NDARC Technical Report No. 272
EXECUTIVE SUMMARY
Demographic characteristics of injecting drug user (IDU) participants
In 2006, one hundred and twelve IDU were interviewed in Queensland for the IDRS. Approximately two thirds of the sample were male, about two thirds were unemployed, fewer than one in five had a grade 12 education or higher, 45% had a prison history, and a significant minority (13%) identified as Indigenous. More than a third of the sample were currently in some form of drug treatment, typically methadone or buprenorphine substitution treatment.
The average age of the IDU sample interviewed for the IDRS has been increasing in recent years, reflecting an ageing cohort of injecting drug users accessing Needle and Syringe Programs (NSP) in Queensland. Although those nominating heroin as their drug of choice are typically older than those nominating methamphetamine, this was not the case in 2006.
Patterns of drug use among the IDU sample
On average, IDU in 2006 reported first injecting at about 19 years of age – which is consistent with previous years. Also consistent with previous years, there was a positive correlation between age and age at first injection, indicating that more recent recruits into injecting may be starting to inject at a younger age. Over half of the sample reported first injecting methamphetamine, and these IDU were significantly younger than those reporting heroin as their first injected substance.
Heroin
The impact of the 2001 heroin shortage continues to be evident in the Queensland heroin market, with evidence of on-going, and perhaps increased, suppression of supply, and unstable purity. There has been relatively little change in the price of heroin over time, indicating that at the retail level, price may be a relatively insensitive indicator of market dynamics. Perhaps indicative of this on-going suppression of the heroin market, there was evidence of a continued decline in heroin use among IDU in 2006. The average age of IDU attending NSP continues to increase, and those injecting heroin are typically older than those injecting methamphetamine. To an increasing extent heroin may be, as some key experts (KE) have described it, “a drug of a previous generation”.
The continued decline of the heroin market in Queensland is also reflected in indicator data, with declines in the number of arrests for possession, the number of calls to telephone help-lines, the rate of self-reported overdose, and the number of pharmacotherapy registrations. The number of hospital admissions for opioids has been low and stable, however, this figure may also reflect the increasing number of IDU turning to alternative opioids (see Section 11.5) in response to a suppressed heroin market. Despite this, the number and weight of heroin importations intercepted at the Australian border increased in the first two quarters of 2006.
In contrast to most other Australia jurisdictions, the vast majority of opioid pharmacotherapy clients in Queensland are registered with a public prescriber. Despite high rates of injecting drug use and opiate dependence among new prison receptions, only 1% of client registrations in Queensland (versus 6.4% nationally) were in correctional facilities.
Methamphetamine
The IDRS monitors trends in three forms of methamphetamine: powder, ‘base’ and crystal (‘ice/crystal’). While the former two are mostly locally produced, crystal methamphetamine or ‘ice/crystal’ is mostly imported. As in previous years, in 2006 patterns of use and trends associated with powder and base differed substantially from those for ice/crystal.
Changes in illicit drug markets are not always reflected in the price of street-level quantities of the drug, and as in previous years, the price of a point of all forms of methamphetamine remained stable at $50. According to some KE, a point is loosely synonymous with “fifty dollars worth”. In 2006 there was some evidence of a decrease in the price of powder and base methamphetamine, with the price of larger quantities falling slightly. Conversely, the median price of larger quantities of ice/crystal increased, although IDU continue to report widely varying prices for larger quantities of the drug.
While the majority of IDU once again rated all forms of methamphetamine as ‘easy’ or ‘very easy’ to obtain, ice/crystal was considered less readily available than the other forms, with availability less stable over time. The perceived availability of all forms of methamphetamine fell in 2006. IDU consistently (and accurately) rate ice/crystal as higher in purity than powder and base, and there was little change in the perceived purity of each form from 2005. As seizure data do not distinguish among forms of methamphetamine, these data are limited in their ability to detect changes in purity over time.
The proportion of IDU reporting recent methamphetamine use dropped again in 2006, with only a small minority reporting daily use in the last six months. In 2005 there was evidence of a shift away from ice/crystal to less pure forms of methamphetamine. In 2006 however, the reverse occurred, with a larger minority of IDU identifying ice/crystal as the form most recently used. These divergent trends in methamphetamine use by form underscore the importance of distinguishing between powder, base and ice/crystal in monitoring methamphetamine trends.
Indicator data continue to suggest high levels of health and legal problems among regular methamphetamine injectors. Telephone help line and hospital admission data provided no evidence of a further increase in health-related problems among methamphetamine users, however, given that many methamphetamine users do not access treatment for their drug use, the actual incidence of acute health-related problems among this group is difficult to determine.
