EXECUTIVE SUMMARY
Demographic characteristics of people who inject drugs (PWID) participants
Demographic characteristics of the regular injecting drug user participants interviewed were generally consistent with those interviewed in previous Hobart IDRS studies. Participants were predominantly male (55%), and had an average age of 35 years. Participants had completed 10 years of education on average, two-thirds (68%) were currently unemployed, and one-third of the sample reported a previous prison history (37%).
Half of the participants (55%) were injecting a few times per week (but not every day), with 36% injecting at least once daily. Opioids were the predominant drug of choice among the cohort (66%), and were the class of drug most injected in the preceding month amongst three-quarters of the sample (73%). Two-fifths were involved in some sort of drug treatment at the time of interview (40%).
Patterns of drug use among the PWID sample
The major trends identified in the 2011 Tasmanian IDRS report relate to indications of emerging changes in patterns of methamphetamine and pharmaceutical opioid use amongst local PWID, along with ongoing use of coincident opioid and benzodiazepine (particularly alprazolam) use. Main trends are summarised by each drug type below.
Heroin
The rate of recent heroin use among Tasmanian PWID cohorts decreased dramatically from 38% in 2000 to 8% in 2010. In 2011, a small increase in the proportion of participants reporting recent use was observed (19%), however the median frequency of this use was very low (4 days in the preceding six months). This was in spite of 30% of the sample reporting heroin as their drug of choice.
Very few of the PWID participants interviewed in 2011 could report on local trends in price, purity or availability of heroin. The median and modal prices that participants reported last paying for heroin were $75 for a cap and $400 for either 0.5g or 1.0g. It should be noted that very few participants were able to comment. The majority of participants who commented noted that heroin was difficult to access in Tasmania, and that this situation had not changed in the preceding six months. No clear trend was discernible regarding purity of heroin
The clear majority of indicators – such as the continuing low prevalence of heroin use among clients of the state’s Needle and Syringe Program (NSP), the low median rate of use of heroin (four days in the last six months among those who had used the drug) and that, of the 30% of the PWID sample that reported heroin as their drug of choice, only half had recently used heroin – indicated that the low availability of heroin in the state, identified in earlier IDRS studies, continued in 2011.
Methamphetamine
Almost all PWID participants in 2011 (98%) reported lifetime use of some form of methamphetamine (powder, base/paste, crystal/ice or liquid). Seventy-seven percent of the sample reported use of any form in the six months preceding the interview, at a median frequency of 20 days, equating to use on average once per week. This level of use is similar to that reported between 2008 and 2010 (70-80%), but lower than reported between 2000 and 2007 (83-95%).
Previous years have seen major upheavals in methamphetamine markets in Hobart, often tied to changes in the availability of higher-potency forms of the drug. Between 2001 and 2005, there was a steady increase in use of methamphetamine, both among the IDRS PWID cohort (85% in 2001; 95% in 2005) and among clients of the state’s NSP (30% in 2004; 59% in 2005). In 2006 and 2007, the proportions of PWID participants reporting recent use of methamphetamine stabilised (83% in 2006; 88% in 2007). Since 2008, the rate of recent use amongst IDRS participants has been somewhat lower (ranging between 70-80%), as has the rate of transactions through the statewide NSP (ranging between 31-36%).
The most commonly used form of the drug was powder methamphetamine, used by 67% of participants. Use of base/paste methamphetamine decreased dramatically in 2008 from 79% of the sample in 2005 to 25% in 2008. This declining trend stabilised in 2009, and in 2011, 39% reported recently using this form. Use of crystal methamphetamine declined from 69% of the 2003 cohort to 26% in 2011.
In 2011, frequency of use of any form of methamphetamine in the preceding six months was 20 days (out of a maximum of 180 days), similar to the rate reported in 2010 (24 days). In the current sample, the median frequency of use for powder methamphetamine was 10 days, for base/paste seven days, and for crystal methamphetamine six days.
Market prices locally for powder and base/paste presentations of methamphetamine appear to have remained relatively stable since 2005, particularly in relation to ‘point’ amounts (approximately 0.1g) of the drug, at $50 for either form. Modal purchase prices for larger amounts of powder and ‘base/paste’ have also remained stable since 2004 at $300 per gram. ‘Point’ purchases of crystal methamphetamine have also remained stable at $50 since 2004 (no price data was provided by participants for gram purchases in 2011). Participants predominantly regarded the prices of each presentation of the drug as remaining ‘stable’ in recent months.
