NDARC Technical Report No. 245 (2006)
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.
In 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 2005.
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-three 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 justice-related fields. Of these individuals, 8 reported on groups that predominantly used opioids (diverted pharmaceuticals), 8 on cannabis, 12 on groups primarily using methamphetamine, and 4 on groups whose substance use varied greatly depending on availability.
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 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
Demographic characteristics of the regular injecting drug user participants interviewed were generally very similar to those interviewed in previous Hobart IDRS studies. Participants were predominantly male (62%), and had an average age of thirty-one years. On average, participants had completed 10 years of education, and two-thirds (64%) were currently unemployed. One third of participants had a previous prison history. A slightly lower proportion of the 2005 IDU participants were involved in some sort of drug treatment at the time of interview, compared with the 2004 cohort (65% vs. 55%), with 43% currently enrolled in a methadone maintenance program.
The majority of participants (62%) were injecting a few times per week, but not every day, with 30% injecting at least once per day. In a slight change from previous Tasmanian IDU samples, where opiates were the predominant drug of choice (70% in 2004), just over half (54%) of the current cohort reported an opiate as their drug of choice. Similarly, while in previous years, opioids were predominantly reported as the drug most commonly injected by IDU participants (69% in 2004), in the current cohort there was a relatively equal proportion nominating opioids (51%) and methamphetamine (47%) as the drug most commonly injected in the month prior to interview.
Patterns of drug use among IDU
The 2005 IDRS detected a number of trends during the preceding six to twelve months. The major trends identified relate to indications of emerging changes in the local methamphetamine market and culture amongst consumers; the changing patterns of pharmaceutical opiate use amongst local IDU; and the continuing trend toward coincident opioid and benzodiazepine (particularly alprazolam) use.
Very few of the IDU consumers interviewed in the 2005 Tasmanian IDRS could report on local trends in price, purity, or availability of heroin. Consistent with patterns seen in previous studies, only a small proportion of the cohort (19%) reported using the drug in the preceding six months, with this use being very infrequent (6 of the previous 180 days), despite a high preference for heroin as a drug of choice. Similarly, use of heroin among clients of the states Needle Availability Program remained below 2% of all non-pharmacy client transactions in 2004/05.
The price of heroin purchased within the state was reported as $100 per packet (0.05-0.2g) and $360 per gram, and considered stable in recent months by the very small number of consumer reports on use (n=8). Consistent with trends noted in previous years, the majority of IDU considered heroin as difficult or very difficult to access, and that this situation had not changed in recent months. In further support of this, half of those reporting on availability had accessed the drug through having it sent directly to them from another jurisdiction, rather than being able to access the drug locally.
Consumers predominantly used rock-form heroin and considered the drug as low to medium in subjective purity in the preceding six months. Consumers were very mixed in their reports of changes in purity, and as there was only a single seizure of heroin in Tasmania in 2004/05 (of 0.2g), and none in the preceding three years there is no objective purity data to compare consumer reports against.
The majority of indicators, such as a steadily declining proportion of use of heroin among clients of the states Needle Availability Program, and a low level of heroin use in the IDU cohort despite a high preference as a drug of choice, indicate that the low availability of heroin in the state, identified in earlier IDRS studies, has continued in 2005.
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 (95%), despite just one-third (34%) nominating it as their drug of choice. Moreover, the proportion of clients of the states Needle Availability Program reporting predominant use of methamphetamine has steadily increased from 31% of recorded transactions (almost 3,000 cases) in 1999/00 to 59% in 2004/05 (more than 24,000 transactions).
The market prices locally for all three presentations of methamphetamine appear to have remained relatively stable since those reported in the 2004 IDRS study, particularly in relation to the most common purchase amount, a point (0.1g) of the drug at $50 for any form. Modal purchase prices for larger amounts of powder and base/paste methamphetamine remained stable since 2004 at $300 per gram. However, there were some indications of a decrease in median prices for grams of crystal methamphetamine, falling from $400 in 2004 to $340 in the 2005 survey.
IDU reports on subjective purity of powder methamphetamine were low to medium and fluctuating toward decreased purity in recent months. Base was considered by consumers as medium to high in subjective purity, with potency fluctuating in recent months. Consumers considered crystalline methamphetamine used locally as high in subjective purity, with this remaining stable or trending toward increased purity in the preceding six months. Only a small number of methamphetamine seizures were analysed in the 2004/05 financial year (n=10), and the median purity of these samples was 32% (range 19-36%).
Consumers regarded both powder and base/paste forms of methamphetamine as easy to very easy to access, with availability stable (or increasing for powder) in recent months. In contrast, equal proportions of consumers found crystal methamphetamine easy and difficult to access, and while most noted no recent change in availability, decreasing levels of use between the 2004 and 2005 surveys suggest a further decrease in local availability of crystal methamphetamine.
