Tasmanian Drug Trends 2012: Findings from the Illicit Drug Reporting System (IDRS)

 

Demographic characteristics of people who inject drugs 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 (59%), and had an average age of 35 years. Participants had completed 10 years of education on average, three-quarters (77%) were unemployed at the time of the interview, and almost one-fifth of the sample reported a previous prison history (38%).

 

Almost three-fifths of participants (58%) were injecting multiple times per week (but not every day), with 26% injecting at least once daily. Opioids were the predominant drug of choice among the cohort (53%), and were the class of drug most injected in the preceding month amongst three-fifths of the sample (59%). Half were involved in some sort of drug treatment at the time of interview (49%).

 

Patterns of drug use among the PWID sample

The major trends identified in the 2012 Tasmanian IDRS report relate to indications of emerging changes in patterns of methamphetamine and pharmaceutical opioid use amongst local PWID, along with an ongoing pattern of coincident opioid and benzodiazepine (particularly alprazolam) use. 

 

Heroin

Just 9% of the sample reported use of heroin in the six months preceding the interview, at a median frequency of six days. The rate of recent heroin use among Tasmanian PWID cohorts has decreased dramatically from 38% in 2000, despite one-quarter of the sample reporting heroin as their drug of choice.

 

Few of the PWID participants interviewed in 2012 could report on local trends in price, purity or availability of heroin. The median price that participants reported last paying for heroin were $50 for a ‘cap’ (0.1g) and $400 for 1g. 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. Subjective reports of heroin purity suggest this to medium.

 

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 (six days in the last six months among those who had used the drug) and that, of the 25% of the PWID sample that reported heroin as their drug of choice, only one-quarter had recently used heroin – indicated that the low availability of heroin in the state, identified in earlier IDRS studies, continued in 2012.

 

Methamphetamine

Almost all PWID participants in 2012 (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 23 days, equating to use on average once per week. This level of use is similar to that reported between 2008 and 2011 (70-80%), but lower than reported between 2000 and 2007 (83-95%).

 

The most commonly used form of the drug was powder methamphetamine, used by 70% of participants. Recent use of base/paste methamphetamine was reported by 43%. Use of crystal methamphetamine declined from 69% of the 2003 cohort to 26% in 2011; however, in 2012 a small increase was observed (43%).

 

In 2012, frequency of use of any form of methamphetamine in the preceding six months was 23 days (out of a maximum of 180 days), similar to the rate reported in 2011 (20 days). In the current sample, the median frequency of use for powder methamphetamine was 12 days, for base/paste eight days, and for crystal methamphetamine five 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 increased to $60 in 2012, after consistently being reported to cost $50 since 2004. Gram purchases in 2012 were reported to cost $350, which is similar to reports in previous years. 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 were divided in relation to purity: one-third reported it to be low and one-quarter respectively noted it to be either medium or had fluctuated somewhat. Participants were also divided with regard to reports on purity of ‘base/paste’: one-third reported it to be medium and two-fifths respectively noted it to be either high or had fluctuated somewhat. Participants considered ice/crystal methamphetamine used locally as ‘high’ in subjective purity, with potency remaining stable in recent months.

Participants interviewed in 2012 regarded powder and base/paste forms of methamphetamine as ‘easy’ or ‘very easy’ to access, with availability stable in recent months. Participants were divided with regard to availability of crystal methamphetamine, with half respectively reporting access to be either difficult or easy. Most participants considered this situation to have remained unchanged over the preceding six months.

 

Trends in 2012 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 increased slightly in 2012, 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 after several years of a declining rate of use of crystal methamphetamine (from 27% in 2006 to 5% in 2011), a small increase was reported in 2012 (10%, p=0.3) (Matthews & Bruno, 2013). These findings suggest that, whilst the crystal methamphetamine market remains somewhat limited in Tasmania, continued attention is warranted.

