NDARC Technical Report No. 270
EXECUTIVE SUMMARY
Demographic characteristics of injecting drug user (IDU) participants
One hundred and fifty-two IDU participated in the 2006 survey. Sixty-one percent were male, 82% were unemployed or on income support (such as disability or sickness benefits or the New Start jobseeker’s allowance) at the time of interview. The average age of respondents was 35 years (range 18-58 years). Twenty-two percent of the sample identified as Aboriginal and/or Torres Strait Islanders (A&TSI). Educational status of the sample varied, ranging from five years completed, 54% percent of the sample having completed year 10 and 13% having completed year 12. Thirty-nine percent had obtained a trade or technical qualification and 3% had completed a university or college qualification such as a degree. Fifty-nine percent had not completed any further education after leaving school. Sixty-three percent had a previous prison history. The average age of first injection was 19 years (range 9-40).
Patterns of drug use among the IDU sample
Heroin
As in previous years, the majority of the sample continued to nominate heroin as their drug of choice (49%), the drug they had injected most often in the last month (42%), and the drug they had injected most recently (42%). These figures were substantially lower than previous years: in 2004, heroin was the last drug injected and most commonly injected drug in the past month for 80% of the sample, and 64% (each) in 2005. Eighty-one percent of participants reported use on one or more occasions in the six months preceding interview.
The median days on which heroin was used also continued to decline from 96 days in 2005 (i.e. approximately every two days) to 72 days (i.e. three times per week) in 2006; 2006 was also the year in which there was the lowest proportion of daily heroin users since the IDRS began (25%). As in 2005, the median number of days on which heroin was used differed by geographical area. However, although in 2005 a decrease in days of use was seen in South West Sydney and use remained stable in central Sydney, 2006 saw a stabilising of days of use in the South West (67 days in 2005; 65 in 2006) and a halving in the days of use in central Sydney (from 180 days, or daily, use in 2005 to 90 days in 2006).
The median price for a gram ($300) and a cap of heroin ($50) remained stable in 2006 and prices remained higher than those reported prior to the heroin shortage in 2001. Heroin remained accessible in 2005, with 69% of those commenting reporting that it was either ‘easy’ or ‘very easy’ to obtain. However, there was some suggestion of a decrease in availability, as the proportion reporting that it was ‘difficult’ or ‘very difficult’ to obtain increased from 9% in 2005 to 28% in 2006. Participants tended to report availability as having remained stable (47%) or more difficult (35%).
The majority of participants (among those who commented) reported that heroin purity was currently low (64%) and decreasing (48%). Key expert (KE) comments on price, purity and availability were consistent with IDU reports, with some discussion around different pricing methods and indications that heroin quality was generally poor. KE and IDU commenting on heroin use typically characterised users as engaging in polydrug use, using other drugs such as illicit opioids, benzodiazepines and stimulants in response to continued low heroin availability/purity. There was suggestion of a slight increase in homebake use among some
groups of drug users, reflected in a slight increase in IDU reports of use. However, the use of this opioid remained uncommon and infrequent.
Key experts (KE) also noted the appearance of Afghani brown alkaline heroin, predominantly in central Sydney with some indication of its use extending to South-West Sydney for a short period. This had prompted a number of harm reduction efforts by health providers, who noted that this form of heroin requires different injection preparation methods. However, all KE noted that the predominant form remained white (or off-white) powder, believed to be sourced from South East Asia.
Indicator data reflecting harms related to heroin use remained stable or decreased over the past year, and remained substantially lower than figures recorded prior to 2001. The NSW heroin market has not returned to pre-shortage levels of use or associated harm.
Methamphetamine
Seventy-two percent of participants had used some form of methamphetamine (speed powder, base, ice or liquid1,2) in the preceding six months, representing an increase from 2005 (58%). The most common form used was ice/crystal (57%; an increase from 38% in 2005), followed by speed powder (49%; an increase from 38% in 2005). Prevalence of base use remained fairly stable at 43% (38% in 2005), and prevalence of liquid methamphetamine remained stable and low (5%; 6% in 2005). Frequency of methamphetamine use (any form) also increased, to a median of 26 days (i.e. approximately weekly use), compared to 2005 (16 days, i.e. just over fortnightly use). The proportion of daily methamphetamine users increased from 5% in 2005 to 10% of the entire sample in 2006. Again these increases were mainly observed in the use of speed powder and ice/crystal, with frequency of base and liquid methamphetamine use remaining stable.
