NDARC Technical Report No. 248 (2006)
Demographic characteristics of injecting drug user (IDU) participants
One hundred and fifty-four IDU participated in the 2005 survey. Sixty-two percent were male, 85% were unemployed or on income support (such as disability or sickness benefits or the New Start jobseekers allowance) at the time of interview. The average age of respondents was 35 years (range 19- 55 years). Twenty-three percent of the sample were Aboriginal and/or Torres Strait Islanders. Educational status of the sample varied, with three respondents (2% of the sample) having completed no full years of schooling, 53% percent of the sample having completed year 10 and 16% having completed year 12. Twenty-three percent had obtained a trade or technical qualification and 7% had completed a university or college qualification such as a degree. Seventy percent had not completed any further education after leaving school. Seventy-nine percent had a previous prison history. The average age of first injection was 19 years.
Patterns of drug use among the IDU sample
As in previous years, the majority of the sample continued to nominate heroin as their drug of choice (72%; comparable to 78% in 2004), the drug they had injected most often in the last month (64%), and the drug they had injected most recently (64%). However, whilst heroin remained the most commonly reported drug that participants had injected in the last month, and also the drug that they had injected most recently, these figures decreased from 80% (each) reported in 2004.
The median days on which heroin was used also decreased from 120 (i.e. approximately five days per week) in 2004 to 96 days (i.e. approximately every two days), and 2005 saw the lowest proportion of daily heroin users since 1998. The median number of days heroin was used differed according to geographical area, with a decrease observed in South-West Sydney (from 96 days in 2004 to 67 days in 2005) and an increase in central Sydney (from 160 days to 180 days). Concurrent increases have been observed in the proportion of participants engaged in drug treatment, predominantly methadone, at the time of interview (47% in 2003, 60% in 2004 and 67% in 2005) and this has impacted upon findings.
The median price for a gram of heroin ($300) and a cap of heroin ($50) remained stable in 2005 and prices remained higher than those reported prior to the heroin shortage in 2001. Heroin availability remained similar to 2004 levels, with the majority (86%) of participants who commented reporting that it was either easy or very easy to obtain (compared to 93% in 2004). Over half of participants (59%) reported that availability had remained stable (compared with 66% in 2004).
An increased proportion of participants who commented reported heroin purity to be low as compared with 2004 (47% in 2005 as compared with 39% in 2004), making it the most commonly selected response category with which to describe it (other response options being high, medium, fluctuates and dont know). Very few participants perceived potency to be high (5%). NSW police seizure data indicated that the median purity of low-level heroin seizures remains low (approximately 27%) and has not returned to levels reported prior to 2001. Key expert (KE) comments on the price and availability of heroin were consistent with IDU reports.
Indicator data reflecting harms related to heroin use (overdose numbers, arrests and entry into treatment other than pharmacotherapy) showed relatively stable rates over the past year, and remained substantially lower than figures recorded prior to 2001, suggesting that the NSW heroin market has not returned to pre-shortage levels of use or associated harm.
Fifty-eight percent of participants had used some form of methamphetamine (speed powder, base, ice or liquid) in the preceding six months, a proportion comparable to 2003 (56%). Similar proportions reported use of speed (38%; 35% in 2004), while a marginally larger proportion reported having used base compared with 2004 (38%; 31% in 2004), and there was a slight decrease in proportions using ice (38%; this figure was 45% in 2004). Use of the liquid form of methamphetamine remained uncommon at 6% (5% in 2004). Frequency of use of all forms of methamphetamine remained sporadic with the majority of users doing so fortnightly or less often, although a slight increase was observed in the proportion of daily users (from 3% in 2004 to 7% of users in 2005).
A point (0.1 of a gram) was the most popular purchase amount for all three main forms of methamphetamine, and the median price remained stable at $50 for speed powder, base and ice. Speed powder was cheaper than the more potent forms (base and ice) when bought in larger amounts such as half grams, grams and eightballs (3.5g).
