unemployed and over half (59%) had a history of previous imprisonment. The median number of years spent at school was 10. Over half the sample (54%) reported having some kind of post secondary school qualifications and almost half (48%) were currently undertaking some form of treatment for drug use. Compared to 2003, in 2004 there were slightly more males in the sample, more who reported having a tertiary qualification from a university or college, and more who were in some form of treatment for drug use at the time of interview.
Patterns of drug use among IDU
The drug most commonly first injected by the sample was amphetamine (53%), followed by heroin (39%). Compared to 2003, in 2004 there was no change in the proportions nominating heroin and methamphetamine as their preferred drug among the IDU sample. Specifically, 48% reported heroin as their drug of choice and 34% reported some form of methamphetamine as their drug of choice. However, similar proportions reported heroin or methamphetamine as the drug most injected in the last month. Since 2002 there has been an increase in the proportion of IDU that reported injecting heroin most often in the last month (22% to 33% to 37%) and a concurrent decrease in the proportion reporting methamphetamine as the drug most injected (57% to 43% to 39%). Therefore, in 2004 there is still a discrepancy between what people want to use and what they are actually using, which may depend on a variety of factors including price, availability and quality of what is available.
Polydrug use was common among the IDU in 2004 and has remained consistently so across the years, with no real differences being reported from 2003 to 2004. Similar to 2003, in 2004 there was substantial crossover between heroin users and methamphetamine users in the IDU sample. Thirty-six IDU (36%) had used both heroin and some form of methamphetamine, in the last six months.
Frequency of injecting in the last month was greater than weekly for two-thirds of the sample, with 38% reporting injecting at least once a day. Overall, there was a decrease in the reported frequency of injecting in the last month, from 2003 to 2004.
Heroin
Overall, there was a decrease in the price of heroin from 2003 to 2004, continuing the downward trend since the peak in 2002, with the price now the same as the pre-shortage level of 2000 ($320 per gram). Heroin was still considered ‘easy’ or ‘very easy’ to obtain by most IDU and availability was reported as stable to easier in the preceding six months. There was an increase in the proportion of IDU obtaining heroin from a dealer’s home or from a street dealer, and a concomitant decrease in the proportion being supplied by mobile dealers. According to the majority of IDU, heroin purity remained at low to medium levels in 2004, with increased proportions also reporting fluctuating or decreasing purity. IDU perceptions were supported by indicator data, which shows the median purity of SAPOL heroin seizures has remained relatively stable across the last few years, with median purity of 25% in 2003/04. Purity of SAPOL heroin seizures remains well below pre-shortage levels.
A small increase in the proportion of IDU that had recently used heroin was noted, continuing the increase since 2002. There was however, a decrease in the median number of days used following the dramatic rise in frequency seen in 2003. This may indicate a stabilisation of heroin use following the post-shortage ‘bounce-back’ of 2003.
Analysis of IDU that nominated heroin as their drug of choice indicated users continue to supplement or substitute their heroin use with other opioid substances such as morphine and methadone. There was an increase in the proportion of IDU reporting use of rock heroin and a decrease in the proportion of IDU reporting use of powder heroin, and a slight majority (59%) reported rock as the form used most in the last six months. It was suggested by several KES though that rock heroin is actually compressed powder heroin.
SAPOL data revealed that total heroin-related possession and provision offences remained relatively stable from 2002/2003 to 2003/2004. KES provided little or no comment on street level offending, unless to say that no change in type or level of crime had occurred recently.
Similarly, experience of recent heroin overdose among IDU remained low. This was reflected in the latest ABS data on opioid overdose deaths, which showed a decline in the number of accidental opioid overdose deaths in SA from 2002 to 2003.
The proportion of opioid-related calls to ADIS remained stable. An analysis of the presentations to all DASC treatment services for heroin or other opioids also revealed little change since 2003. However, a small increase was apparent in the proportion of clients admitted to DASC inpatient (detox) services nominating any type of opioid substance (including heroin) as their primary drug of concern (18.7%), representing a slightly higher proportion than those nominating amphetamines as their primary drug of concern (17.4%). Both state (SA) and national hospital data showed the number of opioid-related admissions were stable (as at 2002/03) and still below pre-heroin shortage levels. SA emergency data attendances for heroin and other opioids also appeared stable in 2003/04 compared to the previous year, and below pre-shortage levels.
Methamphetamine
Overall there have been decreases in the price of all three forms of methamphetamine from 2003 to 2004. In contrast to 2003, there was little difference in the median price paid for a ‘point’ of all three forms of methamphetamine in 2004. The median price of a gram of powder remains considerably cheaper than either base or crystal. Again it was noticeable in 2004 that there were wide ranges in reported prices paid, particularly of a gram, across all types of methamphetamine. IDU reported the price of all forms of methamphetamine as stable. KES reports are in agreement with IDU information on price.