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). Increases were observed in the median prices paid for larger quantities of base, and decreases were observed in the median prices paid for larger quantities of ice/crystal. However, it should be noted that prices quoted for larger quantities were based on small numbers of participants, and should be interpreted with caution.
The three main forms of methamphetamine (speed, base and ice/crystal) were typically reported by users as ‘very easy’ or ‘easy’ to obtain. This was particularly the case for ice/crystal, which was reported as ‘very easy’ to obtain by approximately one-third of the entire sample, as compared with one-tenth of participants in 2005. Availability was typically reported to have remained stable over the six months preceding interview.
As in previous years, user perceptions indicated that ice/crystal and base were higher in purity than speed powder, with ice/crystal most commonly being reported as ‘high’, base as ‘medium’ and speed powder as ‘low’. KE reports indicated that speed powder was typically 9-20% pure, while ice/crystal fluctuated and could reach up to 80% purity. Reports by IDU and KE generally suggested that purity had remained stable over the preceding six months.
KE reported on a range of methamphetamine forms, with ice/crystal and speed powder mentioned most often, and few reports of base use. However, a number of KE also noted that while users most often spoke about ‘ice’, they were often uncertain as to what extent users were also using other forms of methamphetamine. While use of ice/crystal was reported to have increased among clients of some health services over the past few years, opinions about the extent of this use were in some cases critical of media reports of a so-called ‘ice epidemic’. Law enforcement KE in some areas reported that they had increased staff skills training in response to an increase in problematic behaviour among methamphetamine users, and a health KE in another area reported that their service had increased anger management training for clients in response to increased numbers of methamphetamine users. One KE had observed a decrease in ice/crystal use among some users due to negative experiences reported by the users they had contact with.
As in previous years, indicator data reflecting harms related to methamphetamine use presented a mixed picture, with increases noted in the number of recorded incidents of possession/use in the inner city, methamphetamine lab detections, and the number of calls regarding ice/crystal to telephone help lines. A number of health indicators showed figures as being stable (e.g. admissions to emergency departments), while decreases were observed in the number and rate of methamphetamine-related hospital admissions.
Cocaine
A moderate increase in cocaine use was observed in 2006, although this did not approach the high levels reported in 2001 during the peak of the heroin shortage. Sixty-seven percent of participants reported cocaine use in the preceding six months (as compared with 60% in 2005), and the median days of use increased from 12 days in 2005 (i.e. approximately fortnightly use) to a median of 20 days in 2006 (i.e. just under weekly use). Ten percent of participants reported daily use over the past six months. Cocaine use was more prevalent among participants recruited in central Sydney than those recruited in the South-West. Reports of crack cocaine were almost non-existent among the IDU sample, a finding reflected in KE reports.
Reports of cocaine availability remained relatively stable, with 71% of those who were able to comment reporting it to be either ‘easy’ or ‘very easy’ to obtain as compared with 69% in 2005. However, a decrease was observed among those reporting cocaine as ‘very easy’ to obtain, from approximately one-third of participants in 2005 to approximately one-fifth in 2006. Overall, while cocaine remained readily available to a large proportion of the sample, this may be indicative of a slight decrease in availability compared with 2005. Availability was commonly perceived to have remained stable over the preceding six months. More broadly; however, law enforcement KE indicated an increase in cocaine availability across the state.
Prices for cocaine remained stable. Caps remained the most common purchase amount ($50; n=47), although there was a decrease in the number of participants reporting purchase (n=61 in 2005).
IDU participant reports on cocaine purity were mixed, with one-quarter of the sample (one-third of those commenting) reporting it as ‘medium’, and 16% each reporting it as ‘high’ or ‘low’. Purity was most often rated as having been ‘stable’ (26% of the sample, or 36% of those able to comment on cocaine market characteristics) over the six months preceding interview, although a substantial proportion thought that it was decreasing (18% of the sample, or 25% of those commenting). Overall these reports indicated little change from 2005.
KE comments regarding use patterns were generally consistent with those of IDU, suggesting that cocaine use remained more prevalent in central Sydney, and was used more sporadically in other areas. Also consistent with these geographic differences, indicator data showed that cocaine use had increased in the inner city (number of visits to the Sydney Medically Supervised Injecting Centre [MSIC] where cocaine was injected and number of visits to three inner city Needle and Syringe Programs (NSPs) where cocaine was reported as the last drug injected), and had remained stable and higher than other areas of NSW (recorded incidents of cocaine possession/use). State-wide indicator data suggested that harms related to cocaine use had increased or remained stable.