Two-thirds (69%) of participants completing the section on speed powder price, purity and availability reported that it was very easy or easy to obtain and that availability had remained stable (66%). According to participants completing the base price, purity and availability section, base was also easy or very easy to obtain (79%), with availability remaining stable (68%). Ice remained readily available for the majority of those commenting, with 53% stating that it was easy or very easy to obtain, and this represented a decrease from 79% in 2004. An increase was also observed among those who thought it was difficult or very difficult to obtain (from 16% in 2004 to 38% in 2005). However, the majority of participants commenting on ice availability reported that it had remained stable over the six months preceding interview.
Purity of methamphetamine seizures made by NSW Police has increased slightly over the past twelve months, from approximately 10-15% to 24%. Participants who felt able to comment on perceived purity continued to report speed powder as being of low (36%) or medium (34%) purity and that this had remained stable (37%). Reports on base were more mixed, although it was most commonly rated as medium or high (63%), with this having remained stable. Ice was perceived as the strongest form overall, with 66% reporting it as medium or high, and with the largest proportion selecting the response option high (46%). Again, purity of ice was most often reported to be stable (42%).
KE reported on a range of methamphetamine forms, with ice, base and speed powder all commonly mentioned, and comments were generally consistent with those of IDU, with the exception of increases in use and related problems in some geographical areas (Western Sydney, the inner city, and among client admissions to two rehabilitation units). As in previous years, indicator data reflecting harms related to methamphetamine use presented a mixed picture, with the majority of indicators remaining stable or continuing to fluctuate over the last twelve months, while others increased (e.g. recorded police incidents of possession/use in inner Sydney, calls to Family Drug Support [a telephone helpline] regarding methamphetamine, and inpatient hospital admissions for methamphetamine dependence). These may reflect what are presumably low treatment numbers for methamphetamine, as compared with heroin, several reasons for which have been suggested. These include the possibility that a proportion of methamphetamine users may not wish to obtain treatment, a lack of knowledge regarding treatment options among users, a lack of existing treatment options in their area and/or reticence to attend existing treatment agencies.
A moderate increase in cocaine use was observed in 2005, although this did not approach the high levels reported in 2001 during the peak of the heroin shortage. Sixty percent of participants reported cocaine use in the preceding six months (as compared with 47% in 2004) and although the frequency of use remained sporadic, the median number of days cocaine was used doubled, from approximately once per month to twice per month. Eleven percent of the sample reported daily cocaine use, again representing an increase from 3% in 2004.
Reports of availability remained relatively stable, with 69% of those completing survey items on cocaine price, purity and availability reporting it to be either easy or very easy to obtain as compared with 66% in 2004. However, a notable increase was observed among those reporting cocaine as very easy to obtain, rising to 48% (32% of all respondents) from 32% (15% of all respondents) in 2004. Again, availability was commonly perceived to be stable.
The price per cap of cocaine remained stable at $50. An increase was observed in the number of participants who reported purchasing cocaine in the six months preceding interview, with 61 reporting buying a cap during this time (this figure was 34 in 2004). Slight fluctuations in price were reported for other common purchase amounts as compared with 2004.
Purity of cocaine seized by NSW Police fluctuated slightly over the past twelve months, but remained higher than previously. Participants most commonly reported that cocaine was of medium (40%; representing 20% of the entire sample) or low purity (28%; or 18% of the entire sample). However, reports were fairly mixed, with one-fifth (20%) reporting it to be of high purity. Purity was also most often rated as having been stable (34%) over the six months preceding interview, although a substantial proportion thought that it was decreasing (32%).
KE comments and indicator data were generally consistent with those of IDU, and suggested that increases in cocaine use had been observed in some areas, particularly the inner city and South-West Sydney.
The cannabis market has remained relatively unchanged since the commencement of the NSW IDRS in 1996, and the majority of participants (80%) reported having used cannabis in the six months preceding interview. Frequency of use among these IDU remained at 180 days (daily use) in 2005.
Large proportions of participants reported use of both the hydroponic (hydro) and outdoor grown (bush) forms of marijuana, with hydro appearing to dominate the market. The use of resin (hashish) and oil (hash oil) remained rare. The price of hydroponic cannabis was $20 per gram (the most popular purchase amount) and the overwhelming majority of those completing the price, purity and availability section of the survey (92%) reported that it was readily available, i.e. easy or very easy to obtain. The price per gram of bush cannabis was the same as for hydro ($20), but larger amounts were slightly cheaper than for hydro. Bush was less readily available, with 53% reporting it to be readily available (i.e. easy or very easy) to obtain. Fewer participants were able to comment on bush potency, which is often in itself an indication of lower levels of use and availability. As in 2004, potency of hydroponic cannabis was reported to be high and bush was reported to be medium.
