Demographic characteristics of REU
The sample of 100 REU interviewed in 2012 were typically in their early twenties (range 18- 57 years) and just over one-half were male (55%). Participants were generally well educated and either employed (on a full- or part-time/casual basis) or currently engaged in study. A majority of participants (85%) had completed Year 12, and 43% had completed tertiary qualifications (university or trade/technical). One-half (50%) were employed (either full-time or part-time/casual) and two-fifths (39%) were currently students. Few participants had come into contact with drug treatment agencies (5%). These demographic characteristics are generally similar to previous cohorts. However, there were significantly more full-time students (35% vs. 11%) and significantly fewer who had already completed a university degree (19% vs. 42%), when compared to 2011.
Patterns of polydrug use over time
Polydrug use was the norm among the REU interviewed, with most having used a range of drug classes in the preceding six months. Recent use of alcohol, tobacco, cannabis, and methamphetamine powder was most common and at least one-quarter had used benzodiazepines, LSD, nitrous oxide, cocaine, mushrooms or amyl nitrite. Compared to 2011, a significantly smaller proportion reported recent use of MDA (4% vs. 21%), mephedrone (10% vs. 35%) and opioids other than heroin, methadone or buprenorphine (4% vs. 16%) in 2012.
On average participants had been using ecstasy for 5 years and had first used ecstasy at around 17 years of age (range 13-29 years) compared to an age of 19-20 years among previous samples.
Ecstasy had typically been used in tablet (92%) or capsule (75%) form in the last six months, with use of ecstasy powder less common (30%). The proportion reporting recent use of ecstasy capsules increased significantly in 2010 and has remained stable since this time.
Ecstasy was typically swallowed, but snorting of ecstasy was also common. In 2010 there was a significant increase in the snorting of ecstasy tablets (89% vs. 71%) and capsules (82% vs. 38%) relative to 2009 and this has been maintained in 2011 and 2012. There was a wide variation in the frequency of ecstasy use among the sample, ranging from monthly to several times a week. On average, ecstasy had been used fortnightly with a median of two tablets taken in a typical session. Younger participants reported a higher median frequency of use (18 days) relative to older participants (10 days).
Ecstasy was typically last used at music-related venues including nightclubs and pubs; or in private residences.
There were some concerning patterns of use among the sample from a health perspective. One-quarter had recently used ecstasy weekly or more frequently (23%) and/or had used ecstasy in a ‘binge session’ (a continuous 48 hour period of drug use without sleep) (27%), and almost one-fifth (17%) reported using more than two tablets in a typical session of use. Whereas the long-term effects and risks of extended ecstasy use are not completely understood, evidence from toxicology studies in rats and neuropsychological studies in humans indicate that the safest pattern of use is to use the drug infrequently and in small amounts. Thus, those using the drug frequently or in large amounts for extended periods of time may be at a greater risk of neurological and neuropsychological harm.
Ecstasy was typically consumed in combination with other drugs – in a typical session, alcohol, cannabis, and tobacco were commonly used. A large majority (85%) reported consuming more than five standard drinks when they were under the influence of ecstasy. High levels of concomitant binge alcohol and ecstasy use is an issue of concern. There is an increased risk of dehydration when alcohol is combined with ecstasy, and larger quantities of alcohol can be consumed when under the influence of psycho-stimulants without experiencing immediate effects of intoxication; however, the harms associated with this use still occur. Moreover, there is emerging evidence from animal studies that alcohol may dramatically alter the pharmacology of 3,4-methylenedioxymethamphetamine (MDMA) in the brain (Hamida et al., 2008), which may exacerbate the potential for neurological harm from the drug.
Data from the NDSHS showed a steady increase in the national prevalence of ecstasy use in Australia between 1995 (0.9%) and 2007 (3.5%), with a significant decrease noted in 2010 (3.0%). The estimated prevalence of recent ecstasy use in Tasmania increased from 1.6% in 2004 to 2.4% in 2007, with a non-significant decrease found in 2010 (1.7%).
Price, purity and availability of ecstasy
The median last purchase price for ecstasy was $30 for one tablet (range $18-40) or one capsule (range $5-40). No recent price changes were noted and three-quarters (74%) of the sample indicated that price had recently remained stable.
Ecstasy was reported to be medium (47%) or low (20%) in purity, a return to baseline following the low purity estimates observed in 2010 and 2011 when two-fifths (41-47%) of the sample reported that ecstasy was low in in purity.
The proportion reporting that ecstasy was ‘easy’ or ‘very easy’ to obtain was significantly higher in 2012 (86%) relative to the decreased availability reported in 2010 (63%) and 2011 (70%). Recent availability was reported to have remained stable (73%) or to have become ‘easier’ (14%) in the past six months.
