NDARC Technical Report No. 178 (2004)
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 informant 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 2003.
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 informant (KI) 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 informants’ (KI) included needle availability program staff, drug treatment workers, health workers, youth and outreach workers, and staff from police and community corrections. Of these informants, 7 reported on groups that predominantly used opioids (diverted pharmaceuticals), 11 on cannabis and 13 on groups primarily using methamphetamine.
In order to complement and validate the key informant 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 State’s 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 (70%), and had an average age in the late twenties (29 years). On average, participants had completed 10 years of education, and two-thirds (69%) were currently unemployed. One-quarter of participants had a previous prison history, which was a reduction from the one-third seen in the previous two IDU samples. A high proportion of the current IDU participants were currently involved in some sort of drug treatment, with 58% currently enrolled in a methadone maintenance program.
The majority of participants (68%) were injecting a few times per week, but not every day, with 17% injecting at least once per day. As per previous IDRS IDU samples, two-thirds (64%), 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 (41%), it was rarely the drug most commonly used by IDU participants (just 3%), with 48% most commonly using methadone, 29% methamphetamine, and 19% most commonly injecting morphine in the six months prior to interview.
Patterns of drug use among IDU
The 2003 IDRS detected a number of trends during the preceding six to twelve months:
While the availability of heroin in the state appeared to have been slowly increasing during 1999 and 2000, data from the 2001 and 2002 IDRS studies suggested that the drug was becoming increasingly difficult to access locally. Indicators from the current study suggest that the decline has halted and availability of the drug has stabilised at a low level. Recent use of heroin was seen in just 26% of the IDRS IDU sample, despite the fact that 41% 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 2002/03.
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 reported in previous IDRS studies. 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.
Over the past three years of the IDRS in Hobart, higher-purity forms of methamphetamine have steadily 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 (89%), despite the participants predominantly preferring opioids (64%). 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 50% in 2003 (almost 15,000 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 half of the IDU participants in the current study. However, a major change was seen this year in the level of availability of the higher-potency forms of the drug. Among the 2002 IDRS IDU participants, the ‘form’ of methamphetamine most commonly used was the waxy, sticky, gel-like ‘base/paste’ presentation of the drug, used by 74% of the cohort. In 2003, this was used by less than half of the respondents (46%). Instead, it appears that the availability of the particularly high purity form, crystalline methamphetamine (‘crystal meth’ or ‘ice’) has substantially increased in 2003, and has become the form most commonly used among the IDU cohort in the current study. In the 2002 study, just 20% of the IDU cohort had recently used this form of the drug, however, in the 2003 study, 69% had recently used crystal methamphetamine.
IDU reported all forms of methamphetamine to be easily available in the preceding six months. Indeed, both IDU and key informants regarded the ready availability of relatively high potency methamphetamine (crystal methamphetamine in particular) as responsible for anecdotal descriptions of an increasing number of people using methamphetamine, particularly among younger individuals (mid teens to twenty years), in recent months. There were also continued anecdotal suggestions of methamphetamine attracting opiate users away from that market.
However, with the greater availability and use of higher purity methamphetamine came anecdotal suggestions of increases in the negative effects of methamphetamine use, such as paranoia and agitation, among IDU. Moreover, both key informants and IDU reported concerns around recent anecdotal reports of deaths due to heart failure associated with excessive crystalline methamphetamine use. While such information is yet to be verified, it is clear that, with these indications of expending levels of availability and use, careful monitoring of both the methamphetamine market and the impacts on the physical and mental health of users is warranted in the coming years.
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 in a recent sample of 100 regular ecstasy users in Hobart (Bruno & McLean, 2004a). Only a very small proportion of the IDRS IDU sample reported recent use of the drug (9%), which locally is almost exclusively a powder. By the few IDUs who could comment on trends in availability, cocaine was considered difficult to access, a situation that was considered stable in the preceding six-month period. The cocaine that is used by Tasmanian IDU appears generally to be imported in small quantities by users directly from dealers in mainland states. Tasmania Police made no seizures of cocaine in 2002/03, following just single seizures in the preceding two financial years. These patterns of low levels of availability seem to have remained reasonably stable over the past few years, however, it is noteworthy that increasing proportions of the Tasmanian IDU sample over the past three years have reported lifetime use (39%, 47% and 52% in the 2001, 2002, and 2003 surveys respectively) of cocaine.
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 88% using the drug in the preceding six months, and the majority of these individuals using the drug daily. IDU regarded purchase prices of cannabis as remaining stable in the preceding six months. Hydroponically-cultivated cannabis head remains the form most commonly smoked by IDU, although substantial proportions also reported using both hydroponically-grown (95%) and outdoor cannabis (89%) in the preceding six months. In concert with this, intelligence reports from Tasmania police in recent years have indicated an increasing trend toward hydroponic cultivation of the drug, with increasing proportions of cannabis seizures being indoor or hydroponic in origin, and reports from all three state Drug Investigation Services branches suggesting that outdoor plantations of cannabis seem to be on the decrease.