KE reports on cannabis were generally consistent with those of IDU. KE reports suggested that frequency and use patterns had remained stable, with health services in some areas noting an increase in people seeking treatment. A number of KE also noted an increase in mental health problems among younger cannabis users. Some changes were reported in cannabis cultivation. Indicator data also reflected the stability of the market, with very little change occurring over the past year, although increases in the numbers of treatment episodes for counselling and withdrawal management were observed.
Use of illicit pharmaceuticals
Just under one-fifth (17%) of participants reported use of illicitly obtained methadone syrup in the six months preceding interview, representing a decrease from 29% in 2004, and use was sporadic (less than monthly). Approximately half of those who had used illicit methadone had also been engaged in methadone treatment during this period, indicating that methadone was being diverted by those engaged in treatment, as well as to those who were not. Approximately one-tenth (11%) of participants reported injecting illicit methadone syrup in the preceding six months, again representing a decrease from 2004 (22%). Again, just over half (53%) of this group were engaged in methadone treatment during this period. Illicit methadone was considered to be readily available with 60% of those completing survey items on illicit methadone price and/or availability reporting that it was easy or very easy to obtain; one-fifth reported that it was difficult.
Use and injection of illicitly obtained physeptone tablets remained uncommon, with 3% reporting use and 1% reporting injection in the six months preceding interview.
Small percentages (8%) reported the use of illicit buprenorphine in the preceding six months, with less than half (46%, n=6) of these persons reporting engagement in buprenorphine treatment during this period. Five percent of participants reported injecting illicit buprenorphine in the preceding six months on a median of two days, 38% of whom (n=3) had been in treatment during this time. Eighteen percent of participants who had used buprenorphine (licit and/or illicit) in the six months preceding interview reported illicit buprenorphine as the form they had used most often. These figures are comparable to 2004 data.
One-quarter (27%) of the sample reported use of morphine, predominantly obtained from illicit sources, in the six months preceding interview. Overall, twenty-three percent of the sample reported use of illicit morphine in the six months preceding interview. Almost one-quarter (24%) had injected morphine in the last six months, and among those who had injected it in the month preceding interview, 62% (8% of the entire sample) had experienced at least one associated injection-related problem. Frequency of use was low, with a median of four days (less than monthly use) reported. MS Contin was the most common brand of morphine used, with 100mg tablets costing a reported median price of $25. Nineteen percent reported buying morphine (compared to 21% in 2004), predominantly from street dealers.
Approximately one-quarter (27%) of the sample felt confident to comment on the price and/or availability of illicit morphine. Among these participants, 50% thought that it was either easy (31%) or very easy to obtain (19%). Availability was generally considered to have remained stable.
Oxycodone and other opioids
In 2005 a distinction was made between licit and illicit oxycodone and other opioids due to concerns that illicit use of, and problems associated with, diversion of oxycodone may be increasing. In previous years, oxycodone was included under other opioids.
Sixteen percent of participants reported use of oxycodone in the six months preceding interview and 11% of the sample reported injecting it in this time. Frequency of use was low, at a median of one day in the preceding six months. Seventy percent of those who had used oxycodone reported that they had usually obtained it through illicit sources.
Use of other opioids not specified elsewhere (e.g. codeine and pethidine; whether licitly or illicitly obtained) was also relatively uncommon, with 14% reporting recent use on a median of eight days (i.e. just over monthly use). Four percent reported injecting other opioids in the six months preceding interview on a median of seven days. Panadeine Forte, a pharmaceutical drug containing 30mg codeine, continued to be the main form used and approximately half (47%) of those reporting other opioid use had obtained them illicitly.
Use of homebake heroin (a form of heroin extracted from pharmaceutical opioids) remained uncommon among the IDU participant sample.
Prevalence of benzodiazepine use remained stable, with almost two-thirds (65%) reporting use in the six months preceding interview, although a substantial decrease was observed in frequency of use. In 2005, participants had used on a median of 29 days (i.e. more than once per week), as compared with 60 days in 2004 (approximately 2-3 days per week). However, the proportion of daily users remained stable at approximately 20%.