In 2004, all forms of methamphetamine were reported as ‘easy’ or ‘very easy’ to obtain by the majority of IDU able to comment, and base methamphetamine was considered easiest to obtain, followed by powder and crystal. The majority also reported that availability of all forms had recently been stable or getting easier. Availability was largely unchanged compared to 2003, except for a perceived increase in availability of base methamphetamine. The majority of KES also reported availability as ‘easy ‘ or ‘very easy’ and stable. There was a decline in the proportion of IDU reporting that they usually obtained powder and base methamphetamine from mobile dealers, and rise in the proportion scoring from dealer’s homes.
Since 2003, there has been an overall slight increase in the perceived purity of all forms of methamphetamine. Purity of all forms was considered largely stable, but perceptions were somewhat equivocal with substantial proportions of IDU reporting change or fluctuation in purity recently. However, the base and crystal forms were still perceived as high or medium purity by the majority of those IDU able to comment. Overall, SAPOL seizure data indicates that the median purity of methamphetamine has remained stable, with median purity of 19.8% in 2003/04. However, there was a decline in median purity over the last three quarters of 2003/04, which may indicate the start of a downward trend.
The proportion of IDU reporting recent use of any methamphetamine remained stable, but large decreases were seen in the frequency of use of base and crystal methamphetamine. However, there was only limited support of decreased use of methamphetamine among IDU from KES reports.
SAPOL data revealed an increase in methamphetamine related provision offences, but the number of possession/use offences remained stable compared to 2003. There was also evidence from SAPOL data on clandestine laboratory detections that local manufacture of methamphetamine was still a major contributor to the SA methamphetamine market.
Nationally, the number of accidental deaths with methamphetamine as the underlying cause increased in 2003 compared to 2002, according to ABS data. Calls to ADIS in SA regarding methamphetamine remained stable, but there was a decrease in both total admissions to DASC treatment services and to DASC’s inpatient (detox) services with methamphetamine as the primary drug of concern. State (SA) hospital admissions data showed the number of amphetamine-related admissions was continuing to increase (as at 2002/03), though national data showed a slight decline in numbers from 2001/02 to 2002/03. SA (RAH) emergency data attendances for amphetamines may suggest a decline in the number of amphetamine-induced psychosis.
Cocaine
Similar to 2003, only a very small number of IDU were able to supply information regarding the price, purity or availability of cocaine, which was reflective of the very low numbers of IDU that had used cocaine in the last six months (a total of 6, compared to 15 in 2003). In addition, although several KES were able to provide some information on cocaine, this was limited and none could nominate cocaine as their main area of expertise. Consequently, the data for price, purity and availability of cocaine in 2004 is of limited value.
The small number of KES and IDU either using cocaine or able to provide information in itself indicates the lack of a sizeable and visible cocaine market in Adelaide, particularly amongst the IDU sampled by the IDRS. Indicator data, such as the number of cocaine possession and provision offences, calls to ADIS, DASC treatment services data for cocaine, and SA hospital admissions data also support this presumption. However, this does not exclude the possibility that a cocaine market exists beyond the scope of this survey.
Cannabis
Overall, there had been little, if any, change in cannabis market indicators since 2003. The median price paid for either a ‘bag’ or an ounce of cannabis has been stable for a number of years, with little difference in price between the hydro and bush/outdoor types ($200 or $180 per ounce, respectively). The majority of IDU reported that the price of cannabis had remained stable in the past six months. Approximately 80% of IDU able to comment perceived either hydro or bush cannabis was ‘very easy’ or ‘easy’ to obtain and around two-thirds reported that availability had been stable in the previous six months. The majority reported scoring the cannabis they had used last from a friend and that the source had been a small-time ‘backyard’ user/grower. Eighty-five percent or more also perceived the potency of either hydro or bush as high or medium, and over two-thirds reported that the potency had been stable recently.
The proportion of IDU reporting recent use, and the frequency of use, of cannabis remained high, with the majority reporting mainly using hydro cannabis in the six months prior to interview. KES reported no changes in any parameter of the cannabis market, or use of cannabis among IDU, in 2004 compared to 2003.
A continuing decline in the number of provision offences related to cannabis was recorded by SAPOL in 2004, but possession/use offences remained the same as for 2003. The number of calls to ADIS concerning cannabis remained stable, as did the total number of presentations to DASC treatment services. Cannabis-related hospital admissions were stable as at 2002/03.
Other opioids
As in recent years, in 2004 the use of other opioid substances by IDU was common, with 79% reporting recent use of some type of opioid substance, excluding heroin. There were some changes however, in the use of other opioids by IDU in the 2004 sample. Specifically, although the proportion of IDU reporting recent use of morphine or other opioids (oxycodone or codeine) remained stable, there was a decrease in the frequency of use, particularly of morphine, following a rise over the last couple of years. The price and availability of morphine was unchanged since 2003, so this decrease was most likely influenced by the increased availability, and decreased price, of heroin over the same period. As in 2003, the majority of morphine users reported use by injecting, and mainly used illicit supplies of Kapanol® and MS Contin®.
In addition, in 2004 there was a decrease in the proportion of IDU that reported recent use of illicit methadone, while the proportion reporting use of illicit buprenorphine remained stable. Although there was no change in the proportions reporting use of illicit buprenorphine by injecting, there was a doubling of the proportion reporting recent injection of licit buprenorphine, concomitant with an increase in the percent of IDU on a buprenorphine treatment program in 2004. It is worth noting however, that of those IDU that reported use of any methadone or buprenorphine, 75% or more reported mainly licit use in the last six months.