PWID participants reporting on subjective purity of powder methamphetamine considered this to be ‘low’ to ‘medium’, and that this had either remained stable or decreased over the preceding six months. ‘Base/paste’ was considered by participants to be ‘medium’ in subjective purity; and that this had remained stable over the preceding six months. Participants considered ice/crystal methamphetamine used locally as ‘high’ in subjective purity, with potency remaining stable in recent months.
Participants interviewed in 2011 regarded powder form of methamphetamine as ‘easy’ or ‘very easy’ to access, with availability stable in recent months. Similarly, the majority of participants who had recently used base/paste methamphetamine reported that it was ‘easy’ or ‘very easy’ to access, and that this situation had remained stable in the preceding six months. Amongst the participants able to comment on trends for crystal methamphetamine, availability was considered to be either ‘easy’ or ‘very easy’, and that this situation had remained unchanged over the preceding six months.
Trends in 2011 represent subtle changes both for the methamphetamine market overall (for the PWID demographic) and within it; in contrast to trends in previous years, indicators suggest that overall use of methamphetamine has been lower since 2007 (both in IDRS and NSP data), and that amongst those recently using this drug the majority of participants reported powder as the predominant form of methamphetamine used. Use of crystal methamphetamine appeared to have stabilised in 2011, after several years of decreasing use. A companion study in Hobart carried out during a similar period examining drug use among regular ecstasy users (REU) also noted reductions in levels of use of crystal methamphetamine: the rate of recent use decreased from 27% in 2006 to 5% in 2011 (Matthews, Peacock & Bruno, 2012). These findings suggest a limited crystal methamphetamine market in Tasmania in 2011.
Cocaine
It appears that the availability and use of cocaine in Hobart continues to be very low, at least within the populations surveyed in the current study or accessing government services, with use of the drug among clients of the state’s NSP virtually non-existent (<0.1% of non-pharmacy equipment transactions). Only a very small proportion of the Tasmanian IDRS PWID participants reported recent use of the drug (7%), and the median frequency of this use was very low (two days of the last 180).
Reflecting the very low level of cocaine use amongst IDRS participants, very few participants were able to comment on trends related to price, purity and availability. Participants noted a one gram purchase cost a median price of $200, and availability was generally considered to be difficult. In keeping with this trend of low level use, Tasmania Police have made very limited numbers of cocaine seizures in the last decade.
These patterns of low levels of availability and use in these cohorts appear to have remained reasonably stable over the past few years. In contrast to this, there has been a gradual increase in the level of recent use of the drug in different local consumer populations such as frequent ecstasy consumers (Matthews, Peacock & Bruno, 2012) which may provide indications of emerging changes in local markets for the drug.
Cannabis
Almost all participants in the 2011 Tasmanian sample reported lifetime use of cannabis (97%), with most reporting use in the preceding six months (78%). The median frequency of this use was daily, which has been consistent in the Tasmanian PWID cohorts since 2000; however, the proportion of PWID participants reporting daily use has decreased from 75% in 2001 to 49% in 2011. Those PWID participants who used cannabis predominantly reported use of hydroponically-cultivated cannabis. While cannabis remains the most commonly used illicit drug, both in the PWID sample and in the state, there are indications of decreasing levels of use more generally, with the National Drug Strategy Household Survey (NDSHS) suggesting that past-year use of cannabis in Tasmania declined from 15.8% in 1998 to 8.6% of those aged 14 years and over in 2010.
Participants reported the modal price of a 1g purchase of bush/outdoor-cultivated cannabis was $25; the median price for a quarter ounce was $70, and one ounce $200. The majority of participants who commented reported stable price trends for this form of cannabis over the preceding six months. Hydroponically-cultivated cannabis was reported to cost a modal price of $25 for 1g; the median (and modal) price for a quarter ounce was $100, and $300 for one ounce. The majority of participants who commented reported stable price trends over the preceding six months.
Similar to previous years, participants described the subjective potency of outdoor-cultivated cannabis as ‘medium’, with this level generally considered ‘stable’ in the preceding six months. Hydroponically-cultivated cannabis was regarded as ‘high’ in subjective potency by participants who commented, with this level regarded as ‘stable’ in recent months.