In summary, while there was evidence for a reduction in the perceived purity and availability of ecstasy in Hobart in recent years, the perceived purity and availability of ecstasy seems to be returning to baseline levels in 2012.
Ecstasy markets and patterns of purchasing
Consistent with previous years, ecstasy was typically last purchased from friends and last obtained from a friend’s home, the respondent’s own home, a private party or a public bar. Over one-half (57%) indicated they typically purchased ecstasy both for themselves and others, with a median of three tablets (range 1-160 tablets) purchased per occasion. Although the ecstasy market is predominantly based on individuals sourcing the drug for other friends while making no cash profit, those that purchase ecstasy in larger quantities may be putting themselves at risk of being arrested as a provider rather than a consumer of the drug. Under Tasmanian legislation, the offences of possession, supply, and trafficking of a controlled substance are based on various factors including ‘intent’ and are not necessarily determined by the quantity of the seized substance. However, the offence of trafficking, which carries the largest penalty, may be determined by possession of a trafficable amount of a controlled substance. For ecstasy (MDMA), this trafficable amount is 10 grams.
Two-thirds (64%) of the 2012 REU sample had used some form of methamphetamine in the preceding six months, which is similar to the proportion in 2011 (52%, 95%CI 41-63%) but significantly higher relative to 2010 (48%, 95%CI 38-58%). This upward trend in recent use is in contrast to the downward trend observed among both REU and the general population (NDSHS, 2007) in recent years.
Methamphetamine was used on a median of three days during this period (once every two months on average) in relatively small amounts (1-2 points).
Recent use of methamphetamine powder was most common (61%), with low levels of use of methamphetamine base (16%) and crystal methamphetamine (10%).The proportion reporting recent use of methamphetamine powder (61%) in 2012 was greater than the proportion between 2009 and 2011 (40-47%) but similar to the years prior to this (62-77%). Methamphetamine powder was typically swallowed or snorted; base was typically swallowed, smoked or injected, whereas crystal was typically smoked.
The median last purchase price for one ‘point’ (0.1 g) of methamphetamine powder was $50 (range $20-$100) which is higher than previous years ($35-40). The median last purchase price for one gram of methamphetamine powder ($300) was also higher than the prices reported between 2009 and 2011 ($250-255).
Methamphetamine powder was reported to be ‘low’ or ‘medium’ in purity, with a greater proportion indicating that it was low in purity in 2012 (40%) in comparison to previous years (3-23%).
Methamphetamine powder was considered ‘easy’ or ‘difficult’ to obtain among those who commented, with a significant reduction observed in the proportion perceiving that it was ‘easy’ or ‘very easy’ to obtain in 2012 (53%) when compared to previous years (71-90%). In summary, there were indications of increased use, increased price, and decreased purity and availability of methamphetamine powder in 2012. Small sample sizes in relation to crystal and base and low levels of recent use among the current cohort both indicate low availability of these forms in 2012.
One-quarter (26%, 95%CI 18-35%) of the 2012 sample had used cocaine during the six months preceding the interview which was not significantly different to the proportion in 2011 (39%, 95%CI 28-50%) but significantly fewer relative to 2010 where almost one-half of the sample reported recent use (49%, 95%CI 39-59%). This downward trend in recent use is in contrast to the upward trend observed in Tasmanian in recent years.
Cocaine was most typically snorted and was used on a median frequency of two days (range 1-20 days) in the last six months compared to a median of 1 day among the 2011 sample. An average of 0.5 grams was used in a typical session. Cocaine was typically last used at a nightclub, a public bar, or a private residence.
The median last purchase price for one gram of cocaine was stable at $300 (range $200- 400) and no recent price trends were noted.
Cocaine was primarily reported to be ‘low’ (46%) or ‘medium’ (46%) in purity and this purity was reported to have remained ‘stable’ (46%) or to have ‘decreased’ (36%) in the last six months. The proportion reporting that cocaine was ‘low’ in purity was greater in 2012 compared to 2011 (46% vs. 26%).
The majority of those who commented on the availability of cocaine indicated that it was currently ‘difficult’ (57%) or ‘very difficult’ (43%) to obtain, and availability was reported to have remained stable in the last six months.
Cocaine had most commonly last been ‘used but not purchased’ or had been purchased from friends.
LSD and other psychedelics
Over three-fifths (67%) of the 2012 sample had used LSD at some stage of their lives. Almost one-third (30%, 95%CI 22-40%) had used LSD in the six months preceding the interview which is similar to the proportion in 2011 (43%, 95%CI 32-54) and 2010 (27%, 95%CI 19-36).