Cannabis
The cannabis market has remained relatively unchanged since the commencement of the NSW IDRS in 1996. The majority of participants (80%) in the 2006 IDU sample reported having used cannabis in the six months preceding interview. The median frequency of use among IDU remained at 180 days (daily use) in 2006.
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. There was a slight increase in the number of participants reporting purchase of the resin (hashish) and oil (hash oil) forms compared to 2005; however, overall indications suggested that use remained rare. The price of hydroponic cannabis was $20 per gram (the most popular purchase amount) and the majority of participants (72% of the entire sample, or 94% of those completing the section on cannabis market characteristics) reported that it was readily available, i.e. ‘easy’ or ‘very easy’ to obtain. The price per gram of bush cannabis was also $20, but, as in previous years, larger purchase quantities of bush were slightly cheaper than for the equivalent quantity of hydro. Bush was more difficult than hydro to obtain, with fewer participants able to complete survey items on bush market characteristics (price, potency and availability), and only 15% of the sample (49% of those able to comment on bush market characteristics) reporting it to be ‘easy’ or ‘very easy’ to obtain. As in 2005, 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, and that the number and profile of clients attending treatment services had remained stable in many areas. However, some health KE noted an increase in people seeking treatment for cannabis use, and one KE had received an increased number of queries from people concerned about workplace drug testing and drug driving testing. 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.
Use of illicit pharmaceuticals
Illicit methadone
One-quarter (25%) of participants reported use of illicitly obtained methadone syrup in the six months preceding interview, a similar level compared to 2005 (17%), and use was sporadic (less than monthly). Just under half of those who had used illicit methadone had also been engaged in methadone treatment during this period, suggesting that methadone was being diverted by those engaged in treatment, as well as to those who were not. One-fifth of participants reported injecting illicit methadone syrup in the preceding six months (11% in 2005), indicating that prevalence had increased slightly from 2005 and was similar to 2004 findings. Frequency of injection was also reported as less than monthly. Again, just under half of this group were engaged in methadone treatment during this period.
Reports on illicit methadone availability were somewhat mixed, although almost one-third of the sample reported that it was ‘easy’ or ‘very easy’ to obtain. There was some indication of a price increase, with the median price per ml increasing from 50c to 75c; however, the modal price remained at 50c per ml. KE reports indicated that reasons for diversion may be many and varied; research into the reasons for diversion is currently being conducted.
Use and injection of illicitly obtained Physeptone tablets remained uncommon, with 2% each reporting use and injection in the six months preceding interview.
Illicit buprenorphine and buprenorphine-naloxone
An increase was observed in the reported use of illicit buprenorphine in the preceding six months, from 8% in 2005 to 19% in 2006. Less than one-third of these participants reported engagement in buprenorphine treatment during this period. The prevalence of illicit buprenorphine injection during the six months prior to interview also increased, from 5% in 2005 to 15% in 2006, although the frequency of injection over this period remained low (less than monthly).
In 2006, items were included on buprenorphine-naloxone (Suboxone), which was listed on the Pharmaceutical Benefits Scheme 1-2 months prior to interview. There were no reports of buprenorphine-naloxone diversion in 2006.
Morphine
Prevalence of morphine use among the NSW IDRS IDU has gradually increased since 2001, with 37% of the 2006 sample reporting use in the preceding six months. However, frequency of use remained low (median of 7 days in 2006). One-third of the sample reported the use of illicitly obtained morphine in the six months preceding interview, on a median of 8 days (i.e. approximately 1-2 times per month). Use of licitly obtained morphine was uncommon, with 7% of the sample having used it on a median of 5 days. The majority of participants who reported morphine use in 2006 were recruited in central Sydney, with much lower rates of use in the South West. This was also reflected in KE reports, and indicator data from the Sydney MSIC (located in Kings Cross, central Sydney) which showed a clear increase in clients injecting morphine.
Nineteen percent of participants reported injecting morphine in the month preceding interview, and, of these, just over half (55%; 11% of the entire sample) reported experiencing problems that they attributed to morphine injection, such as difficulty finding veins and prominent scarring or bruising. MS Contin remained the most common brand of morphine used, with 100mg tablets (‘grey nurses’) costing a reported median price of $25.
Just over one-third (38%; an increase from 27% in 2005) of the sample felt confident to comment on the price and/or availability of illicit morphine. These participants typically reported that it was ‘easy’ or ‘very easy’ to obtain. Availability was generally considered to have remained stable.
Oxycodone
As in 2005, a distinction was made between licit and illicit oxycodone (e.g. OxyContin, Endone) and other opioids due to concerns that illicit use of, and problems associated with, diversion of oxycodone may be increasing. Until 2005, oxycodone was included under ‘other opioids’.
