EXECUTIVE SUMMARY
Demographic characteristics of IDRS participants
Sample characteristics for the 2011 Illicit Drug Reporting System (IDRS) in South Australia (SA) were generally similar to previous years. Fifty-nine percent of the sample were male, two-thirds (67%) were unemployed and just under half (48%) had a history of previous imprisonment. The median number of years spent at school was 11, with over half reporting some kind of post-secondary qualification (primarily a trade or technical qualification). Forty percent of the sample were currently undertaking some form of treatment for drug use, most commonly pharmacotherapy. These characteristics were largely unchanged from 2010.
There were, however, a couple of differences that were noted among the 2011 sample. The median age of the sample was 39 years which was slightly older than in 2010 (median of 37 years). In addition, there was a significant increase in the proportion of participants who had completed a university qualification (19% vs. 8% in 2010).
Patterns of drug use
The median age of first injection among the IDRS sample was 18 years, which was slightly older than reported in 2010 (17 years). The first drug ever injected by participants was primarily methamphetamine (62%), followed by heroin (33%). However, in relation to drug of choice (favourite or preferred drug) heroin was the most popular drug nominated by participants (44%), closely followed by methamphetamine (37%). Heroin was also the drug injected most often in the last month (45%), again followed by methamphetamine (36%).
Polydrug use was common among participants in 2011, and has remained consistently so across all years of the IDRS.
Heroin
In 2011, the proportion of SA participants who reported recent use of heroin was lower than reported in 2010, although the frequency of use increased threefold to a median of 72 days in a six month period. Daily heroin use also increased, from 10% (of recent heroin users) in 2010 to 25% in 2011. White powder or rock continued to be the most common form of heroin used by participants. Heroin users continued to supplement or substitute their heroin use with other opioid substances such as morphine and methadone, and also with methamphetamine and benzodiazepines.
The price paid for a gram of heroin at last purchase increased to $400 in 2011 (up from $360 in 2010). Despite this, the majority of participants (84%) reported that the price of heroin had remained stable over the six months prior to interview, with only 12% reporting that there had been an increase in price. According to participants, heroin purity was generally reported as ‘medium’ in 2011, whilst perceptions regarding changes in purity over the past six months were mixed.
Heroin was overwhelmingly considered easy or very easy to obtain, and this had reportedly remained stable over the preceding six months.
Experience of past 12 month heroin overdose increased in 2011, continuing an upward trend that has been observed since 2009. Interestingly, a number of key experts noted that there had been a recent batch of high purity heroin which had led to a spate of overdoses. Taken together, the IDRS data and key expert observations indicate that this is a concern that needs to be closely monitored.
Data from the SA Alcohol & Drug Information Service revealed that telephone calls relating to any opioid substance increased in the 2010/11 financial year, whilst data from Drug & Alcohol Services SA (DASSA) showed that the proportion of clients nominating heroin as their primary drug of concern remained stable in 2010/11.
Methamphetamine
In 2011, two-thirds of participants had used some form of methamphetamine in the six months preceding interview, a non-significant decrease from 2010. More specifically, there were slight increases in the recent use of powder and liquid methamphetamine, a slight decrease in the recent use of base and a significant decrease in the use of crystal methamphetamine. Frequency of use has fluctuated considerably over the years. In 2011, the frequency of use for powder increased substantially, whilst there were slight increases in the frequency of liquid and crystal methamphetamine. Inversely, the frequency of base methamphetamine decreased quite substantially. The main route of administration for all forms of methamphetamine was injecting, although there was a decrease in the proportion of participants who had injected base or crystal methamphetamine.
In 2011, there was no consistent trend in the price paid for a point of methamphetamine. More specifically, the last median price paid per point remained stable for crystal, decreased for base and doubled for powder. Few participants were able to comment on the current price of a gram for all forms. Reports regarding the current purity of the three forms of methamphetamine were also mixed. The purity of crystal methamphetamine, as perceived by participants, was largely reported as high with a quarter reporting that it fluctuated. The purity of powder and base methamphetamine was equivocal. All forms of methamphetamine were considered easy or very easy to obtain in 2011, and availability had reportedly remained stable over the preceding six months.
A higher number of calls were received by the Alcohol and Drug Information Service (ADIS) in SA regarding methamphetamine, whilst the proportion of DASSA clients nominating amphetamines as their primary drug of concern also increased. Moreover, the number of clients admitted to DASSA inpatient (detox) services with amphetamine as the primary drug of concern also increased.
Cannabis
Cannabis, though generally not the drug of choice among participants, was used by two-thirds of the sample – stable from 2010. Frequency of use increased quite substantially to a median of 110 days in a six month period. Whilst the majority of cannabis users reported that hydro was the form they had used most in the preceding months, bush cannabis was also commonly used. Of interest was that one-third of the sample indicated that they were unable to distinguish between hydro and bush cannabis, suggesting that either participants use whatever cannabis is available, or are not specifically concerned which type of cannabis they use.
