NDARC Technical Report No. 205
EXECUTIVE SUMMARY
The heroin shortage project was a tri-state initiative involving New South Wales, Victoria and South Australia. The project was co-ordinated by the National Drug and Alcohol Research Centre (NDARC) in New South Wales and was funded by the National Drug Law Enforcement Research Fund (NDLERF). The aims of the project were to assess the impacts of a marked reduction in the supply of heroin as reported by law enforcement and health agencies in early 2001. The impacts examined in South Australia included:
- Changes in the drug market;
- Changes in patterns of drug use;
- Health related impacts;
- Changes in treatment provision for drug based issues;
- Changes in criminal activity; and
- Impacts on health and law enforcement agencies.
Key findings
The key findings resulting from the investigation of the heroin shortage in South Australia are as follows:
- Reduction in the number of fatal and non-fatal heroin related overdoses;
- Not as much heroin is being used across South Australia, as evidenced by hospital, treatment and crime data, than prior to the shortage;
- Methamphetamine is being used much more frequently as evidenced by qualitative information and data relating to treatment, however, hospital and criminal offending does not reflect this increase;
- The use of intravenous benzodiazepines and other opioids was recorded and the intravenous use of drugs in non-injectable forms has lead to increased vascular care issues;
- An increase in mental health difficulties, psychosis and violence was reported for heroin users by Key Informants (KIs) due to increased methamphetamine use. This was not reflected by hospital data concerning drug-induced psychoses;
- No significant increase was recorded for treatment seeking for opioids when the shortage began; and
- There has been a steady increase in the demand for methamphetamine related treatment services. This is an area requiring on-going capacity building in South Australia.
Documenting the shortage
From synthesising the range of sometimes conflicting data the likely situation is that the heroin shortage was a real phenomenon and that it impacted on South Australia at the very beginning of 2001. The heroin shortage began suddenly and without indicators to signal its approach. Within the first few months of the shortage the availability of heroin was severely restricted and what could be sourced was very low purity. After this time heroin became more readily available, though this availability fluctuated. At the present time heroin can be acquired on demand though not as easily or readily as prior to the shortage. The purity of at least the street level heroin has slowly increased though it is not at pre-shortage levels. Heroin users reported large increases in the amount of money they were spending each day if they sought to maintain their heroin use. As purity has increased, total expenditure on heroin appears to have stabilised though it is suggested that costs may be higher than pre-shortage.
Changes in patterns of drug use
The barriers between the traditionally distinct depressant and stimulant using groups were described as having broken down. KI and Intravenous Drug User (IDU) feedback suggests that experimentation with a range of drugs is now more common amongst heroin users.
Opioids: There has been a general decrease in the use of heroin in South Australia that has been maintained to the present time. A market for diverted opioid medications was established during the heroin shortage and subsequently maintained. Diverted medications are mainly injected. Some Indigenous drug users were reported to have left opioid based pharmacotherapy programs (methadone and buprenorphine) once the heroin shortage began to take up methamphetamine use.
Methamphetamine: Whether there has been a rise in methamphetamine use as a consequence of the shortage, as evidenced by hospital presentations and separations, is a more contentious issue. The presented hospital data, which suggests no increase in the use of methamphetamine, conflicts with both qualitative feedback and data obtained from Alcohol and Drug Information Service that would suggest it had.
Cocaine: Cocaine use is not widespread in South Australia. No substantial changes in this market as a response to the heroin shortage were observed.
Benzodiazepines: The use of benzodiazepines has, on balance, probably remained comparable to pre-shortage levels.
Poly drug use: Key Informant feedback suggests that there has been an increase in both the quantity and the range of drugs involved in poly-drug use.
Injecting drug use
The extent of injecting drug use in South Australia has remained stable during the heroin shortage with a potential increase in the extent of injecting drug use being identified in 2002/2003. While the extent of injecting drug use remained stable there has been a marked increase in the injection of drugs that are in a non-injectable form leading to increased vascular care difficulties for drug users. No changes in the prevalence of blood borne viruses could be attributed to the heroin shortage.
Changes in health effects of drug use
Due to the small number of cases within South Australia there were some difficulties in identifying changes in the health effects of drug use from a quantitative perspective. However, despite these difficulties a number of trends were identified. The number of fatal and non-fatal heroin overdoses has reduced since the heroin shortage began. A potential increase in overdose experiences associated with the use of other opioids was identified. Some evidence to suggest increased methamphetamine overdoses occurring post-shortage (unconfirmed by time series analysis to have occurred as a consequence of the shortage) was found. There was also a small rise in emergency department presentations for drug related psychosis. Key Informant data indicated a rise in drug related psychosis and attributed this to increased use of methamphetamine amongst drug users. In addition, the qualitative data revealed an increase in mental health issues, psychosocial functioning and violence and other health issues such as sleep deprivation, appetite suppression, nutritional problems and drug-related injuries.