Participants commenting on cannabis reported that hydroponic cannabis was more easily accessible than outdoor forms: however, both forms were considered ‘easy’ to obtain.
Other opioids
Morphine
Three-quarters (73%) of the Tasmanian sample had used morphine that was not prescribed to them in recent months, with all except three injecting the drug in this time. MS Contin remained the predominant preparation used by this group, used by 61% of the sample as a whole, with Kapanol the next most commonly used (by 34% of the sample).
Tasmanian IDRS studies had shown a decreasing proportion of participants reporting recent use of morphine between 2003 and 2005, as well as a declining frequency of use amongst consumers. This occurred despite a relatively stable proportion of the PWID samples receiving maintenance pharmacotherapies (approximately 50%) and reporting an opioid as their drug of choice (approximately 60%). Since 2005, there has been a trend to increasing rates of morphine use, with particularly notable increases between the 2007 and 2008 samples in terms of proportions reporting recent morphine use (68% and 81% respectively) and in the frequency of this use (24 v. 48 days respectively). In 2011, 75% of the sample reported recent use of any form; at a frequency of 48 days in the preceding six months.
The modal price reported by PWID for all commonly-used morphine formulations was $1 per mg. Prices have remained relatively stable between 2010 and 2011, following an increase from previous reports. Morphine was considered ‘easy’ to ‘very easy’ to obtain by those who commented, and this situation was reported as remaining stable in recent months by a majority of participants, however, a notable minority noted decreasing availability over this period. The overall stable, high level of use and price of morphine indicated a strong local market.
Oxycodone
Illicit oxycodone use among local PWID samples increased in recent years, from 30% reporting use in 2005 to 60% in 2010. This trend was reversed in 2011, with 45% of the sample reporting recent use, at a median frequency of seven days (equates to approximate use once per month). OxyContin tablets were the predominant formulation used in the preceding six months.
Despite their higher relative potency than morphine tablets, preparations of oxycodone tablets had been sold locally at lower comparative prices since 2005. However, between the 2007 and 2008 surveys, consumer reports suggested the cost of these drugs increased (the modal price estimate for 80mg OxyContin tablets doubled from $40 to $80 between 2007 and 2008); subsequently stabilising since this time, and are now price-equivalent with morphine ($1/mg).
Illicit oxycodone was generally considered to be either ‘easy’ or ‘very easy’ to access. This situation was regarded as ‘stable’ over the preceding six months by most participants, however, a notable minority noted decreasing availability. The combination of the rapidly increasing rate of prescription of oxycodone (both nationally and locally), the apparent stable, high demand in the morphine market, and its perceived similarity among users to morphine, render it likely that oxycodone use may continue to be relatively common within the local PWID market. Given the high relative potency of oxycodone, and its possible synergistic effects with other drugs, this is an issue that merits continued careful monitoring.
It is important to note also that the opioids used by this group are not coming from direct doctor-shopping, as the vast majority report obtaining them ‘illicitly’, i.e. not on a prescription in their name.
Methadone syrup
Illicit methadone syrup was used by just two-fifths of the sample (40%) in the past six months, at a median frequency of seven days, equating to use approximately once per month. Almost half of IDRS respondents reporting recent use of illicit syrup (48%) were themselves enrolled in methadone maintenance treatment during this period. The median frequency of use of illicit methadone syrup was similar for participants who had been enrolled in a methadone program in the six months preceding the interview (12 days) to those who had not accessed this form of treatment (6 days).
It is important to recall that the individuals participating in the IDRS are selected on the basis of their regular injection of drugs and, as such, are not representative of all those enrolled in maintenance pharmacotherapy programs. Participants were asked to comment on the reasons for use of illicit methadone syrup: most commonly cited were reasons pertaining to self-treatment for opioid dependence and/or mental health problems, and intoxication. There may be a spectrum of reasons for the use of illicit syrup by those themselves enrolled in the program, but it is important also to consider the role of incomplete stabilisation and of problems in the systems around dose dispensing in these situations. For a recent, detailed investigation of these types of issues, see Fraser et al. (2007).