In 2011, the price last paid for a bag of both hydro and bush remained stable at $25, as it has done for many years. Most of those who were able to comment also perceived the potency of both hydro and bush cannabis as ‘medium’ and stable. Both hydro and bush cannabis were considered very easy or easy to obtain, and availability was stable.
The number of calls to ADIS concerning cannabis remained relatively stable, as did the number of DASSA clients who nominated cannabis as their primary drug of concern. This supports the idea that the Adelaide cannabis market has generally remained stable over the preceding 12 months.
Opioids
In 2011, there was an increase in the use of other illicit opioid substances by SA participants, with 53% reporting recent use of some type of illicit opioid substance, excluding heroin. Twenty percent of participants reported they had used illicit morphine in the six months prior to interview on a median of ten days (range: 1-180) which was similar to 2010 reports. The price of illicit morphine appeared to remain relatively stable in 2011, although only a small number of participants commented thus making it difficult to draw any meaningful comparisons. Although the majority of participants reported that the availability of illicit morphine had remained stable over the preceding six months, there was an increase in the proportion who nominated it as easy to obtain. As in previous years, the majority of morphine users reported use by injecting and they had mainly used illicit supplies of MS Contin® and Kapanol®.
Similarly, the recent use of illicit methadone syrup remained stable in 2011 (11% in 2011 vs. 12% in 2010) as did the frequency of use. This was also the case for physeptone tablets.
Whilst the number of participants reporting recent use of illicit buprenorphine remained stable in 2011, reported frequency of use halved to a median of 7 days in a six month period.
In 2011, a slightly greater proportion of the sample reported recent use of illicit oxycodone; however, the frequency of use was stable compared to 2010. The majority of participants had injected oxycodone. It is worth noting that the majority reported mainly illicit use of this substance.
Other drugs
Eighteen percent of IDRS participants had used ecstasy and six percent had used some type of hallucinogen in the six months prior to interview, with both recent use and frequency of use remaining stable compared to 2010.
In 2011, the proportion of participants who reported recent use of illicit benzodiazepines (34%) doubled compared to participant reports in 2010 (17%). Prevalence and frequency of recent cocaine use remained stable in 2011, with twelve participants reporting that they had used cocaine on a median of two days within the preceding six months.
There was a significant increase in both lifetime and recent use of over the counter (OTC) codeine. Frequency of recent use increased slightly from a median of six days in 2010, to nine days in 2011. The only route of administration was swallowing, and the main brands used were Nurofen Plus® and Panadeine®.
The recent use of illicit pharmaceutical stimulants was relatively stable in 2011, with 9% of the sample reporting use over the preceding six months. There was, however, a substantial drop in frequency of use – from a median of 26 days in 2010 to 4 days in 2011.
Tobacco use remains highly prevalent among PWID, with 94% of the sample reporting that they had consumed tobacco on a median of 180 days in the six months preceding interview (i.e. daily use). Alcohol use was less common, with 54% of the sample reporting use on a median of 14 days in the past six months. Both alcohol and tobacco use remained stable from 2010.
Health-related issues
In 2011, there was a significant decrease in the self reported mental health problems (other than drug dependence) among PWID in the six months preceding interview. However, among those who had experienced a mental health disorder, depression continued to be the most commonly reported problem and the majority reported that they had attended a professional for such problems.
The Kessler Psychological Distress Scale (K10) (Kessler & Mroczek, 1994) was incorporated into the participant survey to give a measure of levels of psychological distress among the participants. Half of the participants were assessed to be at a high or very high risk of psychological distress.
Risk behaviours
The number of participants who reported ‘borrowing’ needles remained low and stable in 2011 (n=6), whilst the number of participants who had lent needles doubled (n=14). There was a decline in the sharing of injecting equipment (other than needles), with significant declines in the sharing of tourniquets and water. Re-use of one’s own needles (55%) and equipment (54%) was much more common.
In 2011, seventy-two percent of the participants reported experiencing at least one type of injecting-related health problem in the month prior to interview. By far the most commonly experienced problem was prominent scarring/bruising around the injection site, followed by difficulty injecting. About a third of participants reported that they had experienced a dirty hit, stable from 2010.
In 2011, the median expenditure on illicit drugs remained stable at $100.
Law enforcement
The prevalence of self-reported criminal activity in the month preceding interview remained stable in 2011, as did the prevalence of past year arrest. Drug dealing and property crime remained the most commonly committed crimes. Furthermore, the proportion of participants who reported a prison history also remained stable in 2011.
Driving a car while under the influence of alcohol was reported by 12% of participants who had driven in the preceding six months. Eighty-five percent reported driving under the influence of an illicit drug during that time, mainly cannabis, heroin and methamphetamines.
Special topics of interest
Heavy Smoking Index (HSI) for nicotine dependence
Among those who smoked daily, half had had their first cigarette within five minutes of waking up and 49% reported smoking between 11-20 cigarettes a day. Approximately one-quarter of daily smokers scored 5 or above indicating high nicotine dependence, with the mean HSI score being 4.
Alcohol Use Disorders Identification Test
In 2011, IDRS participants were asked to respond to the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). Just under half of males who had recently drank alcohol, and 36% of females, scored 5 or more indicating the need for further assessment. The overall mean score was 4.3.
