NDARC Technical Report No. 215 (2005)
EXECUTIVE SUMMARY
In 1998, the National Drug and Alcohol Research Centre was commissioned by the Commonwealth Department of Health and Family Services (now the Australian Government Department of Health and Ageing) to begin a national trial of the Illicit Drug Reporting System (IDRS), following previous employment of the methodology in New South Wales, South Australia and Victoria. The intention of the IDRS was to provide a coordinated approach to the monitoring of data associated with the use of heroin, cocaine, methamphetamine and cannabis, in order that this information could act as an early warning indicator of the availability and use of drugs in these categories.
The 1999, the Tasmanian component of the national IDRS gathered information on drug trends using two methods: key expert interviews with professionals working in drug-related fields, and an examination of existing indicators. For the 2000 IDRS, funding was provided by the National Drug Law Enforcement Research Fund to expand this methodology and include a survey of people who regularly inject illicit drugs in addition to the methods employed previously. This funding and methodology was continued in 2001 and into 2004.
Injecting drug user (IDU) survey
One hundred people that regularly injected illicit drugs (IDU) were interviewed using a standardised interview schedule which contained sections on demographics, drug use, price, purity and availability of drugs, crime, risk-taking, health and general drug trends.
Key Expert (KE) survey
Thirty-one professionals working with substance-using populations provided information about a range of illicit drug use patterns in clients they had direct contact with. These 'key experts' (KE) included needle availability program staff, drug treatment workers, health workers, youth and outreach workers, and staff from police and justicerelated fields. Of these individuals, 9 reported on groups that predominantly used opioids (diverted pharmaceuticals), 7 on cannabis and 15 on groups primarily using methamphetamine.
Other indicators
In order to complement and validate the key expert interview data, a range of drug use indicator data was sought from both health and law enforcement sectors. Guidelines for the acceptability of these sources aimed to ensure national comparability, and required that the sources were available annually, included 50 or more cases, were collected in the main study site and included details on the main illicit drug types under study. Included in this analysis were telephone advisory data, drug offence data, hepatitis C incidence data, data from the 1998 and 2001 National Drug Household Studies, and data from clients of the States Needle Availability and Pharmacotherapy programs, as well as drug and alcohol treatment services.
Demographic characteristics of injecting drug users (IDU)
Demographic characteristics of the regular injecting drug user (IDU) participants interviewed were generally very similar to those interviewed in previous Hobart IDRS studies. Participants were predominantly male (65%), and had an average age of thirty years. On average, participants had completed 10 years of education, and three-quartes (76%) were currently unemployed. One-quarter of participants had a previous prison history. A high proportion of the current IDU participants were involved in some sort of drug treatment at the time of interview, with 54% currently enrolled in a methadone maintenance program.
The majority of participants (53%) were injecting a few times per week, but not every day, with 27% injecting at least once per day. As per previous IDRS IDU samples, twothirds (70%), reported an opiate as their drug of choice, with the remainder predominantly nominating a stimulant drug. While heroin was the most commonly nominated drug of choice (38%), in no instance was it the drug most commonly injected by IDU participants, with 48% most commonly using methadone, 29% methamphetamine, and 20% morphine in the six months prior to interview.
Heroin
While the availability of heroin in the state appeared to have been slowly increasing during 1999 and 2000, data from local IDRS studies since this time have suggested that the drug has become steadily more difficult to access locally. Recent use of heroin was seen in just 19% of the IDRS IDU sample, despite the fact that 38% regarded it as their drug of choice. Use of heroin among clients of the state's Needle Availability Program remained below 2% of all client transactions in 2003/04.
The small number of participants that could report prices for heroin indicated that the drug was purchased for $50 per 'packet' (approximately 0.1g) and $350 per gram, similar prices to those similar prices to those reported in previous IDRS studies. There were mixed opinions regarding the purity of heroin, with many IDU wary of purity of the drug purchased locally.
As further evidence of a low availability of the drug locally, the majority of individuals that had recently used the drug reported it as 'difficult' or 'very difficult' to access and Tasmania police have not made any seizures of heroin in the past two financial years. The majority of indicators, and findings such as the low median rate of use of heroin (4 days in the last six months amongst the 19% of the sample that had used the drug), indicate that the traditional low availability of heroin in Tasmania has continued, and possibly further declined, in 2004.