LSD had been used on a median of 3 days (range 1-30 days) in the preceding six months. Two tabs or drops of liquid LSD (range 0.5-4) was taken orally in a typical session of use, which is higher than the median of one tab/drop observed in previous years.
LSD was last used at a dance party or at private residences such as the consumer’s own home or a friend’s home, or a private party.
The median last price for one tab/drop of LSD in 2012 was $20 (range $5-25) and no recent price trends were noted.
The purity of LSD was considered by REU to be ‘high’ (56%) or ‘medium’ (35%) and to have remained stable during the last six months.
A large majority of those commenting indicated that LSD was ‘very easy’ (31%) or ‘easy’ (42%) to obtain and that availability had recently been stable (74%).
LSD was typically last obtained from friends and was most commonly last obtained from private residences or at a dance party.
One-quarter of the sample (26%) had used psychedelic mushrooms on a median of 2.5 days (range 1-24 days) in the last six months.
Over three-fifths of the REU sampled (69%) had used cannabis during the six months preceding the interview.
While the National Drug Strategy Household Survey demonstrated a decrease in cannabis use in the general population nationally between 2004 (11.3%) and 2007 (9.1%), there was a significant increase in use between 2007 and 2010 (10.3%). In contrast, recent cannabis use in Tasmania continued to decrease between 2007 (10.8%) and 2010 (8.6%).
Among the REU sampled, cannabis had typically been smoked, with around half recently ingesting the drug. The median frequency of cannabis use was 120 days (range 1-180) or approximately five days per week, compared to a significantly lower median frequency in previous years (11-25 days). Daily cannabis smoking was reported among one-third (32%) of the entire sample which is also significantly greater than previous years (5-17%).
The median quantities used on the last day of use during this time were 8 cones (range 1- 30) or 1 joint (range 0.2-6).
The median last purchase price for one ounce of hydroponically-grown (‘hydro’) cannabis was $300 (range $150-350) compared to a median of $250 (range $70-320) for ‘bush’ grown cannabis. The median last purchase weight for one $25 bag of ‘hydro’ was 1.5 grams (range 1.2-2.5 g), compared to a median of 2 grams (1.5-2.3 g) for ‘bush’.
The potency of ‘hydro’ was reported to be high (55%) and the potency of ‘bush’ was reported to be medium (56%) with no recent changes noted.
Both ‘bush’ and ‘hydro’ were reported to be ‘easy’ or ‘very easy’ to obtain, and this level of availability was generally perceived to have remained stable during the six months preceding the interview.
A large majority (98%) of the 2012 REU sample had recently consumed alcohol, on an average of three to four days a week in the last six months. A majority (96%) had used alcohol at least weekly (but not daily), which is significantly greater than the 2011 sample (87%), and substantially higher than the estimate of prevalence in the general population (44%, among those aged 20-29 nationally – a comparable age group to the current REU cohort).
Tobacco had recently been used by four-fifths (80%) of the sample. Almost one-half (49%) reported daily use in the last six months, which is a significant increase relative to the last 5 years (31-36%) and higher than the 2010 population estimate for this age group (20-29) both in Tasmania (25.5%) and nationally (18%).
Mephedrone and other emerging psychoactive substances
The proportion of REU reporting recent use of mephedrone in 2012 (10%) was significantly fewer relative to both 2011 (27%, 95%CI 18-38%) and 2010 when almost one-half of the sample reported recent use (47%, 95%CI 38-57%). Mephedrone was snorted or swallowed on a median of 2.5 days (range 1-12 days) in the last six months. Of those who commented on the last source of mephedrone (n=10), a majority had last obtained mephedrone from a friend (80%), dealer (10%), or acquaintance (10%) with none reporting that they had obtained the drug from the internet.
Recent use of other emerging psychoactive substances (EPS) was relatively low. The most commonly used substances in the last six months were DMT (6%), DXM (4%) and synthetic cannabinoids (4%). In addition, over one-tenth of the sample reported recent use of capsules of ‘unknown contents’ (16%) or use of ‘herbal highs’ (8%).