Illicit methadone syrup was reported to cost a median of approximately $1 per mg in 2011, consistent with the majority of reports since 2001. Participants reported prices to be stable in recent months. Methadone syrup was most frequently purchased from friends. The majority of participants noted that availability of illicit methadone syrup was ‘difficult’ or ‘very difficult’; and that this situation had either remained stable or decreased in the preceding six months
There have been continuing reports of participants injecting combinations of alprazolam and methadone syrup in the past seven local IDRS studies, a practice that carries an increased risk of overdose, injection-related harms, and adverse social or legal consequences because of the particular disinhibitive effects of this combination, which both PWID participants and KE noted as concerns in regard to this trend.
Physeptone
Relatively consistent with previous IDRS reports, almost two-fifths of the sample (37%) reported recent use of illicit Physeptone (methadone tablets), at a median frequency of seven days (equates to use approximately once per month). The modal price of illicit Physeptone tablets doubled between 2010 and 2011 from $10 to $20. Physeptone was regarded as ‘difficult’ or ‘very difficult’ to access, with this level of availability remaining stable or declining somewhat in the preceding six months. Physeptone was most commonly sourced from friends.
Benzodiazepines
The majority of participants reported lifetime use of prescribed or non-prescribed benzodiazepines (87%), and four-fifths of the sample reported recent use (81%). Recent use of non-prescribed alprazolam was reported by 40% of the sample, at a median frequency of six days (equating to approximately once per month), and other non-prescribed formulations of benzodiazepines were used by 51% of the sample, at a median frequency of 20 days (equating to use approximately once per week).
Participants were divided with regard to ease of access of illicit benzodiazepines: two-fifths of the sample considered access to be either ‘easy’ or ‘very easy’; whilst two-fifths noted it was either ‘difficult’ or ‘very difficult’ to access these drugs. Illicit benzodiazepines were most commonly sourced from friends either as a gift or purchase, rather than through theft, forgery or feigning symptoms to doctors (doctor-shopping).
There are clear indications that, following a reduction of the injection of benzodiazepines among PWID between 2002 and 2003 (arising from the restriction and eventual removal of the preferred temazepam gel capsules from the market), injection of benzodiazepines remained an ongoing part of the local drug culture, with Tasmanian PWID continuing to inject at rates higher in comparison to those identified in other Australian jurisdictions. As noted in previous IDRS studies, it was also clear that alprazolam (Xanax in particular) appeared to have largely replaced the local illicit market for temazepam gel capsules among those PWID particularly interested in benzodiazepine injection, with this drug being used in similar ways to temazepam capsules by consumers, such as in simultaneous combination with methadone syrup or other opioids.
Regulatory changes were implemented in September 2007 by the Tasmanian Pharmaceutical Services Branch regarding prescribing of alprazolam, with an aim to decrease misuse of this drug.
Between the 2003 and 2008 studies, the proportion of the PWID samples reporting recent injection of alprazolam increased from 11% to 30%. In 2010, this rate of injection decreased significantly to 14%, however, in the current study, this rate again increased – albeit not significantly – to 22% of the sample.
The ongoing injecting use of alprazolam remains a concern given the serious psychological and physical harms associated with benzodiazepine injection. Additionally, the overall level of use and availability of benzodiazepines generally remains high within local PWID, particularly among primary users of opioids, which is again of concern given the increased risk of overdose when the two substances are combined, and the highly variable half-lives across different benzodiazepine types. As such, patterns of benzodiazepine use and injection in the state continue to warrant very close attention.
Health-related trends
Non-fatal overdose
Opioids: One-third of the sample reported ever having experienced an opioid overdose (36%), and 7% reported this occurring in the preceding 12 months from use of morphine, methadone, heroin or oxycodone, or a combination of these.
Fatal overdose
Opioids: The number of accidental deaths in Tasmania attributable to opioid use in 2007 was 11, which equates to a rate of 23 per million of population. In 2008 and 2009, smaller numbers of deaths due to opioid use were reported, however, the precise number was not provided to protect confidentially. Nationally in 2009, 433 deaths were attributed to such causes, which equates to a rate of 19 per million population. This rate was slightly higher than reported in 2008 (n=337, 16 per million population).