The number of arrests for use/possession of ‘amphetamine-type stimulants’ (ATS) in Queensland rose again in 2006, however, because KE reports suggest that ATS continue to be a priority for law enforcement, the observed increase in arrests may reflect increased law enforcement efforts in the ATS market, rather than increased market activity. Furthermore, the inclusive ATS category encompasses not only amphetamine and methamphetamine, but also 3,4-methylenedioxymethamphetamine (MDMA), or ecstasy, which is now the second most commonly used illicit drug in Queensland and Australia after cannabis (AIHW, 2005). Until it is possible to disaggregate MDMA and methamphetamine related events in Queensland arrest data, these data will be of limited use in monitoring the methamphetamine market.
The number of clandestine laboratories detected in Queensland has fallen dramatically in the last two years, however this does not necessarily indicate a decline in domestic methamphetamine production. In light of recent increases in precursor control and legislative changes to facilitate prosecution of methamphetamine ‘cooks’, this reduction in the number of labs detected may reflect increasing organisation of methamphetamine production in Queensland, with fewer ‘backyard’ producers willing, or able to, manufacture the drug. In the absence of more detailed information about the nature or production capacity of lab detections, this drop in lab detections is difficult to interpret.
Cocaine
Cocaine use has traditionally been rare, sporadic and opportunistic among IDU in Queensland, and this continued to be the case in 2006. Among the small proportion who indicated recent use, the frequency of use was very low and roughly equal numbers reported using intranasally (‘snorting’) and injecting. The small number of IDU who reported on cocaine renders reports of price, purity and availability less reliable. Indeed, reports among IDU were widely variable, suggesting that supply channels for this group are not well established. There was little evidence of change in the price of cocaine in 2006, with the price continuing to vary between $200 and $300 per gram. IDU disagreed regarding the purity and the availability of cocaine in 2006, however, some KE reported an increase in the availability of high-purity cocaine in south-east Queensland.
Although there seems to be relatively little contact between cocaine users and either health or law enforcement agencies in Queensland, arrest data provide some evidence of an increase in the size of the cocaine market. Indeed, the number of arrests for cocaine use/possession in Queensland increased substantially from 1999/00 to 2005/06, however, the total number still remains very low. The number of hospital admissions and telephone help- line calls related to cocaine has been low and variable in recent years. Anecdotal reports from users and KE suggest that there may be a sizeable and growing niche market for cocaine among non-injectors in Queensland, however, at present there is little reason to suspect that use of this drug will increase substantially among IDU.
Cannabis
The cannabis market in Queensland has traditionally been distinguished by its relative stability over time, although trends emerging over the last few years indicate that the market is not entirely static. As is the case with methamphetamine, in order to better understand the cannabis market it is important to distinguish between two forms of the drug: hydroponic cannabis (‘hydro’) and so-called ‘bush’ cannabis. Although these terms reflect the common understanding that ‘hydro’ is typically grown in small, indoor hydroponic plantations, while ‘bush’ is grown in large, outdoor crops in remote locations, there is surprisingly little evidence to confirm this view. Given our present level of knowledge, it would be prudent to simply consider ‘hydro’ synonymous with ‘higher potency’ and ‘bush’ with ‘lower potency’ cannabis.
As in previous years, in 2006 IDU typically rated hydro as ‘high’ potency and bush cannabis as ‘medium’ potency, although again, without objective purity data against which these perceptions can be compared, it is difficult to know how informative these reports are. Consistent with their ratings of potency, IDU reported that the price of hydro was about one- third higher than that for bush, however, there was evidence of an increase in the price of both forms in 2006. Hydro was reported to be ‘easy’ or ‘very easy’ to obtain, with bush perceived to be slightly less readily available; the perceived availability of both forms decreased slightly in 2006. Again consistent with previous years, in 2006 most IDU reported obtaining their cannabis from a friend or a dealer’s home.
The number of arrests for cannabis use/possession rose markedly from 2000/01 to 2004/05, before falling in 2005/06. This arrest figure includes both arrests and instances of diversion, however, and renders findings difficult to interpret. Clearly, there is a need for further research into the dynamics of the cannabis market in Queensland.
The vast majority of IDU reported recent cannabis use, with the proportion reporting use in the last six months increasing from 76% in 2005 to 85% in 2006. The average frequency of use among users was stable at an average of about 4 days out of 7 – considerably lower than the national average of daily use among IDU interviewed for the IDRS.
KE reported a growing recognition among users and the general community that regular, heavy cannabis use can lead to significant health problems. Consistent with this notion, the number of inpatient hospital admissions for cannabis, and the number of calls to telephone help- lines in relation to cannabis, have increased. To what extent this increase reflects an increase in problems, and/or an increase in treatment-seeking behaviour among problematic users, is a matter for continued investigation.