Patterns of other drug use
Consistent with previous years, less than one-tenth reported recent use of ketamine (4%), or GHB/GBL/1,4B (2%) and just 4% reported recent use of MDA which is a significant reduction relative to the increase in recent use (21%) observed among the 2011 sample. One-quarter (24%) reported recent use of amyl nitrite and frequency of use was relatively low at two days in the last six months or approximately once every three months. One-quarter (27%) reported low frequency (less than monthly) use of nitrous oxide. Almost one-third (31%) of REU had used benzodiazepines during the last six months, with one-quarter (25%) reporting illicit (non-prescribed) use and one-tenth (10%) reporting licit use. The proportion of REU reporting illicit benzodiazepine use is much higher than recent estimates of past-yearly use in the general population aged 20-29 years (2.6%). However, use of illicit benzodiazepines was relatively low in frequency, at 5 days (range 1-90 days) in the last six months. A small proportion of the sample (4%) had recently used antidepressants; 4% reported recent licit use and 1% reported recent illicit use.
The use of other pharmaceuticals and opioid drugs was relatively rare among the regular ecstasy users interviewed in the current study, and those that had recently used these drugs had generally done so infrequently. One-fifth (20%) of REU reported recent illicit use of pharmaceutical stimulants (such as dexamphetamine or methylphenidate) in 2012. The median frequency of use was 3 days (range 1-20 days) in the last six months, with a median of 2 tablets (range 1-7.5) taken in a typical session of use. Only small proportions of the 2012 sample had recently used heroin (1%), methadone (4%), buprenorphine (2%) or ‘other opioids’ (restricted pharmaceuticals and alkaloid poppy derivatives). Less than onetenth reported recreational use of stimulant based (5%) over-the-counter preparations and 16% reported recent non-pain use of over-the-counter codeine preparations.
Overdose. Less than one-tenth (4%) of the 2012 REU sample had overdosed on a drug in the preceding six months. This is consistent with the relatively low proportion of participants reporting an overdose episode in the years prior to 2011. In 2012, 4% reported a recent overdose episode on a stimulant drug (e.g., cocaine, ecstasy and other stimulants) and 2% reported a recent overdose on a depressant drug (primarily alcohol). While these symptoms of overdose were not medically trivial, most participants had not received any formal medical treatment in relation to an overdose episode.
Access to health services. Despite regular substance use, just over one-tenth (11%) of REU had accessed health services in relation to drug use in the last six months, and, when they did so, this was most commonly a GP (55%) or a drug and alcohol worker (18%). Participants were most likely to access services in relation to the use of alcohol (50%), cannabis (30%), or ecstasy use (10%). The main issues involved in these treatment episodes were mental health problems (27%), acute physical problems (18%), and cutting down use (18%).
Mental health problems
One-third (34%) of the 2012 REU sample reported experience of mental health problems during the six months prior to the interview, most commonly anxiety (71%) and/or depression (50%). Just two-fifths (41%) of those who had experienced mental health problems had attended a health professional in relation to these problems during this time.
Mean scores on the Kessler psychological distress scale (K10) were higher among the current sample of REU relative to the general Australian population (National Health Survey; ABS, 2009). The proportion of the sample with scores categorised as ‘very high’ was similar to the general Australian population (5% vs. 3.5%); however, the proportion of REU with scores classified as ‘high’ was significantly greater than the general population (28% vs. 8.5%). Those classified in the ‘high’ range have increased rates of experience of mental health problems and may benefit from interventions with health professionals.
Almost two-fifths (39%) of the 2012 sample reported a recurrent drugrelated problem, suggestive of possible substance abuse. One-third of the sample (33%) indicated that their drug use had recurrently interfered with their responsibilities at home, at work, or at school, one-fifth (21%) had recurrently found themselves in a situation where they were under the influence of a drug and could have put themselves or others at risk, almost one-fifth (19%) reported repeated problems with family, friends, or people at work or school, and a very small proportion (3%) reported recurrent drug-related legal problems. Problems were most commonly attributed to cannabis and alcohol. Ecstasy dependence. Two-fifths (41%) of REU reported experiencing significant symptoms of dependence in relation to ecstasy, compared to a smaller proportion over the past three years (12-18%).
Drug treatment data
While a consistent number of calls have been made to the Tasmanian Alcohol and Drug Information Service over the last few years in relation to ecstasy (4-17 calls), these account for a small percentage (between 0.7% and 2.6%) of the calls made to this service. Data from the National Minimum Data Set (NMDS) for alcohol and other drug treatment services in Tasmania show that ecstasy was the principal drug of concern in only 0.6% of all treatment episodes in the 2010/11 period (equating to approximately 10 treatment episodes out of a total of 1,653).
Tasmania hospital admission data
There has been a substantial reduction in Tasmanian cannabis-related hospital admissions over the last three reporting periods with 22 cases reported in 2009/10. The Tasmanian admission rate observed in 2008/09 and 2009/10 is considerably lower than national rates (per million population).