 

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 small proportion of the Tasmanian IDRS PWID participants reported recent use of the drug (11%), and the median frequency of this use was very low (one day of the last 180).

 

Reflecting the very low level of cocaine use amongst IDRS participants, 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 $400, and $80 for one ‘cap’ (typically 0.1g). Amongst a small number of participants, availability was considered to be easy, and this had remained relatively unchanged in the preceding six months. In keeping with this low level of 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 had been a gradual increase in the level of recent use of the drug in different local consumer populations such as frequent ecstasy consumers, however, this trend has reversed since 2011 (Matthews & Bruno, 2013). This may provide indications of emerging changes in local markets for the drug.

 

Cannabis

Almost all participants in the 2012 Tasmanian sample reported lifetime use of cannabis (97%), with most reporting use in the preceding six months (81%). 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 2012. 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 median price of a 1g purchase of bush/outdoor-cultivated cannabis was $25; $70 for a quarter ounce; and $200 for an ounce. 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 median price of $25 for 1g, which has remained unchanged for several years. The median prices for both quarter ounce and one ounce purchases decreased in 2012 ($90 and $250 respectively).

 

Reports regarding potency of bush/outdoor cannabis were mixed: almost half considered this to be medium; and around one-quarter respectively noted this to be either low or high. Participants were generally in agreement that this has not changed over 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

Two-thirds (64%) of the Tasmanian sample had used morphine that was not prescribed to them in recent months. MS Contin remained the predominant preparation used by this group, used by 88% (of recent morphine users), with Kapanol the next most commonly used (51%).

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%). In 2006 this trend was reversed, with both the rate and frequency of use increasing. In 2012, both the rate of recent use (64%) and the median frequency of this use (20 days) decreased slightly – however, this was not a statistically significant change.

 

The modal price reported by PWID for all commonly-used morphine formulations was $1 per mg. Prices have remained relatively stable between 2011 and 2012, 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. The overall stable, high level of use and price of morphine indicates a strong local market.

 

Oxycodone

Illicit oxycodone use among local PWID samples has increased in recent years, from 30% reporting use in 2005 to 56% in 2012, at a median frequency of 24 days (equates to weekly use). 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, and this situation was regarded as ‘stable’ over the preceding six months by most participants.

 

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 29% in the past six months, at a median frequency of 24 days, equating to use approximately once per week. 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 the same for participants who had been enrolled in a methadone program in the six months preceding the interview and those who had not accessed this form of treatment (24 days respectively).

 

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, pain and/or in response to their prescribed dose being inadequate. 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 2012, 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 remained stable in the preceding six months

 

There have been continuing reports of participants injecting combinations of alprazolam and methadone syrup in the past eight 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. This practice has decreased from 40% of the sample in 2005 to 5% in 2012.

 

Physeptone

Between 2004 and 2009, reports of use of illicit Physeptone varied between 37% and 52%, with no clear trend discernible. However, since 2009, the rate of recent use has decreased from 50% to 34% in 2012. The median frequency of use has remained relatively stable over all years, ranging between three and 12 days in the preceding six months. The median price of illicit Physeptone tablets doubled between 2010 and 2011 from $10 to $20. This has remained unchanged in 2012. Physeptone was regarded as ‘difficult’ or ‘very difficult’ to access, with this level of availability remaining stable in the preceding six months. Physeptone was most commonly sourced from friends and known dealers.

 

Benzodiazepines

The majority of participants reported lifetime use of prescribed or non-prescribed benzodiazepines (81%), and three-quarters of the sample reported recent use (73%), at a median frequency of 90 days (which equates to use second daily). Whilst a greater proportion of participants reported recent use of illicit rather than prescribed benzodiazepines (62% v. 46%), the median frequency of use was markedly higher for use of prescribed tablets (180 days v. 18 days).