Treatment
The number of people receiving opioid pharmacotherapy and opioid detoxification services did not substantially increase as a consequence of the heroin shortage. This lack of an increase conflicts with the qualitative data reporting a large demand during the early parts of the shortage. At the present time the number of opioid-related inpatient and outpatient contacts is lower than pre-shortage levels. Data concerning opioids other than heroin and diverted medications did not show any significant increase in the number of treatment related contacts. This is in contrast to qualitative feedback suggesting an increased use of these drugs amongst heroin users.
A marked and statistically significant increase was noted in methamphetamine related inpatient contacts as a consequence of the heroin shortage. The numbers of methamphetamine related outpatient contacts also increased. However, this increase is seen as a continuation of a trend established prior to the advent of the heroin shortage. The quantitative data supports the qualitative feedback concerning a marked increased in the use of methamphetamine.
The number of inpatient and outpatient contacts for benzodiazepines showed no significant impact from the heroin shortage.
Changes in crime
The available quantitative data did not demonstrate changes in the rates of incidents per month that were likely attributable to the heroin shortage. The only exception to this was the statistically significant spike in incidents of robbery without a weapon following the advent of the heroin shortage. While changes in crime rates that may be related to the heroin shortage were generally not found, several trends were evident.
To the degree that crime data reflect the extent of drug use:
- Heroin use is presently at much lower levels than pre-shortage;
- Other opioids are not commonly used in Adelaide; and
- The use of methamphetamine has not increased in response to the heroin shortage and the incident rates are presently much lower than pre-shortage levels.
There were a number of areas of conflict between the qualitative and quantitative feedback. These shall be discussed in turn:
- There is insufficient quantitative data to support KI reports of an overall increase in the rates of acquisitive crime associated with the heroin shortage;
- There is insufficient quantitative data to support KI reports that there has been a sustained increase in behavioural and violent crimes, associated with the heroin shortage and the uptake of methamphetamine;
- The quantitative data has not demonstrated an increase in the number of incidents of methamphetamine production offences despite KI suggestions that more ‘cooks’ have emerged as a result of the shortage;
- A suggested increase by KIs in the incidents of fraud, derived from heroin dealers engaging in these activities to replace lost income due to the shortage, was not reflected in the quantitative data. However, the number of fraud charges per month is reasonably high and any impact from heroin dealers may simply have been absorbed into the data set. Without detailed information as to the number of heroin dealers in South Australia at the time of the shortage this qualitative feedback can be neither supported or refuted;
- A rise in prostitution offences expected by KIs was not reflected in the quantitative data. However, there has been a marked decrease in the number of prostitution offences recorded since early 1999. Hence, the generally low numbers of offences interspersed with significant peaks may be more reflective of changing police practices as opposed to being indicative of actual rates of illegal activity; and
- A rise in driving offences expected by KIs due to the effects of methamphetamine was not reflected in the quantitative data.
Qualitative and quantitative data was in agreement on one point. The reports from KIs suggest that an increase in stress and panic by heroin users led to an increase in opportunistic crime. Evidence for this was found in the quantitative data. An increase in the number of incidents of robbery without a weapon was related to the heroin shortage. As this form of robbery did not involve the pre-meditation that can be implied by weapons offences this data is supportive of KI reports of a brief period of increased, highly opportunistic crime.
Impacts on health agencies
Despite a steady pre-shortage increase in problematic use of methamphetamine, the heroin shortage highlighted that Adelaide drug treatment services tended to be heroin focussed with a paucity of programs addressing other drug use. The need for capacity building at the time of the shortage around both methamphetamine based issues as well as other opioids and benzodiazepines was readily apparent. Methamphetamine dependence was also seen as a particularly difficult area to effectively treat.
Impacts on law enforcement agencies
The primary impact of the heroin shortage on law enforcement agencies in South Australia, as identified by Key Informants, has been a shift in the focus of Operation Mantle (a major South Australian Police (SAPOL) drug initiative) to methamphetamine, an increase in having to deal with ‘clan labs’ (amphetamine producing laboratories controlled by Outlaw Motor Cycle Groups (OMCG)) and the provision of more information to police on how to handle people acting under the influence of methamphetamine.