Use of illicit opioids
Trends in illicit opioid use among IDU are, to an extent, the mirror image of those for heroin. In the context of a sustained suppression of the heroin market in Queensland, IDU appear to be increasingly sourcing and injecting a range of alternative opiates including morphine, methadone, buprenorphine and oxycodone. Compared to heroin, these alternative, pharmaceutical opioid preparations are of consistent purity, and relatively consistent price and availability. However, because they are not designed to be injected, they carry the potential for significant injection-related harm.
Illicit Methadone
Following trends in opioid pharmacotherapy treatment, the proportion of IDU reporting recent use and injection of illicit methadone has decreased since 2004, while the proportion reporting use and injection of illicit buprenorphine increased. In 2006 fifteen percent of IDU reported recent use of illicit methadone, with almost all of these reporting recent injection of illicit methadone.
Illicit Buprenorphine
Use and injection of illicit buprenorphine have increased consistently since 2003, with one in four reporting recent injection in 2006. There continues to be extensive diversion of buprenorphine among IDU, with half of those who reported recent use indicating that they had mostly used illicit buprenorphine in the last six months. At least one dispensing service in south-east Queensland has implemented a policy precluding buprenorphine take-away doses, in an effort to reverse this trend.
Morphine
Use and injection of illicit morphine continues to be endemic among IDU in Queensland. In 2006 more than half of those interviewed reported recent use and injection of illicit morphine, and almost one in ten identified morphine as their drug of choice. Among those reporting recent morphine use, MS Contin100mg tablets continue to be the favoured brand for injection.
Oxycodone
In recent years there has been a trend among IDU in Queensland towards use and injection of illicit oxycodone. Prior to 2005, IDU interviewed for the IDRS were not asked specifically about oxycodone, however, in 2005 sixteen percent reported recent use, and 14% specified recent injection. In 2006 these proportions increased to 21% and 18% respectively. Just as the majority of IDU report that they mainly use illicit (versus licit) morphine, 70% of those reporting recent use of oxycodone in 2006 reported mainly using illicit oxycodone. The preferred brand for injection appears to be Oxycontin.
Benzodiazepines
Following increased restrictions on the availability of 10mg temazepam gel capsules in May 2002, rates of benzodiazepine injection among IDU dropped markedly in 2003, and this reduction has been sustained through 2006. By contrast, in 2006 more than two- thirds of IDU reported recent benzodiazepine use, with most using orally. The proportion of IDU reporting daily benzodiazepine use increased from 3% in 2001 to 15% in 2005, and remained high (14%) in 2006, perhaps reflecting shifting prescribing practices rather than diversionary activity. Roughly equal proportions reported mostly using licit and illicit benzodiazepines recently, indicating that benzodiazepine diversion and injection is still a health concern for this population. As in previous years, in 2005 the vast majority of IDU reported mostly using Valium.
Other drugs
Consistent with KE reports, a significant proportion of IDU continue to report experiencing mental health problems, most commonly depression. Consistent with this, a substantial proportion of IDU each year report recent use of antidepressants. In 2006 roughly one-in-four IDU reported using antidepressants in the last six months, with most of these reporting licit use (i.e. as prescribed). As in previous years, no IDU in 2006 reported injection of antidepressants.
Only a small proportion of IDU in Queensland report recent use of hallucinogens each year, however, this proportion more than doubled in 2006, to 12%. Furthermore, and consistent with KE reports of an increase in LSD availability and use, the median frequency of hallucinogen use among recent users doubled in 2006, to 5 days in the last 6 months. Hallucinogen use remains at a relatively low level among IDU, however, use increased noticeably in 2006.
Ecstasy (MDMA) is usually associated with ‘recreational’ drug users rather than injecting drug users, however, given its high level of availability, it is not surprising that a proportion of IDU will report recent use. In 2006 just over one in four IDU (28%) reported recent ecstasy use, with the majority of these using orally rather than injecting. Among recent users the typical frequency of use was 4 days in the last 6 months, indicating sporadic and/or opportunistic (versus regular) use.
In 2006 roughly one in four IDU reported lifetime use of inhalants, however only 3% reported recent use: one using amyl nitrate, one using nitrous oxide (‘bulbs’) and one failing to identify the inhalant used. These findings are consistent with KE reports that inhalant use is primarily a concern among youth, younger than those recruited for the IDRS. A number of KE from a correctional setting expressed concern regarding the health effects of inhalant use on younger prisoners, particularly young Indigenous prisoners.
Although IDU are typically thought of as illicit drug users, many also use licit drugs. Among IDU interviewed in 2006 almost two- thirds reported recent alcohol use, although only 13% reported daily alcohol use. Consistent with KE reports of increasing heavy drinking among young women, there was no significant difference in rates of daily drinking between males (13%) and females (15%). Whereas only a minority of IDU are daily drinkers, the vast majority smoke tobacco on a daily basis; in 2006 ninety six percent reported recent tobacco use, typically on a daily basis.