Methamphetamine
Over the past four years of the IDRS in Hobart, higher-purity forms of methamphetamine have generally increased in availability in the state. This easy availability of high-potency forms of the drug may have made use of methamphetamine particularly attractive among IDU, with almost all of those surveyed in the current study using some 'form' of the drug in the six months prior to interview (91%), despite the participants predominantly preferring opioids (70%). Moreover, the proportion of clients of the state's Needle Availability Program reporting predominant use of methamphetamine has steadily increased from 31% of recorded transactions (almost 3,000 cases) in 2000 to 52% in 2004 (almost 20,000 transactions).
In terms of the 'forms' of methamphetamine used among the IDU cohort, the traditional low-purity powder form, which reports from Tasmania police suggest remains the most common form of the drug available in the Tasmanian market, was used by approximately three-fifths (60%) of the IDU participants in the current study in the six months prior to interview. This is a clear increase from the 51% of the IDU participants reporting recent use of this preparation in the 2003 study, however, methamphetamine powder remains uncommon as the form of methamphetamine predominantly used by this demographic (31%). In a reversal of the trends seen in the previous IDRS study, the major change seen this year was in the level of availability, and hence use, of the higher potency forms of the drug. Among the 2003 IDRS IDU participants, the 'form' of methamphetamine most commonly used was the high purity crystalline methamphetamine ('crystal meth' or 'ice'), used by 68% of the 2003 cohort in the six months prior to interview. In the current study, this form was used by just over half the participants (52%), and was rarely reported as the form of methamphetamine tat participants had predominantly used in the preceding six months. Instead, use of the waxy, sticky, gel-like 'base/paste' presentation of the drug had substantially increased from 51% of the IDU participants in 2003 to 72% in 2004, and was the form of methamphetamine most commonly used recently by almost half of those sampled. This is a return to the patterns of use of methamphetamine seen in the 2002 IDRS IDU cohort, prior to the rapid increase in availability of crystal methamphetamine in 2003. As would be expected, reported patterns of availability of each of these different 'forms' of methamphetamine were consistent with the patterns of recent use: IDU consumers regarded powder and base as very easy to access and stable in the preceding six months, with ice predominantly regarded as being 'easy' to access and remaining stable or declining in recent months.
The price for all three forms of methamphetamine (powder, base/paste and crystal) remained stable in 2004, with the most commonly price paid $50 for a point or packet. However, gram prices were more variable. While prices for grams of base/paste remained stable at $300 per gram, prices for crystal methamphetamine increased from $350 to $400 between the 2003 and 2004 surveys.
The signs of decreased availability of crystal methamphetamine locally may be attributed to the impact of arrests made by Tasmania Police of high level suppliers of this form of the drug, disrupting the supply chain for ice into the state. However, as per previous years, there continue to be anecdotal reports of increased local production of methamphetamine powder, and possibly base.
There continue to be IDU and key expert reports of an increasing number of users, and an increase in younger (late teen) users and female consumers of methamphetamine locally. Also, consumers reported the rise of a different 'type' of methamphetamine consumers, described as the 'crystal meth set', groups more likely to be regularly employed and have more disposable income. IDU also reported the continuation of a trend noted since 2001, with increasing numbers of IDU shifting from being predominant users of opioids to becoming predominant users of methamphetamine. While the level of use and availability of crystalline methamphetamine had declined in the window of time tapped by the 2004 IDRS study in comparison to the 2003 sample, there are anecdotal reports of increasing availability of this form in the late months of 2004. As this form had proved particularly attractive both to regular IDU and other demographic groups, careful monitoring of both the methamphetamine market and the impacts on the physical and mental health of users is warranted in the coming years.