Following a restriction in the availability of benzodiazepine gel capsule preparations (Euhypnos, Nocturne, Normison & Temaze) being introduced on 1 May 2002, and the subsequent removal of these drugs from the pharmaceutical market in March 2004, the prevalence of benzodiazepine injection has markedly decreased. Between 2001 and 2003, approximately 20% of participants reported recent injection of benzodiazepines, a proportion which decreased to 13% in 2004 and 2% in 2005. Similarly, the median days on which they were injected has decreased from 20 days in 2003 (i.e. just less than once per week) to two days in 2005. Among those reporting daily use, none reported intravenous use in the preceding six months. Forty percent of the sample reported using illicitly sourced benzodiazepines, and Valium/diazepam and Serepax/oxazepam were the most commonly reported forms used.
Just over one-fifth (23%) reported use of anti-depressants over the six months preceding interview on a median of 179 days (i.e. almost daily use). These were licitly obtained, and taken orally. Little change was observed in recent use of anti-depressants as compared with 2004; however, these figures have steadily increased since 1997 (13%).
Hallucinogen, ecstasy and inhalant use remained relatively infrequent. Hallucinogen (LSD and magic mushroom) use in the six months preceding interview was reported by 5% of the sample on a median of one day, and 2% had injected them on a median of one day. Ecstasy use during this period was reported by 19% on a median of two days, and twelve percent reported injecting it over this period on a median of 1.5 days. Only two percent of participants reported inhalant (amyl nitrate and glue) use on a median of six days.
Just over half of the sample (54%) had consumed alcohol in the preceding six months on a median of 12 days, i.e. approximately twice per month. Five percent of the sample consumed alcohol daily. These figures represent little change from 2004. By contrast, virtually all participants (97%) reporting smoking tobacco in the six months preceding interview on a median of 180 days (i.e. daily); a finding that has remained consistent across all previous years of the IDRS.
The proportion of IDU sharing needles remained stable, with 14% reporting that they had used a needle after someone else in the preceding month (compared with 13% in 2004) and a slight decrease was observed in those reporting that someone else used a needle after them (15%; as compared with 21% in 2004). The proportion reporting shared use of other injecting equipment such as filters and water also decreased slightly (43%; compared to 52% in 2004).
Since 2001, there has been a steady increase in the proportions of IDU reporting a private home as both their usual injection location (from 55% in 2001 to 68% in 2005) and the location of their last injection (from 47% in 2001 to 64% in 2004 and 60% in 2005). Figures were similar in 2005 as compared to 2004. Less than a fifth of IDU reported that their usual location was a public place (17%; consistent with results obtained in 2004 and a sizeable decrease from 42% in 2001) and approximately one-quarter reported it as their most recent location for injection (26% in 2005, as compared to 49% in 2001). Thirteen percent reported that they usually injected at the Sydney Medically Supervised Injecting Centre in Kings Cross, and the same proportion (13%) reported it had been the location in which they had last injected. This represents a relatively slow but consistent increase since 2001, when these figures were 3% and 4%, respectively.
Two-thirds (66%) of participants reported injection related health problems in the past month (compared to 65% in 2004), with 36% reporting multiple problems (comparable to 38% in 2004). Consistent with previous years, prominent scarring/bruising of injection sites (39%) and difficulty injecting (46%) were the most frequent problems reported. Over half of the sample (60%) reported ever having overdosed on heroin, and 11% had done so in the last twelve months. Three percent of participants reported overdosing on any drug in the last month typically heroin in conjunction with another depressant drug such as methadone or benzodiazepines.
One-fifth of the IDU sample reported driving under the influence of an illicit drug in the six months preceding interview, and this was typically heroin, cannabis and/or cocaine. Even higher rates have been reported by other research conducted on IDU participants in Sydney (Darke et al., 2004). Driving under the influence of illicit drugs remains a topical issue, generating research and the implementation of policies such as road-side drug testing. Dissemination strategies to distribute information about the effects of different drugs upon driving to IDU appears justified.
There was little change in 2005 in the proportion of participants (73%) who reported spending money on drugs on the day prior to interview. The median amount spent was $90.