Associated harms
The number of syringes being dispensed to IDU in Queensland has continued to climb, with almost five and a half million syringes dispensed throughout the State in the 2005/06 financial year. At the same time, despite on-going harm reduction efforts targeting safe injecting, the proportion of IDU reporting recent sharing of injecting equipment increased from 21% in 2005 to 32% in 2006. A number of KE noted that while many IDU are aware of the risks of sharing needles, many have limited knowledge of the risks associated with sharing other injecting equipment.
The rate of Hepatitis C notification in Queensland fell from a peak of 3,330 notifications in 2000 to 1,901 notifications in 2005, before rising again to 3,053 notifications in 2006. The prevalence of Hepatitis C infection among IDU remains high, and this is reflected in the rate of Hepatitis C infection among prisoners in Australia, which in 2004 was estimated at 34% of new receptions (56% of those with a history of injecting drug use) (Butler, Boonwaat, & Hailstone, 2005). At present, important harm reduction measures such as needle exchanges are not extended to IDU incarcerated in Queensland, or any other state or territory of Australia (Black, Dolan, & Wodak, 2004).
As in previous years, the majority of IDU in 2006 reported usually injecting in a private home, however, almost one third (33%) reported usually injecting in riskier locations such as a car, the street, or a public toilet. The number of injection-related problems reported by IDU increased noticeably between 2005 and 2006, perhaps driven by a combination of the continued ageing of the IDU samples attending NSP, and the continued increase in injection of pharmaceutical opioid preparations. The most commonly reported injection-related problems were scarring or bruising, and difficulty injecting.
Although two- thirds of IDU reported usually injecting in a private home, almost half reported driving under the influence of drugs at least once in the last six months. The drugs mostly commonly used prior to driving were those used by the largest proportion of IDU: methamphetamine, cannabis and heroin. Given the significant risks associated with this behaviour, there is a clear need to further examine when, where and why IDU choose to drive under the influence of drugs, and what level of risk they perceive to be associated with this activity.
More than a third of IDU in 2006 reported having become verbally aggressive after substance use recently, with 41% reporting becoming verbally aggressive during withdrawal. Smaller, although not insignificant, proportions reported becoming physically aggressive under the influence of (14%), or withdrawing from (14%), a drug in recent times. The drugs most commonly associated with verbal aggression during intoxication were alcohol, methamphetamine and heroin, while the drugs most commonly associated with verbal aggression during withdrawal were methamphetamine (particularly powder methamphetamine), heroin and cannabis. In contrast to anecdotal reports of a strong link between crystal methamphetamine use and aggression, only 2% of IDU reported physical aggression associated with ice/crystal use recently. By contrast, given the relatively limited use of alcohol in this group, the proportion reporting aggression associated with alcohol use is significant.
There was little change in rates of self-reported criminal activity between 2005 and 2006, with more than a third reporting drug dealing recently, and one in five reporting property crime recently. Few IDU reported engaging in violent crime or fraud recently, however, more than half reported having been arrested in the last 12 months. Given the significant health and psychosocial problems faced by this group, contact with law enforcement agencies may provide an additional opportunity for referral into treatment, and/or for the provision of harm reduction messages.
Mental health problems – particularly anxiety and depression - continue to be common among IDU, with one in four reporting recently seeing a mental health professional in 2006. The proportion reporting experiencing mental health problems is considerably larger, indicating a degree of unmet healthcare need in this group.
Implications
Illicit drug markets in Queensland, as in other jurisdictions, continue to fluctuate and to interact. Accordingly, these markets should be monitored on a regular basis, and should not be interpreted in isolation from one another. The 2006 Queensland IDRS documented a number of new trends, and provided further evidence of interdependence among illicit drug markets in Queensland. In particular, it seems clear that changes in the availability of heroin have been associated with changes in the use of methamphetamine, and changes in the use of other opiates including morphine, methadone, buprenorphine and oxycodone. It is also clear that the cannabis market in Queensland is dynamic, and that further research is required to understand patterns of use and other market dynamics.
To the extent that illicit drug markets are interdependent, supply reduction, demand reduction and harm reduction policies should adopt a holistic view, recognising that targeting the use of one drug may impact on the availability and use of other drugs. In order to minimise drug-related harm, the realities of endemic polydrug use and interdependent illicit drug markets must be recognised. The data presented here further underscore the importance of this recognition.
Citation: Kinner, S. & Lloyd, B. (2007) QLD Drug Trends 2006: Findings from the Illicit Drug Reporting System (IDRS). Sydney: National Drug and Alcohol Research Centre.