Cocaine
It appears that the availability and use of cocaine in Hobart continues to be very low, at least within the populations surveyed in the current study or accessing government services. This low availability of the drug locally is supported by similar low levels of use reported in a recent sample of 100 regular ecstasy users in Hobart (Matthews & Bruno, 2005). Only a very small proportion of the IDRS IDU sample reported recent use of the drug (4%), which was exclusively in powder form. By the few IDUs who could comment on trends in availability, cocaine was considered difficult to access, a situation that was reported as being stable in the preceding six-month period. The cocaine that is used by Tasmanian IDU appears generally to be directly imported by consumers from dealers in mainland states or require an extended wait to access. Tasmania Police made no seizures of cocaine in 2002/03 or 2003/04, following single seizures in the preceding two financial years. These patterns of low levels of availability and use seem to have remained reasonably stable over the past few years, with possible indications of further declining availability in recent months. However, it is noteworthy that around half of the Tasmanian IDU sample over the past three years have reported lifetime use of cocaine, an increase from patterns seen in the 2000 and 2001 surveys, and there are indications of some use among different populations of drug consumers locally (Bruno & McLean, 2004; Matthews & Bruno, 2005).
Cannabis
Most aspects of the cannabis market and patterns of use appear to be relatively stable. Among the IDU surveyed, cannabis use continued to be almost ubiquitous, with 84% using the drug in the preceding six months, and the majority of these individuals using the drug daily.
The price of bush and hydroponic cannabis has remained stable at $25 per gram. Bush cannabis was purchased at modal prices of $200 an ounce (28g), compared to hydroponic/indoor cultivated cannabis at $250 an ounce. Both key experts and IDU consumers reported that these prices had remained reasonably stable in the preceding six months, however modal purchase prices of outdoor cannabis had increased, and prices of indoor cannabis decreased in comparison to the 2003 survey ($150 for outdoor and $300 for indoor respectively).
Hydroponically-cultivated cannabis head remains the form most commonly smoked by IDU, although substantial proportions also reported using both hydroponically-grown and outdoor cannabis in the preceding six months. Both indoor- and outdoor- cultivated cannabis was reported as 'easy' to 'very easy' to obtain by consumers and key experts, with this availability regarded as remaining stable in recent months. However, there are indications that the availability of cannabis has possibly reduced in comparison to the situation identified in the 2003 survey, following large seizures by Tasmania police in late 2003 and early 2004. Intelligence reports from Tasmania police in recent years have indicated an increasing trend toward hydroponic or indoor cultivation of the drug, and smaller sizes of those crops grown outdoors.
Cannabis remains the most widely used illicit drug both in the IDU sample and the State, however there is an indication of decreasing prevalence of use of cannabis in recent years in the State from two large studies (the National Drug Strategy Household Survey and the Australian School Students' Alcohol and Drugs Survey), along with a slowly decreasing prevalence in the local IDRS IDU samples (90% in 2000, 84% in 2004).
Morphine
Morphine was reported to cost $70 per 100 mg, and the price was described as stable. Morphine was considered 'easy' to 'very easy' to obtain and the availability in the six months preceding interview as stable to becoming more difficult to obtain. Nearly two thirds (62%) of the sample had used morphine in the past six months, with all but two injecting the drug in this time. MS Contin remains the predominant preparation used by this group, used by 48% of the sample as a whole and the form used predominantly by two thirds of those reporting recent morphine use, with Kapanol, Ordine, and Anamorph used to a lesser extent. The median frequency of use of morphine amongst local IDU cohorts, and in recent years, the proportion of cohorts reporting recent use, has steadily declined over time. There are continuing reports both from consumers and key experts that morphine is losing users to methamphetamine and other types of pharmaceutical opiates.
Illicit use of methadone
Diverted methadone syrup was reported to cost $1 per mg of the drug, a price that was considered stable by participants. This was reported as 'easy' to access, and this regarded as remaining stable in recent months. However, both IDU consumers and key experts note that the drug is really only available where there is a standing arrangement with a person on the program, and is almost uniformly reported as being accessed from friends (86%). Moreover, much of the use of diverted methadone syrup comes from individuals themselves receiving methadone maintenance, with key experts noting clients purchasing small amounts of the drug to avoid physical withdrawal if they had precipitously used their takeaway doses, or traded it due to, or to avoid, 'standover' threats and aggression from others.