Pharmaceutical opioids
In 2011, participants were asked questions about the use of pharmaceutical opioids and pain. Approximately one-quarter of the sample reported that they had recently used pharmaceutical opioids, and of these 41% reported using them for pain relief and almost one-third to treat self-dependence. Nineteen percent of those who commented reported being refused pharmaceutical medications due to their injecting history.
Over the counter codeine
In 2011, participants in the IDRS survey were asked questions about the use of over the counter (OTC) codeine for medical and non-medical purposes. Fifty percent reported use within the preceding six months, 48% of the sample reported using OTC codeine for medical purposes and 8% reported using it for non-medical purposes. The main type of medical purpose was acute/short-term pain (69%).
Injecting equipment use
Ninety-five percent of the sample reported the use of 1ml needle and syringes in the last month, followed by a 3ml syringe (13%) and detachable needle (12%). The re-use of 1ml needle and syringes was reported by 50% of the sample, with two-thirds reporting that they had cleaned 1ml needle/syringes in the month preceding interview.
Mental and physical health problems (SF12)
The Short Form 12-Item Health Survey (SF-12®) is a questionnaire designed to provide information on general health and wellbeing, and it was administered for the first time in the IDRS in 2011. IDRS participants scored a mean of 40 for the mental component score and 43 for the physical component score. They scored substantially lower than the Australian population, indicating that they have poorer mental and physical health than the general population.
Health service access
Participants in the 2011 IDRS were asked about access to health services in the previous four weeks. The majority of participants (n=57) reported visiting a General Practitioner (GP) in the last four weeks, on a median of one occasion. Of those, three-quarters reported visiting a GP once in the last four weeks and one-quarter reported the visit was substance use related.
Online activities
Over half of the sample reported that they had never used the internet in the last month, while 17% reported daily internet use. Of those who had used the internet in the last six months, around one-third reported going ‘online’ to get information about drugs.
Policy
In 2011, questions were added to the IDRS in order to gather data about how PWID themselves perceive drug policy in Australia. It was found that virtually the entire sample supported needle and syringe programs to reduce problems associated with heroin use, whilst the majority also supported methadone/buprenorphine maintenance programs, treatment with drugs (not including methadone) and regulated injecting rooms.
The majority of the sample also supported the legalisation of cannabis for personal use, and just over half supported the legalisation of heroin for personal use.
Interestingly, around one-quarter supported the increased penalties for sale or supply of methamphetamine or heroin
Implications
The findings from the 2011 SA IDRS have policy and research implications, and a number of recommendations are outlined below. It is worth noting that several of these issues have already received attention and/or may be in the process of further investigation.
- Although the prevalence of heroin use remained stable in 2011, the frequency of use increased three-fold to a median of 72 days in a six month period. This is the highest frequency of use recorded since 2003. This is somewhat concerning, especially when accompanied by an increase in daily use, and it highlights the importance of continued education and harm reduction strategies.
- There was a slight increase in recent heroin overdoses, which continues an upward trend that has been observed since 2009. In addition, a number of key experts (KE) reported that there had been a recent spate of heroin overdoses, which was likely the result of a batch of high purity heroin. Although this is a group of experienced users, this emphasises how important it is for PWID to buy drugs from a reliable source so that they can be certain about the quality and strength. In addition, it is important to always test a small dose before taking the whole dose.
- The proportion of participants who had ‘lent’ needles and syringes in the past month doubled to 14% in 2011. Although this remains relatively low, the consequences of sharing injecting equipment are substantial. Re-use of one’s own needles and equipment also remained high, with over half of the sample reporting that they had done this in the month preceding interview. It is imperative that harm reduction strategies continue to be disseminated among this population, particularly in regards to safe injection practices and vein care.
- There was a substantial increase in the use of illicit benzodiazepines, and a significant increase in the use of OTC codeine. This indicates that the development and implementation of strategies to reduce diversion of, and non-adherence with, prescribed pharmaceuticals is warranted.
- Tobacco use remains alarmingly high among PWID, with 88% of the sample reporting that they were smoking daily and 94% reporting any use in the six months preceding interview. This is in stark contrast to the general community, where the prevalence of smoking has been steadily decreasing. As such, it is recommended that health campaigns be targeted specifically towards this group.
- The development and implementation of services and strategies to cater for those with substance use and mental health appears warranted, especially considering the proportion of participants assessed as having high or very high psychological distress as measured by the Kessler Psychological Distress Scale (K10) and low SF-12 scores compared to the general population.
- It is widely recognised that engaging citizens is important in the policy making process and is a core element of good governance. Unfortunately, the opinions of PWID have often been neglected in drug policy debates, with preference being given to broader population attitudes. The policy questions included in the 2011 IDRS show that the PWID have strong views regarding measures to reduce problems associated with drug use. Indeed, given their first-hand experience, PWID are in a better position to determine whether such policies would be/are effective, and as such it is strongly encouraged that in the future more consideration be given to the views of PWID, and other drug using populations.