In 2008/09 there was a substantial reduction in Tasmanian admissions in relation to methamphetamine, with a rate well below the national admission rate observed for this period (76 vs. 157 admissions per million population). This disparity was also observed in 2009/10 (45 vs. 136 admissions per million population), along with decreased rates of admissions both nationally and in Tasmania.
There has been very few hospital admissions recorded in Tasmania in relation to cocaine.
Injecting drug use Less than one-tenth (6%) of the 2012 REU sample had recently used substances intravenously, on a median frequency of 7.5 days (range 1-35) during the last six months (or just over monthly on average). Methamphetamine, ecstasy, other opioids, and pharmaceutical stimulants were the most common drugs injected in the last six months. Sharing of needles and equipment was relatively uncommon.
Blood-borne viral infections. Three-fifths (64%) of the 2012 REU sample had been vaccinated for hepatitis B and one-third had been tested for hepatitis C (35%), or for HIV (35%).
Sexual risk behaviour. Three-fifths (60%) of REU reported penetrative sex with a casual partner during the six months preceding the interview and almost three-fifths (58%) reported sex with a casual partner while under the influence of drugs, most commonly alcohol, ecstasy, or cannabis. When under the influence of drugs, only around one-quarter (26%) reported ‘always’ using protective barriers with a casual partner and one-tenth (12%) ‘never’ used protective barriers. One-half (50%) of those who reported sex with a casual partner indicated that they did not use any protective barriers on the last occasion in the previous six months.
One-quarter of the sample (28%) had never had a sexual health check-up. A majority (78%) of the sample had never been diagnosed with a STI and the remainder had been diagnosed in the last year (5%) or more than a year ago (16%). The most commonly diagnosed STI was Chlamydia (91%). Drug driving. Of those who had driven a car, almost one-half (47%) reported driving at a time when they perceived themselves to be over the legal alcohol limit during the last six months, and one-half (47%) reported driving within an hour of taking illicit drugs in the last six months. Most commonly, participants reported driving under the influence (DUI) of cannabis, ecstasy or methamphetamine powder.
The proportion of REU reporting DUI of ecstasy and methamphetamine has gradually declined since 2006 but a reversal of this trend was noted in 2012. DUI of cannabis has remained relatively stable over time but has increased over the past two years.
Alcohol Use Disorders Identification Test (AUDIT). One-third (33%) of REU who completed the AUDIT scored in zone 4 (those in this zone may be referred to evaluation and possible treatment for alcohol dependence) which is similar to the proportion in 2011 (36%) but significantly greater than the proportion categorised in zone 4 in the two years prior to this (18-21%). A further 26% scored in zone 3 (harmful or hazardous drinking), one third (33%) scored in zone 2 (alcohol use in excess of low-risk guidelines1), and just 8% scored in zone 1 (a level reflecting low-risk drinking or abstinence).
Binge drug use. One-third (31%) had recently ‘binged’ on ecstasy or related drugs (a continuous period of use for more than 48 hours without sleep), on a median of 2 occasions (range 1-24) in the last six months. Substances most commonly used in a binge session of use were alcohol (94%), ecstasy (87%), energy drinks (65%), cannabis (55%), methamphetamine (powder 48%; base 3%; crystal 13%), and LSD (32%).
Criminal activity, policing and market changes. Around one-quarter (26%) of the 2012 REU sample reported taking part in any criminal activity in the last month. The most common crimes were drug dealing (18%) and property crime (12%). Over one-tenth (14%) of REU had been arrested during the preceding 12 months. Arrests were generally for nondrug related offences.
Law enforcement data:
Arrests and seizures by Tasmania Police. There was a substantial increase in the number of both consumer and provider arrests and seizures in relation to ecstasy between 2006/07 and 2009/10 relative to any previous years. In 2010/11 and 2011/12 a substantial reduction in both the number of arrests and the number of seizures was noted relative to recent years.
The number of methamphetamine-related arrests substantially increased in the 2006/07 and 2007/08 periods. Following a reduction in arrests between 2008/09 and 2010/11, there was an increase in 2011/12 compared to 2010/11 (156 vs. 104). The number of methamphetamine-related seizures increased gradually between 1999/00 and 2006/07. Since this time the number of seizures has reduced or remained stable; however, an increase in the number of seizures was noted in both 2010/11 (153 seizures) and 2011/12 (256 seizures) relative to the two years prior to this (111-115 seizures).
Since 2006/07 the number of cannabis-related arrests has remained relatively stable while the number of seizures has increased gradually with a slight decline observed in 2011/12 with 2,576 seizures reported compared to 2,875 in 2010/11.