Diverted Physeptone tablets of methadone were reported as costing $10 per 10mg tablet, a price that was considered stable by IDU. These were predominantly regarded as 'difficult' to access, with this level of availability regarded as remaining stable to decreasing in recent months. Consistent with this, both the proportion of the IDRS IDU sample and the frequency of this use had declined for the first time in the 2004 survey following steady increases since 2000: from 32% of the IDU sample reporting use in 2000, rising to 64% in 2003, and 52% in the current study.
Illicit use of buprenorphine
Buprenorphine, recently adopted as a maintenance treatment option for opioid addiction in the state, appears to have made little impact on the illicit opioid market, with only four individuals participating in the 2004 survey reporting illicit use of the drug in the preceding six months (all but one injecting the drug in this time). However, given that substantial levels of diversion have occurred in jurisdictions where buprenorphine maintenance treatment is more common, careful monitoring of this issue is clearly warranted as Tasmania's buprenorphine program expands, particularly given the existing culture of use of pharmaceutical products among local IDU.
Other opioids
The level of use of oxycodone use amongst the IDU sample has risen steadily in the two years that such use has been examined, rising from 21% in 2003 to 32% of the cohort using such drugs in the six months prior to interview in 2004, following anecdotal reports of use in 2002.
Continuing the trend seen in the past two years of the IDRS, both use of preparations of alkaloid poppies and the number of poppy crop thefts remained low in 2004. Rates of both were around one-third that of the rates seen in the 2000 study: in 2004, only 13% of the IDU surveyed reported using some preparation of alkaloid poppies, with 24,128 poppy capsules stolen, in comparison to the 34% reporting use and 62,500 capsules stolen in 2000.
Benzodiazepines
There are clear indications that, following a reduction of the injection of benzodiazepines among IDU between 2002 and 2003, arising from the restriction and eventual removal of the preferred temazepam gel capsules from the market, injection of these drugs has largely stabilised among local IDU consumers, at a level relatively high in comparison to that in other Australian jurisdictions. As noted in the 2003 study, it is also clear that alprazolam (Xanax in particular) appears to have largely replaced the local illicit market for temazepam gel capsules among those IDU particularly interested in benzodiazepine injection, with this drug being used in similar ways to temazepam capsules by consumers, such as in simultaneous combination with methadone syrup or other opioids. Between the 2003 and 2004 studies, both the proportion of the IDU samples reporting recent injection of alprazolam, and the frequency of such use in the preceding six months, had increased (11%, median frequency of 20 days in the preceding six months among the 2003 IDU cohort, to 17% and a median frequency of 24 days in 2004), and there are anecdotal reports both of increased demand for, and increased availability of, alprazolam locally. This is a particular concern given the serious psychological and physical harms associated with benzodiazepine injection. Additionally, the level of use and availability of benzodiazepines generally remains high within local IDU (used by 85% of the 2004 IDU sample), particularly among primary users of opiates, which is again of concern given the increased risk of overdose when the two substances are combined. As such, patterns of benzodiazepine use and injection in the state continue to warrant very close attention.
Associated harms
Self-reported rates of sharing of needles or syringes among clients of non-pharmacy Needle Availability Program outlets have steadily declined over time from 2.6% of all transactions in 1995/96 to 0.5% in 200/04. However, all IDRS studies in Hobart have suggested that 5-10% of these cohorts share used needles or syringes at least once in a month. Similar to the improving trends for sharing of needles and syringes, self-reported rates of sharing of other injection equipment (such as water, tourniquets and mixing containers) has steadily decreased among clients of non-pharmacy Needle Availability Program outlets (5.5% in 1996/97 to 0.5% in 2003/04). However, the more stringent definitions applied in the IDRS research suggests that there is still the potential for blood borne virus transmission in the injection practices adopted by approximately half of the IDU cohort, with many sharing mixing containers (30%), water (22%) or tourniquets (21%) in the preceding month (albeit, in most cases, in situations where both people were using sterile injection equipment). Moreover, there are possible indications that some IDRS IDU participants may be relaxing their vigilance around blood awareness in regard to sharing of injecting equipment other than syringes, with rates of sharing of these items somewhat higher than comparative rates in previous local studies.