Injecting risk behaviours
Self-reported rates of sharing of needles or syringes among clients of non-pharmacy NSP outlets had steadily declined over time (from 2.6% of all transactions in 1995/96 to 0.3% in 2005/06); however, in 2006/07, this trend was briefly reversed (with 1.1% of client transactions reporting sharing needles or syringes) - this rate has continued to decrease since this time, to 0.05% in 2010/11.
The current Tasmanian IDRS study identified a similar pattern with rates of sharing amongst PWID participants increasing sharply in 2007, and decreasing over the subsequent periods. Eight percent of the current cohort reported use of another person’s used needle/syringe in the month prior to interview, a rate lower than was reported in 2007 (16%) – a year in which a significantly greater proportion of participants reported sharing injecting equipment – but similar to rates in other years. Similarly, the number of participants reporting providing their used equipment to another person decreased from 29% in 2007 to 10% in 2011, returning to a similar level to that reported in other Tasmanian IDRS reports.
Half of the consumers interviewed (51%) reported re-using their own injection equipment in the month prior to interview, with the majority of these participants re-using on multiple occasions in this time. The main forms of equipment that consumers reported re-using were winged-infusion sets (‘butterflies’), 1ml syringes, 3/5ml barrels, and 20ml barrels. Requiring equipment after-hours (nights or weekends) was the main reasons participants provided for re-using equipment.
These are harmful injection practices, as repeated use of needles leaves them blunt, which could cause damage to the venous system, and use of non-sterile equipment can lead to the introduction of bacteria into the bloodstream, which can lead to infections, septicaemia or endocarditis. Sharing of injecting equipment greatly increases the chance of transmission of blood-borne viruses such as HCV or HIV.
Self-reported mental health
Sixty-nine percent of participants reported experiencing a mental health problem in the preceding six months. Depression and anxiety-related disorders were the most commonly cited. Psychological distress, as measured by the Kessler 10, and mental health component of health, as measured by the Short Form-12 Health Survey (SF-12), demonstrate substantially higher rates of psychological distress in the IDRS sample in comparison to the Australian national average.
Self-reported general health
Self-reported general health amongst PWID participants was generally poorer than was reported for general population samples. IDRS participants scored lower on the Physical Component of the SF-12 than was reported in the National Health Survey (NHS) (ABS, 1995), and lower in all measures of the Personal Wellbeing Index than reported for the general Australian population.
Driving risk behaviour
Two-thirds of the consumers interviewed who had driven a car in the past six months had done so within an hour of using illicit or non-prescribed drugs on at least one occasion (67%). Cannabis and illicit morphine were most commonly involved. While the extent of self-reported driving under the influence of drugs has remained stable in the past five local IDRS studies, the level of drug-driving involving methamphetamine decreased from 74% of those who had driven in 2005 to 20% in 2011(possibly reflecting the trend toward decreasing use of methamphetamine amongst IDRS cohorts), as has the proportion reporting driving after using illicit methadone (56% in 2006 v. 15% in 2011).
Law enforcement trends among PWID
Self-reported criminal activity
Two-fifths of the PWID respondents self-reported involvement in some type of criminal activity in the preceding month (41%). The crimes most commonly reported were property crime and dealing drugs. One-third of the PWID respondents had been arrested in the previous 12 months (34%), a rate slightly but not significantly lower than that reported in 2010 (47%). In Tasmania, most arrests related to property crime.
Arrests
In keeping with low levels of use and availability of heroin in Tasmania among PWID participants, very few heroin-related arrests have been reported by Tasmania Police over recent years. No arrests were reported for the 2000/01-2003/04 and 2006/07-2010/111 financial years, with just single arrests made in 2004/05 and 2005/06.
Conversely, reports of arrests for methamphetamine-related offences had increased from 20 in 1996/97 to 179 in 2006/07. This trend has since reversed, with 95 such arrests being reported by Tasmania Police in 2010/112.
The number of arrests related to cannabis decreased from 1,830 in 2002/03 to 929 in 2005/06, however, in 2007/08, the number of such arrests increased to 1,954, and has remained largely unchanged since this time.
Drug-related charges in Tasmanian Courts
The number of individuals before the Magistrates Court for drug-related matters has remained relatively stable between 2003/04 and 2010/113, with the exception of an increase in 2008/09. Possession and/or use of drugs charges were the most commonly reported charges made under the Drugs of Misuse Act in 2010/11.