Illicit drug diversions/cautions. The total number of drug diversions or cautions and the number diverted to health interventions were substantially lower in 2010/11 compared to 2009/10. While this reduction was in part due to policy changes made in relation to offenders under the age of 18 in accordance with the Youth Justice Act 1997, there was a further reduction in total diversions/cautions in 2011/12 relative to 2010/11 (869 vs. 1,132).
Drug-related charges in Tasmanian courts. The number of individuals before the Hobart Magistrates Court in relation to drug offences in 2011/12 was stable or slightly lower in comparison to 2010/11. Data prior to 2010/11 is not directly comparable due to the introduction of a new data coding system (ASOC, 2008). The number of individuals incarcerated at Hobart Prison in relation to drug-related offences was stable in 2011/12 relative to 2010/11 (81 vs. 80).
Special topics of interest:
Heavy Smoking Index. One-fifth (18%) of daily smokers reported smoking their first cigarette within 5 minutes of waking and one-half (49%) between 5 to 30 minutes of waking. One-half (47%) of daily smokers reported smoking 10 or less cigarettes per day with the remainder smoking more than this. Almost one-fifth (18%) of daily smokers (32%) scored more than 5 on the Fagerstrom test for nicotine dependence, indicating high to very high nicotine dependence, compared to just 5% among the 2011 sample.
Neurological history. One-third (33%) of the 2012 EDRS sample reported lifetime experience of traumatic brain injury. Of those who had ever experienced TBI, one-third (36%) had been under the influence of alcohol and one-tenth (12%) had been under the influence of drugs (most commonly cannabis) at the time of the most serious TBI that they had experienced.
Drug policy. With regard to heroin policy, there was strong support among REU for Needle and Syringe Programs (93%) and methadone/buprenorphine maintenance programs (73%). With regard to the legalisation of drugs for personal use, there was strong support for the legalisation of cannabis (74%) and two-fifths (38%) supported the legalisation of ecstasy. Two-thirds (64%) supported policy to increase penalties in relation to heroin and between one-fifth and one-third supported increased penalties in relation to cannabis, methamphetamine, cocaine and ecstasy.
Body image. Less than one-tenth (8%) of the sample (11% of females and 6% of males) had ever used illicit psychostimulants (most commonly ecstasy or methamphetamine) to lose or maintain weight and 3% reported doing this during the six months preceding the interview. Although the use of illicit psychostimulants for the specific purpose of losing/maintaining weight was relatively low, almost two-fifths (38%) reported that they were concerned about gaining weight if their illicit psychostimulant use was ceased, and this concern was more prevalent among females (42%) relative to males (2%). In addition, over one-tenth (12%, 13% of females and 11% of males) indicated that they were concerned that they had lost too much weight due to IPS use.
It is important to note that the aim of the EDRS is to investigate the patterns of drug use, drug markets, and associated risks and harms among a sentinel group of participants that use ecstasy on a regular basis; as such, this population is not necessarily representative of all consumers of ecstasy and related drugs, and the prevalence of ecstasy and other drug use cannot be inferred from this study. However, the study is designed to identify emerging trends and important issues, and the findings of the 2012 EDRS suggest the following key areas for consideration in future policy.
- Funding of specific health programs to meet the needs of local consumers
There are currently no services that specifically cater to users of ecstasy and related drugs in Hobart, and aside from volunteer organisations at predominantly large-scale events, there is currently very little dissemination of harm-reduction information to these populations. This indicates a clear need for funding and a proactive response in terms of the implementation of harm-reduction strategies. Although approximately one-third of the REU interviewed among previous EDRS cohorts were actively seeking harm-reduction information in relation to the substances that they chose to use, these messages were not necessarily reaching other consumers.
Considering that drug information is typically sought from peers or peer-run organisations (e.g., harm-reduction-based websites such as www.pillreports.com or www.bluelight.co), responses to overdose incidents were typically handled by peers, and the fact that REU do not typically come into contact with traditional health services, it is likely that harm-reduction programs will attain maximum impact if delivered through peer-based organisations and mediums appropriate to the target group such as internet sites and outreach workers or information at events. By contrast, illicit-drug education campaigns based around 'fear arousal' have been shown to be ineffective or to even have contradictory effects (Ashton, 1999; Skiba, Monroe & Wodarski, 2004; West & O'Neal, 2004), and these programs, and associated sensationalised reporting of drug use in the media, run the real risk of undermining the potential for successfully reducing health harms amongst this population.