In more targeted examination of injection practices in the current IDRS study, two notable points for health education interventions were identified. Firstly, in the current cohort, despite being regular injecting drug users, only two thirds of the 2004 local IDRS cohort always self injected in recent months, with those that did not always self inject being significantly younger, more likely to be female and less likely to have completed any further education outside of school. Secondly, two-thirds of the IDU participants had injected others in the month prior to interview, most commonly on occasions where they were also injecting themselves, although in only half of these cases did participants report washing their hands between injections - clearly a behaviour that increases the exposure risk to blood borne viruses.
Blood borne viruses, such as HIV/AIDS and hepatitis B and C are a major health risk for individuals who inject drugs. Surveillance data on the number of hepatitis C cases reported to the Public Health department indicate that, reported incident cases of hepatitis C infection in the state appear to have been steadily declining since 2000, falling to less than 10 cases per annum in the past two calendar years. Reported unspecified (not new infections) cases of hepatitis C, however, appear to have remained relatively stable between 1995 and 2004 at around 300 cases per annum.
A substantial proportion of IDU surveyed experience injection-related health problems, at a relative rate greater than those seen amongst IDU in other jurisdictions, possibly due to the increased harms associated with the injection of pharmaceuticals, which is less common in other jurisdictions. Scarring, difficulties finding veins to inject into (indicative of vascular damage) and experience of 'dirty hits' (feeling physically unwell soon after injection, often associated with the injection of contaminants or impurities, and particularly with the injection of methadone syrup) were the commonest injection related problems experienced by the current IDRS IDU cohort
In 2004, there was a comparable rate of recent experience of non-fatal opioid overdose in the Tasmanian IDU sample in comparison with the National IDRS IDU cohort, despite the predominant local use of pharmaceutical opioids where the dosage is known (which may protect against accidental administration of too large a dose). The increase in rate of experience of non-fatal opioid overdose in the local sample from 2003 may reflect the common use of multiple CNS depressants simultaneously amongst these local participants. In contrast, however, the number of opioid overdose deaths among those aged 14-54 years noted by the State Coroners office appears to have declined in 2003 against a backdrop of a steadily increasing population rate of overdose in Tasmania in recent years.
More than two-fifths (44%) of the IDRS IDU participants reported presenting to a health professional for a mental health issue in the preceding six months. This rate of presentations is substantially greater than that seen in the general population. In comparison to reports in earlier local IDRS IDU surveys, there has been a sharp increase in the number of IDU participants reporting presenting to a practitioner for depression (and using antidepressants) since trends in earlier years, and a steadily increasing rate of individuals presenting for anxiety-related issues (consistent with an increasing use of methamphetamine in these cohorts over time).
Implications
The findings of the Tasmanian 2004 IDRS suggest the following areas for further investigation and possible consideration in policy:
- As Tasmanian illicit drug use culture has been consistently shown to substantially differ from other jurisdictions (with regard to, for example, patterns of use of pharmaceutical products rather than substances such as heroin, due the low local availability of this drug), drug education programs and harm minimisation information campaigns need to be tailored to the particular needs and types of substances used within the state.
- Extension of a regular drug trend monitoring framework into other regions within the state (such as Launceston and the North-West coast) as there has been little specific research examining patterns of drug use within these areas, and due to their access to air and sea ports, and establishment of organised motor cycle group headquarters, availability and use of illicit substances may differ substantially in these regions from patterns seen in Hobart. As such, it may not be appropriate to infer similarity between drug trends and emergent issues identified in Hobart-based studies to these regions.
- Continued emphasis on, and support for, targeted strategies to further reduce the rates of sharing of needles/syringes and other injection equipment (such as tourniquets, filters and mixing containers) among IDU, as well as to minimise the harms associated with poor injecting practice through improving awareness and adoption of safe injection techniques and vein care among IDU. It was identified in the current study that there are a substantial proportion of regular injecting drug users that do not always self-inject, and similarly, large proportions of consumers that inject others but do not always maintain a vigilant cleanliness routine when doing so, and both these groups would be appropriate targets for a focused health education campaign from front line NAP workers, or indeed peer groups, in order to maintain downward pressure on exposure to blood borne viruses among IDU.