Just under half the sample (40%) reported experiencing a mental health problem other than drug use in the preceding six months, and 84% of this group (representing 34% of the entire sample) reported seeking advice from a mental health professional during this time (usually a psychiatrist or GP). Depression continued to be the most commonly reported mental health problem (28% of all participants, compared to 24% in 2004), followed by anxiety (9% of all participants; 10%; in 2004).
Twenty-seven percent of participants reported that they had become verbally aggressive when under the influence of a drug in the six months preceding interview, and 15% stated that they had become physically so. Participants more commonly reported becoming verbally aggressive when in withdrawal or coming down from a drug (38%), while rates of physical aggression were lower at 15%.
Proportions reporting involvement in criminal activity in the month preceding interview (49%) remained relatively stable, and the most commonly reported offences were property crime and drug dealing (27% each). Forty-four percent of participants stated that they had been arrested in the previous twelve months, representing little change from 43% in 2004. As in previous years, the majority of participants (66%) perceived that police activity had increased in the preceding six months. Just over half the sample (60%) reported that their ability to obtain drugs had been unaffected.
The findings of the 2005 NSW IDRS indicate that further attention is required in the following areas:
- Wider implementation of effective interventions for stimulant (cocaine and methamphetamine) users, and development of strategies to engage and retain users in these programs.
- Dissemination of available treatment options for psychostimulant dependence to users.
- Continued provision of services e.g. counselling and withdrawal management for those wishing to cease or reduce cannabis use.
- Careful monitoring by medical practitioners of the diversion of methadone and other opioids such as morphine and oxycodone. Increasing trends towards this have been noted in other jurisdictions, and to a lesser extent in Sydney, NSW.
- Continued surveillance of patterns and prevalence of benzodiazepine use and diversion, and careful monitoring by medical practitioners of the clinical need for their prescription.
- Continued focus on education regarding overdose (particularly with regard to use of multiple depressant drugs) and the dangers of sharing injecting equipment other than needles, including safer injecting strategies. In the context of increased stimulant use, continued education regarding the effects of prolonged use (e.g. agitation, aggression, paranoia and psychosis), strategies to reduce risk (e.g. rest periods between binges) and referral into treatment where appropriate seems warranted.
- Increased/continued awareness of the need for treatment of the comorbid mental health problems that many IDU may be experiencing. Despite the fact that many participants were aware that they had recently experienced such problems, one-fifth of those who reported mental health problems were not receiving help for them. Maintaining links between drug services and mental health services remains critical as rates of comorbidity were reportedly high. In particular, the likelihood that comorbid mental health problems may affect treatment outcome needs to be acknowledged and addressed by both mental health and drug treatment services. Future work might usefully investigate participant awareness and understanding of mental health problems, including treatment service availability. In addition, exploration of barriers to mental health services encountered by this group and identification of where improvements may be made (where possible) would be of continuing benefit.
- While a large proportion of participants who used anti-depressant medication had used it daily, anecdotal evidence from KE and IDU suggest that adherence to these drugs is problematic for a notable proportion of IDU. Investigation into use of, and compliance with, anti-depressant medication by this population may enable more successful treatment.
- Further investigation into driving under the influence of drugs, for example the frequency and circumstances under which it occurs, is already an area of considerable research effort. Dissemination of this information to drug users including IDU would also appear justified.
- High rates of tobacco use have consistently been documented in the IDU samples over time, and consideration should be given to providing smoking cessation treatment education/options to IDU considering ceasing or reducing use whilst in treatment for illicit drug use.
- Continued and ongoing communication between law enforcement and health services to ensure the goals of both organisations are, or continue to be, met as successfully as possible.
- It has also been demonstrated that rural and other metropolitan areas may have different patterns of drug use and related harms (e.g. Day et al., 2005). Further research into this issue might usefully enable user groups, health workers and policy makers in areas with different patterns of drug use and related issues to adapt more general health promotion messages, responses and so on to become more relevant to their particular area and/or client group(s).
Citation: Black, E., Degenhardt, L. & Stafford, J. (2006) New South Wales Drug Trends 2005: Findings from the Illicit Drug Reporting System (IDRS), Sydney: National Drug and Alcohol Research Centre.