Overall, patterns of use and availability of pharmaceutical opioids such as morphine and methadone seem to have generally remained stable since the 2000 IDRS, with 72% of the current IDU sample using morphine and 85% methadone in the six months prior to interview. However, emerging trends noted in previous years within this class of drugs have continued into 2003. The median frequency of use of morphine in the preceding six months within the 2003 IDU sample continued to decline from previous studies, falling from 52 days in the 2000 study to just 21 days among the current cohort. Perhaps balancing this decline in frequency of use of morphine, the proportion of the IDRS IDU samples using Physeptone (methadone) tablets has steadily increased across the past four annual surveys (used by 30% of the IDU sample in 2000 and 64% in 2003). There does not appear to be any substantial increase in the diversion of methadone syrup, with illicit access to methadone was more commonly via Physeptone tablets than through diverted syrup.
MS Contin remains the most commonly used formulation of morphine, although reported use of Ordine, a liquid preparation of the drug, appears to have been increasing over the past four years. Virtually all of those using morphine or methadone tablets had accessed these substances from illicit sources in the six months prior to interview, indicating that access to these products is primarily not coming via doctor shopping from the users themselves.
While some key informants noted a decrease in both benzodiazepine use and injection amongst opiate-using groups, of concern were IDU reports of increasing use of methadone syrup and alprazolam simultaneously (in the same syringe) and a return of a similar mode of use of methadone syrup and temazepam gel capsules. This pattern of use is of considerable concern, not solely due to the deleterious effects of injection of benzodiazepines but also due to the increased risk of overdose on use of multiple central nervous system depressant drugs. Given anecdotal reports of two recent deaths associated with coincident methadone and alprazolam use, this pattern of use merits careful attention in the coming months, particularly from front-line health intervention workers.
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 2003. Rates of both were around one-third that of the rates seen in the 2000 study: in 2003, only 12% of the IDU surveyed reported using some preparation of alkaloid poppies, with 20,223 poppy capsules stolen, in comparison to the 34% reporting use and 62,500 capsules stolen in 2000.
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 three individuals participating in the 2003 survey reporting illicit use of the drug. However, given that substantial levels of diversion has 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.
There are clear indications that there has been a further reduction of the injection of benzodiazepines among IDU between 2001/02 and 2002/03. The proportion of the IDU sample reporting injection of benzodiazepines in the preceding six months fell from 38% in the 2002 study to 31% in the 2003 sample. While it appears that harm reduction efforts, by front-line workers, medical practitioners and policy changes may have had a considerable impact on patterns of benzodiazepine use, there remains a relatively high level of benzodiazepine injection within Hobart when compared to other jurisdictions, despite a reduction in the availability of temazepam gel capsules that are particularly favoured for injection. There are early indications that alprazolam may be replacing the market for temazepam gel capsules among those IDU particularly interested in benzodiazepine injection, with alprazolam injection increasing in recent months. Moreover, this form appears to be used in similar ways to temazepam capsules, such as in simultaneous combination with methadone syrup. 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 88% of the 2003 IDU sample, and 83% of the 2002 cohort), 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.
Self-reported rates to 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 0.63% in 2002/03. However, 6% of the current IDRS IDU cohort reported using another person’s used needle in the month prior to interview. 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 0.4% in 2002/03) and 87% of the current IDRS IDU cohort had not shared any such injection equipment in the month prior to interview. Tourniquets remain the most commonly shared item among IDRS IDU cohorts.
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, following a marked dip in incident cases of hepatitis C between 2000 and 2001, reported incident cases of infection have increased only slightly between 2001 and 2003, with 24 incident cases recorded in 2003.
Comparing reported rates of injection-related harms among the 2002 and 2003 Tasmanian IDRS participants, there were little changes in the level of experience of the commonest problems of scarring and difficulties finding veins to inject into, both indicative of vascular damage, with approximately half of the IDU participants experiencing these issues in the month prior to interview. Experience of ‘dirty hits’ (feeling physically unwell soon after injection, often associated with the injection of contaminants or impurities) appears to have increased substantially between the 2002 and 2003 cohorts (from 18% to 31%), and was primarily associated with the injection of methadone syrup. Overall, a substantial level of injection-related health problems are experienced by local injecting-drug users, at a relative rate considerably higher than IDU in other jurisdictions. This is reflective of the increased harms associated with the injection of pharmaceutical preparations of drugs, which is substantially more common in Tasmania than other jurisdictions. However, local IDU experienced a much lower rate of (non-fatal) overdose than users in other jurisdictions, due to the greater control over the dose of the drug afforded by use of standardised pharmaceutical preparations. While this rate of experience of overdose remains low among Tasmanian IDU, rates of fatal opiate overdoses have been increasing over the past 14 years, rising from less than 10 deaths per million population (aged between 15-44 years) to over 30 deaths per million in recent years.
The findings of the Tasmanian 2003 IDRS suggest the following areas for further investigation and possible consideration in policy:
Citation: Bruno, R. and McLean, S. (2004) Tasmanian Drug Trends 2003: Findings from the Illicit Drug Reporting System (IDRS), Sydney: National Drug and Alcohol Research Centre.