- Investigation into the factors associated with the experience of 'dirty hits' among local IDU and development of strategies to reduce this occurrence.
- Continuing monitoring of the expanding methamphetamine market and patterns of methamphetamine use.
- As use and availability of the higher potency forms of methamphetamine appear to be substantially increasing, clear and practical harm-reduction information for use of these forms of the drug should be accessed and distributed to consumers and health intervention workers. It is important to note also that there are indications that these drugs are increasingly being used by populations other than regular injecting drug users, such as primary ecstasy-using groups, that may not be accessing traditional health/health information services (Matthews & Bruno, 2005). Additionally, since increased levels of use of such high-potency methamphetamine may increase the level of experience of the negative effects of excessive methamphetamine use, development and implementation of practical strategies and training for dealing with such affected individuals should be considered for front line health intervention workers and emergency services workers. Moreover, investigation of the requirement for specialist treatment programs and/or services for primary consumers of these drugs is warranted.
- With the firm establishment of a culture of injection of methadone syrup locally (although this remains predominantly within individuals enrolled in the state methadone maintenance program injecting their own methadone), continued consideration of pragmatic harm reduction approaches to such use is warranted: either at the level of the consumer, with use of butterflies and biological filters; and/or at the policy level, requiring use of sterile water for dilution of methadone doses or switching to Biodone syrup, as this preparation does not contain the agent sorbitol, which can cause irritation and harm to the venous system. Given the level of recent experience of 'dirty hits', primarily associated with methadone syrup injection, among the current IDU cohort, these issues merit renewed attention.
- Use of liquid preparations of morphine (Ordine) has continued to rise over the past four years of the IDRS. This is of some concern as the drug is typically sold 'preloaded' in syringe barrels, and it is often unclear to the user if the injection equipment or the solution is free from infection or contamination. Approaches to reducing the potential harms of this situation, such as increasing the awareness of the risk of this situation among users, or varying prescription practices to reduce the availability of larger containers of the drug, merit consideration as use expands.
- Use of diverted oxycodone among IDU populations has quickly increased across the past three local IDRS studies. Given the rapidly increasing prescription rates for these drugs, and the experience in other countries where diverted oxycodone has been used problematically by demographic groups outside of the regular IDU demographic, continued monitoring of the illicit use of these drugs is particularly important, both locally and nationally.
- Given that injection of buprenorphine carries with it a substantial degree of risk for the development of abscesses, careful monitoring of the diversion of the drug is warranted as Tasmania's buprenorphine program expands. If, as has been seen in other jurisdictions with larger buprenorphine maintenance programs, injection of the drug becomes an issue locally, IDU should be made aware of harm-reducing injection techniques for the drug through front-line harm reduction workers.
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Research into factors that would reduce the harms associated with the intravenous administration of the pharmaceutical preparations of morphine, methadone and benzodiazepines commonly used within the local IDU population, and dissemination
of this information to users through continued training of Needle Availability
Program staff and peer groups. - Continued monitoring of the intravenous use of benzodiazepines, particularly in terms of the combined injection of alprazolam and methadone syrup, as this is a practice that substantially increases the risk of overdose.
- Characterisation and potency testing of cannabis cultivars to investigate continuing reports of high or increasing potency of cannabis.
- While self-reported rates of experience of mental health issues are likely to underrepresent the true extent of these issues, more than two-fifths of the IDU sample reported recently attending a health professional for mental health concerns, a level substantially greater than seen in the general population. As such, the increasing systemic focus in the state toward development and implementation of interventions for such co-morbid populations is clearly warranted and continued enhancement of partnerships between the mental health and alcohol and other drug sectors is crucial to meet the needs of this group.
- Research examining the extent of use, and demographic profiles of (mis)users of drugs such as anabolic steroids, inhalants, and pharmaceutical stimulants in the state, as these populations are not well accessed within the methodology of the IDRS.
Citation: Bruno, R. (2005) Tasmania Drug Trends 2004: Findings from the Illicit Drug Reporting System (IDRS), Sydney: National Drug and Alcohol Research Centre.