Twenty percent of participants reported use of oxycodone in the six months preceding interview on a median of 13.5 days (i.e. approximately once per fortnight). A fairly small proportion of the sample (14%) reported injecting it in this time on a median of eleven days. General use patterns of licitly and illicitly obtained oxycodone were similar, although injection of oxycodone was more common when it was illicitly obtained.
KE reports indicated that the use of oxycodone remained relatively uncommon among IDU; however, it should be noted that it may in some cases be referred to by users as ‘morphine’, so it is difficult to know the extent to which changes in ‘morphine’ also apply to oxycodone.
Twenty-two percent of the sample felt confident to comment on the price and/or availability of illicit oxycodone. The most common purchase amounts were 80mg OxyContin tablets, bought for a median price of $25 each (the same price as for 100mg MS Contin morphine tablets). These participants had mixed views on availability, with similar proportions reporting it as ‘easy’, ‘very easy’ and ‘difficult’ to obtain. Availability was generally considered to have remained stable.
Other opioids
Use of other opioids not specified elsewhere (e.g. codeine and pethidine; whether licitly or illicitly obtained) was uncommon, with 6% reporting recent use on a median of 4.5 days (i.e. less than monthly use). One percent reported injecting other opioids in the six months preceding interview on a median of three days. Panadeine Forte, a pharmaceutical drug containing 30mg codeine, continued to be the main form used; just over one-third of those reporting other opioid use had obtained them illicitly.
Benzodiazepines
Prevalence of benzodiazepine use decreased slightly, with just over half (59%) reporting use in the six months preceding interview on a median of 25 days (i.e. approximately weekly use). By comparison, 65% reported use on a median of 29 days in 2005. The proportion of daily users decreased slightly from 20% in 2005 to 14% in 2006. Injection of benzodiazepines was relatively uncommon, and was substantially lower since the removal of benzodiazepine gel capsules (e.g. Normison, Euhypnos) from the market. Thirty-seven percent of participants (62% of benzodiazepine users) reported use of illicitly obtained benzodiazepines in the last six months, and diazepam and oxazepam remained the most common forms used.
Other drugs
Approximately one-quarter of participants reported antidepressant use in the six months preceding interview, representing little change from 2005. In the vast majority of cases, they were licitly obtained and taken orally.
Hallucinogen, ecstasy and inhalant use remained relatively infrequent. Hallucinogen use in the six months preceding interview was reported by 5% of the sample on a median of two days, and 1% had injected them on a median of 1.5 days. Hallucinogen figures refer to LSD; there were no reports of recent ‘magic mushroom’ use. While over half of the sample had tried ecstasy, recent use was reported by approximately one-quarter of the sample on a median of two days. Twelve percent reported injecting it in the preceding six months on a median of two days. Prevalence of inhalant use (e.g. nitrous oxide, amyl nitrate and paint) remained low at 2%.
Approximately two-thirds of the sample had consumed alcohol in the preceding six months on a median of 20 days, i.e. approximately once per week. Approximately one-tenth of the sample reported daily alcohol use. Tobacco remained the most commonly used substance investigated by the IDRS, with virtually all participants (96%) reporting smoking tobacco in the six months preceding interview on a median of 180 days (i.e. daily); a finding that has remained consistent since 1996 when the project commenced.
Associated harms
Approximately one-third to two-fifths of IDU recruited in NSW reported recent testing for BBVI (hepatitis B, hepatitis C and/or HIV), with high self-reported rates of hepatitis C infection and low rates of HIV infection. Participants reported some confusion in their understanding of their BBVI status Small proportions reported receiving antiviral treatment for hepatitis C.
Survey data suggest that the proportions of IDU reporting borrowing and/or lending of needles and other injecting equipment have remained stable or decreased slightly compared to 2005.
The most commonly reported location for injection (usual and most recent) was a private home, with less than one-quarter of participants reporting that their usual location was a public place. These figures represent little change from 2005. Just over one-tenth reported that they usually injected at the Sydney MSIC, and 15% reported last injecting at the MSIC. While these figures remained stable compared to 2005, an increase in reports of injecting at the MSIC has occurred since 2001, when these figures were 3% (usually injected) and 4%, (last injected).
Two-thirds of IDU participants who had injected in the last month reported at least one injection-related problem during this time (the same figure as in 2005), and 38% percent reported two or more problems during this time (as in 2005). The most commonly reported problems were prominent scarring/bruising of injection sites (51%) and difficulty injecting (42%). Over half of the sample (56%) 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 (either alone or in combination with another drug/s).