- Focused interventions to reduce the harm associated with high risk patterns of drug use, polydrug use, binge drinking (including binge drinking in combination with ecstasy) and tobacco use
Whereas the long-term effects and risks of extended ecstasy use are not completely understood, evidence from toxicology studies in rats and neuropsychological studies in humans indicate that the safest pattern of use is to use the drug infrequently and in small amounts. Thus, those using the drug frequently or in large amounts for extended periods of time may be at a greater risk for neurological and neuropsychological harm. Among the REU cohort in the present study, one-quarter had recently used ecstasy weekly or more frequently (23%) and/or had used ecstasy in a ‘binge session’ (a continuous 48 hour period of drug use without sleep) (27%), and almost one-fifth (17%) reported using more than two tablets in a typical session of use.
Given that ecstasy was typically consumed in combination with other drugs among the current REU cohort, polydrug use is also an issue of concern in this population. Concomitant use of different drugs may have potentially harmful interactions, thus dissemination of information regarding the negative effects of specific drug combinations may be beneficial. Of particular concern is the high level of coincidental ecstasy and binge alcohol use among the REU interviewed in the present study. A large majority (85%) of the REU sample typically consumed more than five standard drinks when under the influence of ecstasy. There is an increased risk of dehydration when alcohol is combined with ecstasy. Additionally, larger quantities of alcohol can be consumed when under the influence of psychostimulants without experiencing the immediate effects of intoxication; however, the harms associated with this use still occur. Moreover, there is emerging evidence from animal studies that alcohol may dramatically alter the pharmacology of MDMA in the brain, in particular increasing the concentration of the drug and its metabolite in particular regions (Hamida et al., 2008), which may exacerbate the potential for neurological harms or problems such as dependence, arising from use of the drug. Hazardous drinking practices are also an issue of general concern in this population. A large majority (96%) of the 2012 REU sample had used alcohol at least weekly during the six months preceding the interview, which is significantly greater than the 2011 sample (87%), and substantially higher than the estimate of prevalence in the general population (44%, among those aged 20-29 nationally – a comparable age group to the current REU cohort). A large majority of REU (92%) scored 8 or more on the Alcohol Use Disorders Identification Test (AUDIT), suggestive of hazardous and harmful alcohol use and the possibility of alcohol dependence, and there was a significant increase in the proportion categorised in zone 4 (those in this zone may be referred to evaluation and possible treatment for alcohol dependence) in 2011 (36%) and 2012 (33%) relative to 2010 (21%). Additionally, the majority of overdose episodes reported by REU in the current and previous EDRS cohorts involved alcohol and/or polydrug use.
Tobacco use is very common among the EDRS cohorts with over four-fifths (80%) of the 2012 sample reporting use in the last six months. Almost one-half (49%) reported daily use in the last six months which is a significant increase relative to the last 5 years (31-36%) and higher than the 2010 population estimate for this age group (20-29) both in Tasmania (25.5%) and nationally (18%). Additionally, the incidence of intermittent tobacco use is extremely high. There is a clear need for focused interventions targeting tobacco use among this population. In addition, traditional interventions (e.g., nicotine patches) may not meet the needs of the high proportion of intermittent consumers, and novel tailored interventions may be necessary to target this group.
- Continued monitoring and focused interventions to increase the awareness of the effects and risks of the use of mephedrone, cocaine, and other emerging substances
Trends have been noted among recent REU samples that indicate significant changes in the ecstasy and related drug markets in Hobart. There was evidence a reduction in the perceived purity and availability of ecstasy in Hobart in recent years coupled with a significant increase in the use of mephedrone capsules. There has also been increased use of ecstasy capsules (and in the snorting of ecstasy as a route of administration) since 2010 and the emergence of an illicit capsule market such that REU are consuming capsules without necessarily knowing what they contain. In addition, notable proportions have reported use of other psychoactive drugs in the tryptamine family (e.g., 2CI, 2CB, 2CE, 2CT- 7, DMT), or other substances such as methylone, DOI, DMT, and MDPV in recent years. ‘Emerging psychoactive substances’ such as mephedrone, methylone and 2CI/2CB/2CE are relatively new substances and little is known about the effects and risks of their use. In 2012 the perceived purity and availability of ecstasy seems to be returning to baseline levels and the proportion reporting recent use of mephedrone has decreased. However, given the changing illicit drug market both nationally and internationally and the continual development and release of new substances and online markets, it is imperative that the use of emerging psychoactive substances are continually monitored and that focused interventions are developed to increase the awareness of the effects and risks of their use among both consumers and health workers in this area.
- Interventions aimed at increasing awareness of safe sexual practices
One-half (50%) of those who reported sex with a casual partner indicated that they did not use any protective barriers on the last occasion in the previous six months. Several KE also commented on sexual risk-taking behaviour among the REU that they were familiar with. Use of protective barriers among this population is an issue of concern given the rapidly increasing notifications of sexually transmitted infections in the general population – for example, the rate of notified cases of Chlamydia infections have increased to 361.7 per million population in 2011 compared to an average of 273.1 over the previous five years (Australian Institute of Health and Welfare, 2012). Among those interviewed in the present study, one-quarter (28%) reported that they had never had a sexual health check-up.