 

Participants generally considered availability of illicit benzodiazepines to be easy or very easy, and that this situation had remained stable in the preceding six months. Illicit benzodiazepines were most commonly sourced from friends, 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. In response to these changes, questions on alprazolam use were incorporated in the IDRS survey. Three-fifths of participants reported ever having used any alprazolam (62%), and two-fifths reported having used this drug in the preceding six months (44%, n=47). Non-prescribed alprazolam was used by 59% of the sample, at a median frequency of 10 days in the preceding six months. Prescribed alprazolam was used by just 3% of the sample, at a median frequency of three days. Injecting use of any alprazolam tablets in the preceding six months was reported by 24% of the sample.

 

Between the 2003 and 2008 studies, the proportion of the PWID samples reporting recent injection of alprazolam increased from 11% to 30%; this rate subsequently declined to 14% in 2010, however, in the current study, this rate again increased – albeit not significantly – to 24% 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-quarter of the sample reported ever having experienced an opioid overdose (25%), and 6% reported this occurring in the preceding 12 months from use of methadone, morphine and oxycodone.

 

Fatal overdose - Opioids

The number of accidental deaths in Tasmania attributable to opioid use in 2008 was 11, which equates to a rate of 2.2 per 100,000 persons. Projected estimates for 2009 and 2010 suggest a slightly lower rate (1.8 per 100,000 persons) (Roxburgh & Burns, 2012). Nationally in 2008, 500 deaths were attributed to such causes, which equates to a rate of 2.3 per 100,000 persons.

 

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 0.3 in 2010/11.

 

The current Tasmanian IDRS study identified a similar pattern with rates of sharing amongst PWID participants increasing sharply in 2007 from 4% to 16%. Since this time, between two and eight percent of each sample has reported sharing injecting equipment. Similarly, the number of participants reporting providing their used equipment to another person decreased from 29% in 2007 to 8% in 2012, returning to a similar level to that reported in other Tasmanian IDRS reports.

 

Three-fifths of the consumers interviewed (63%) reported re-using their own injection equipment in the month prior to interview. The main forms of equipment that consumers reported re-using were 1ml syringes and winged-infusion sets (‘butterflies’). 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 hepatitis C (HCV) or the human immunodeficiency virus (HIV).

 

Self-reported mental health

Half of the sample reported experiencing a mental health problem in the preceding six months (47%). Depression and anxiety-related disorders were the most commonly cited. Psychological distress, as measured by the Kessler 10 (K10), 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.

 

Pain

In 2012, the Brief Pain Inventory (BPI) was included in the survey questionnaire with the aim of examining the relationship between injecting drug use, experience of pain and the therapeutic goals of pharmaceuticals used to manage pain.

 

One-third of participants reported experience of pain (other than everyday pain) on the day of interview (35%). Of this group, almost half reported the pain as chronic non-cancer pain (continuous pain which lasts for more than three months: 46%), one-third reported chronic cancer/malignant pain (35%), and 19% reported acute pain. Participants were also asked on a scale of 0 to 10 (0=no relief, 10=complete relief) how much relief they experienced from any treatments/medications they received. Of those who received treatment/medication for pain (n=31), a mean score of 4.5 (SD 3.1, range 0-10) was reported. In addition, three-fifths of participants experiencing pain noted they had experienced difficulty obtaining sufficient pain relief from a doctor or specialist in the preceding six months.

 

Neurological History

The lifetime prevalence of epilepsy was higher in the IDRS sample than the Australian population estimate obtained in the 2007/08 National Health Survey (3.0% v. 0.7). More than half of the participants (56%) reported a lifetime history of TBI1. Recent studies have estimated the lifetime prevalence of TBI with loss of consciousness as 35% among community samples.

 

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 was the drug most commonly involved. While the extent of self-reported driving under the influence of drugs has remained stable in the past six local IDRS studies, the level of drug-driving involving methamphetamine decreased from 74% of those who had driven in 2005 to 15% in 2012, possibly reflecting the trend toward decreasing use of methamphetamine amongst IDRS cohorts.