Five percent of the sample reported driving under the influence of alcohol in the six months preceding interview on a median of four occasions. Thirty percent reported driving under the influence of an illicit drug in this time, most commonly heroin, methamphetamine and/or cannabis. These are lower than the rates have reported by other research with IDU in Sydney (e.g. Darke et al., 2004).
Almost one-third of the sample reported experiencing a mental health problem other than drug dependence in the preceding six months, and 80% of this group (representing 23% 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 (20%), followed by anxiety (8%) and schizophrenia (7%).
Thirty-six 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 aggressive. Participants more commonly reported becoming verbally aggressive when in withdrawal or ‘coming down’ from a drug (47%), while rates of physical aggression were lower at 15%. The most commonly reported drugs attributed to these instances of aggression were heroin (particularly during withdrawal), methamphetamine and alcohol (when under the influence).
The proportion reporting involvement in criminal activity in the month preceding interview (55%, mainly drug dealing and property crime) has remained relatively stable over time. A marginal decrease was observed in reports of arrest over the preceding twelve months, from 44% in 2005 to 39% in 2006. As in previous years, the majority of participants (57%) perceived that police activity had increased in the preceding six months. Just over half the sample (62%) reported that their ability to obtain drugs had been unaffected by police activity.
Implications
The findings of the 2006 NSW IDRS indicate that further attention is required in the following areas:
- Wider implementation of effective interventions for stimulant (cocaine and methamphetamine) users appears necessary and development of strategies to engage and retain users in these programs would be of benefit.
- Dissemination of available treatment options for psychostimulant dependence to users is required.
- Continued skills training for frontline workers dealing with people who use psychostimulants in a problematic manner and/or who present in crisis appears warranted. This includes health service providers and law enforcement personnel. A number of guideline documents have been developed under the National Drug Strategy (e.g. Baker et al., 2004, Jenner et al., 2004a, Jenner et al., 2006, Jenner et al., 2004b).
- There should be continued provision of services – e.g. counselling and withdrawal management – for those wishing to cease or reduce cannabis use.
- Continued careful monitoring is required by medical practitioners of the diversion of pharmaceutical preparations (e.g. benzodiazepines and opioids), whilst also continuing to appropriately provide these medications to those with genuine clinical need. Provision of targeted harm reduction messages and equipment such as pill filters should be considered for those who continue to inject such preparations.
- There may be many interpretations of the term ‘diversion’ and reasons for doing so. Clear and honest dialogue between case workers/prescribers and clients is crucial in minimising diversion and related harms whilst also achieving the highest rates of treatment adherence. Further research is currently being conducted into this area to increase understanding of this difficult issue.
- Continued monitoring of the currently low prevalence of alkaline heroin and homebake heroin, associated harms and production of the latter within Australia is necessary. Should their use become more widespread, the flexibility in harm reduction efforts (such as information on safer methods of use and provision of the necessary equipment) demonstrated by health services in central Sydney will be required more broadly.
- There should be continued focus on education regarding overdose and safer injecting strategies. In the context of increased stimulant use, a number of actions seem warranted. These include targeted education regarding the effects of prolonged use (e.g. agitation, aggression, paranoia and psychosis), practical strategies to reduce risk (e.g. rest periods between binges), skills training or counselling for users (e.g. on recognising and dealing with anxiety, anger and low mood) and referral into treatment where appropriate. An example of such information may be found in a booklet developed with input from users (‘On Thin Ice: A User’s Guide’ at /).
- Continued emphasis on the importance of regular BBVI testing and vaccination to injecting drug users, including efforts to maximise the availability of these services to injecting drug users (e.g. provision of testing at/near NSPs). Continued efforts should also be made to provide clear messages and interpretations of BBVI test results, including access to follow-up information and referral.
- Increased/continued awareness of the need for treatment of the comorbid mental health and polydrug use problems that many IDU may be experiencing and promotion of available services to injecting drug users are warranted. 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, and effects of drug use on signs and symptoms. 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 antidepressant 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, antidepressant 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.
- Following the introduction of drug driving testing in NSW, dissemination of the legislation and penalties to users appears warranted.
- High rates of tobacco use have consistently been documented in the IDU samples over time, and consideration should be given to providing smoking reduction/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 is recommended 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., 2005a). 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., Roxburgh, A. & Degenhardt, L. (2007) NSW Drug Trends 2006: Findings from the Illicit Drug Reporting System (IDRS). Sydney: National Drug and Alcohol Research Centre.