- Increased awareness of and access to health, mental health and emergency services in this population
The level of harm experienced by the majority of participants was relatively low, with few reporting recent experience of mental health problems, or high levels of psychological distress, few people accessing health services in relation to drug use, and most not experiencing significant symptoms of dependence in relation to either ecstasy or methamphetamine.
However, there was a subset of this cohort that experienced notable symptoms of dependence, recent mental health problems and clinically significant levels of psychological distress. One-third (34%) of the 2012 REU sample reported recent experience of mental health problems (most commonly depression and/or anxiety), with just two-fifths of these individuals (41%) attending a health professional in relation to these problems, possibly indicating an unmet demand. This finding suggests under-recognition of mental health problems and a need to improve recognition and access to treatment for mental health problems in this population.
Similarly, despite regular substance use, just over one-tenth (12%) of the sample had recently accessed health services in relation to drug use. The services most commonly accessed by REU were a GP or a drug and alcohol worker. As such, there may be some benefit in increasing awareness among primary health care practitioners in regard to ecstasy and related drugs and associated problems.
While less than one-tenth (4%) of the 2012 REU sample had overdosed on a drug in the preceding six months, the majority of these had not received any formal medical treatment or were monitored/watched by friends. Thus peer education on how to help friends in an emergency, and the situations in which medical treatment may or may not be appropriate, may also be of benefit for this group.
- Increased awareness of legislation among local consumers with regard to possession, supply, and trafficking of controlled substances
Although the ecstasy market is predominantly based on individuals sourcing the drug for other friends while making no cash profit, those that purchase ecstasy in larger quantities may be putting themselves at greater risk of being arrested as a provider rather than a consumer of the drug. Over one-half (57%) indicated that when they purchased ecstasy they typically purchased the drug both for themselves and others, and a median of three tablets were purchased per occasion. This indicates a need for increased awareness among REU in Tasmania of the risks associated with supplying ecstasy to friends, so that they are able to make informed choices with regard to this.
In addition, consumers are not always aware of the legislation regarding emerging substances such as mephedrone. For example, mephedrone was originally marketed as a ‘legal high’ until recently legislated against in the UK and other European countries. While mephedrone is a border-controlled drug in Australia and is illegal in most Australian jurisdictions due to analogue laws or recent legislation changes, consumers may not be aware of the legal status of this and other emerging substances. Some companies have also marketed substances as being free of mephedrone in order to continue their promotion as ‘legal highs’; however, in some cases testing has revealed these drugs to contain proscribed substances, placing consumers at unwitting legal risk (Brandt et al., 2010).
- Evaluation of the impact of, and further targeting of, drug driving interventions among regular drug consumers
A substantial proportion of the consumers interviewed in the EDRS study in 2012 reported driving while affected by alcohol or drugs (almost one-half of those with access to a vehicle). The proportion of REU reporting DUI of ecstasy and methamphetamine has gradually declined since 2006 but a reversal of this trend was noted in 2012. DUI of cannabis has remained relatively stable over time but has increased over the past two years. Education and law enforcement interventions designed to reduce the prevalence of drug driving are constantly evolving, and monitoring of the impact of such strategies is recommended, particularly where such evaluation could be used to tailor interventions to this demographic.
- Basic science research in relation to emerging drugs (mephedrone, 2CI, 2CB, 2CE) in order to establish best-practice harm reduction information.
A notable proportion of REU report recent use of mephedrone (4-methylmethcathinone), ‘research chemicals’ in the tryptamine family (e.g., 2CI, 2CB, 2CE, 2C-T-7, DMT), or other ‘emerging psychoactive substances’ such as methylone, DOI, DMT and MDPV. There exists a paucity of information about the physiological or neuropharmacological effects of these drugs, and virtually no information about how these drugs may interact with other illicit substances, pharmaceuticals or existing medical issues. This poses substantial risk of harm to the health of consumers. Notably, the rates of use of these substances was greater than drugs such as GHB or ketamine, both of which have received substantially greater media and research attention, and for which harm reduction information is relatively widely available. While the use of such substances may fluctuate due to the changing legal status of these drugs, basic science research in regard to the actions of these drugs in the body and brain, particularly in relation to the most well-established of these drugs, would be a crucial first step for the development of evidence-based harm reduction information that could contribute to maintaining the health of consumers of these drugs.