KES reports of other opioid use were primarily within the context of heroin-using IDU and supported a perception that users were continuing to use other opioids to substitute or supplement their heroin use, despite the ‘return’ of heroin.
Other drugs
There was no change in the proportion of IDU reporting recent use of ecstasy, but a decline in the proportion reporting recent use of hallucinogens in 2004. Frequency of use of both substance types was low and unchanged. There was also no change in the proportion of IDU reporting recent use or injecting of benzodiazepines, but a continuing increase in the frequency of use since 2002 was noted. Most IDU reported use of a licit supply, mainly of diazepam. Anti-depressant use was also stable, with almost exclusively licit use reported.
Associated harms
Despite a decrease in frequency of injecting seen among methamphetamine users in the 2004 survey, there was a marked increase in the proportion of the sample reporting sharing of injecting equipment (excluding needles) in the month before interview. Along with KES reports of complacency and ignorance of ‘safe’ injecting practices among some IDU, particularly the younger and more naïve methamphetamine users, this suggests that reinforcement and/or wider dissemination of harm-reduction messages is required. The high rate of sharing among IDU may impact on what has been a positive downward trend in HCV prevalence over recent years.
The 2004 survey identified that injecting of morphine was common, as was injecting of methadone and buprenorphine, with the use of buprenorphine by injecting more than doubling compared to 2003. Despite a decrease in the prevalence of morphine injecting, there were large proportions of injectors of morphine, methadone and buprenorphine that reported injecting-related problems such as substance dependence, scarring and bruising, difficulty finding veins, and abscesses or infections. Several KES commented that these problems were exacerbated by lack of IDU access and/or proper (single) use of filters and other injecting equipment (primarily due to financial constraints).
Both IDU and KES reported mental health issues as generally stable in 2004. There was no change in IDU reported attendance to a health professional for a mental health problem, with attendance to a GP for depression and/or anxiety predominating. KES concurred with the predominance of depression and anxiety, particularly among opioid users, and that this had been stable recently. There were mixed reports however, regarding whether there had been any change in the prevalence of mental health problems associated with methamphetamine use.
An analysis of expenditure on drugs demonstrated that of those who reported having spent money on illicit drugs on the day preceding interview, heroin users had spent twice as much as methamphetamine users.
There was no change in the prevalence or type of criminal involvement reported by IDU, with drug dealing and property crime remaining the most common. Most IDU perceived that police activity was either stable or increasing and the majority reported that police activity had not made it more difficult to obtain drugs recently.
Implications
In the 2004 SA IDRS survey more evidence is emerging of a stabilisation of patterns of heroin use since the 2001 shortage. In contrast, while heroin use appears to be stabilising, a downturn in some parameters of methamphetamine use have appeared. The following issues were identified from the results of the 2004 survey, which will require ongoing attention from policy makers, researchers and health professionals;
- The increase in availability of heroin in South Australia over the last two years has seen patterns of use among IDU stabilise and approximate pre-shortage patterns. In contrast, there has not been an upturn in secondary indicators such as drug related crimes and overdose experience. Careful monitoring of secondary indicators must be carried out to identify any early indicators of an increase in crime and/or overdose so that early interventions can be instigated. In the case of overdose, vigilance is particularly warranted as the indicator data reported stems from the previous year.
- A substantial downturn in the intensity of methamphetamine use among South Australian IDU has been one of the more surprising findings of the 2004 SA IDRS survey. The sharp decrease in the median number of days used, particularly for base and crystal, stands in contrast to the majority of key expert reports of very little change in the patterns of use. A minority of KES did comment on changes in use and suggested users had "backed off" in their intensity of use and a few also noted a recent decline in attendances to services for methamphetamine related problems. The reasons for this apparent discrepancy between user accounts and KES accounts requires further investigation.
- Although the proportion of IDU reporting use of buprenorphine remains small it is increasing at a steady rate reflecting the uptake of buprenorphine as a form of opioid substitution therapy. The proportion of the sample injecting any buprenorphine, licit or illicit, has doubled since last year and most of this was accounted for by users injecting their licitly obtained supply. With the proportion of IDU taking up buprenorphine as an opioid substitution therapy set to rise a close eye should be kept on the rate of injecting and associated injecting problems.
- Investigations need to be undertaken to see why a sudden rise in sharing of equipment has occurred particularly as a sustained decrease was recorded in 2002 and 2003. Moreover, the discrepancies between KES need to be fully investigated to understand how such disparate views are being held and what potential impact they may have on the provision of resources for educating users about the dangers of sharing injecting equipment. It may be that KES have access to different populations of users and that this will require further elucidation in future reports.
Citation: Weekley, J., Pointer, S. and Ali, R. (2005) SA Drug Trends 2004: Findings from the Illicit Drug Reporting System (IDRS), Sydney: National Drug and Alcohol Research Centre.