Around three-quarters of the cohort had recently used powder form or base/paste methamphetamine, and the median frequency of such use increased between the 2004 and 2005 cohorts, with the median frequency of use of any form of the drug more than doubling to 48 days out of the previous 180 in the 2005 sample, compared to a steady rate of between 20 and 25 out of the previous 180 days in the previous 5 years of the IDRS locally. Indeed, there have been indications of increasing use of methamphetamine both amongst recent IDRS cohorts and amongst clients of the states Needle Availability Program, with Tasmania Police also reporting an increase in identification of local clandestine methamphetamine laboratories (although remaining small in number), and an increase in the number of arrests and weight of seizures relating to methamphetamine in 2004/05 compared to 2003/04.
Consumers noted a change in the local drug culture developing, with methamphetamine being used at greater frequency, and the drug increasingly used among different demographic groups previous predominant consumers of opioids, younger teen-aged groups, and young females, as well as into a wider range of socio-economic groups. Service providers also noted the impact of increasing polydrug use and extended methamphetamine binges on clients seeking their services, and noted concern about the limited range of treatment options available for this client group within the state.
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, with use of the drug amongst clients of the states Needle Availability Program virtually non-existent. Only a very small proportion of the IDRS IDU participants reported recent use of the drug (8%), which was exclusively in powder form. By the very few consumers that could comment on trends in availability, cocaine was considered very 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 directly imported by consumers from dealers or contacts in other jurisdictions. Tasmania Police have made no seizures of cocaine in the past four financial years. These patterns of low levels of availability and use in these cohorts appear to have remained reasonably stable over the past few years. However, it is noteworthy that there has been an increase in the level of use of the drug in different local consumer populations (Matthews & Bruno, 2006) which may provide early indications of emerging changes in local markers for the drug.
Among the IDU consumers surveyed, cannabis use continued to be almost ubiquitous, with 87% using the drug in the preceding six months, and the majority of these individuals using the drug daily.
Consistent with prices reported in 2004, consumers reported purchasing a mode of 1g of indoor or outdoor-cultivated cannabis in a traditional $25 deal of the drug. When accessing outdoorcultivated cannabis, consumers typically purchased in quarter-ounce (median $70) or ounce (median $200) amounts. While prices for ounces were similar in 2004 and 2005, the median cost for a quarter-ounce had increased $10 between the studies. Prices for indoor-cultivated cannabis were higher, at a median of $80 per quarter-ounce and $290 per ounce, with the most common purchase prices reflecting increases in the cost for indoor-cultivated cannabis since those reported in the 2004 study.
Consumers reported that both indoor- and outdoor- cultivated cannabis was easy or very easy to obtain, with this situation remaining stable in recent months. However, there were indications of somewhat increased availability in comparison to the trends identified in the 2004 IDRS survey, following indications of relatively decreased availability between 2003 and 2004. Tasmania Police report a slow shift back toward preferential outdoor cultivation of cannabis, also noting the use of imported seed or of multiple cannabis strains within single crops.
Similar to previous years, consumers described the subjective potency of outdoor-cultivated cannabis as medium to low, with this level generally considered stable in the preceding six months. Indoor-cultivated cannabis was regarded as medium to high in subjective potency by consumers, with this level regarded as stable or increasing in recent months. Cannabis-consuming IDU interviewed generally reported using both indoor- and outdoor-cultivated cannabis in the preceding six months, although indoor-cultivated cannabis was the form most commonly smoked. While cannabis remains the most commonly used illicit drug, both in the IDU sample and in the state, there are indications of decreasing levels of use, both from the National Drug Strategy Household Survey (suggesting that use of cannabis in the previous year in local samples has declined from 15.8% in 1998, and 11.9% in 2001 to 10.9% of those aged 14 and over), and a slowly decreasing rate of use in the IDRS IDU samples, particularly in regard to the proportion of daily cannabis smokers.
Use of illicit pharmaceuticals
Morphine was reported to cost $70 per 100mg, or $50 per 60mg, consistent with prices identified in the 2004 survey, and considered by respondents as being stable in recent months. Morphine was considered easy to very easy to obtain by consumers, and reported as remaining stable or increasing in availability in recent months. MS Contin® remains the predominant preparation used by this group, used by 53% of the sample as a whole, and was the form used predominantly by three-quarters of those reporting recent morphine use, with Kapanol® the next commonest preparation (used by one-third of the sample), and smaller proportions reporting using Anamorph® or MS Mono® in the preceding six months. The median frequency of use of morphine amongst local IDRS IDU cohorts, and, in recent years, the proportion of consumers reporting recent use, has steadily declined over time: falling from 77% of the 2000 IDRS sample using at a median frequency of 52 of the last 180 days to 58% of the 2005 sample using at a median frequency of 11 days in the preceding six months. Similar trends are also apparent in data from the states Needle Availability Program. There are continuing reports, both from consumers and key experts, that morphine is being increasingly rejected by users in favour of methamphetamine and other pharmaceutical opioids.
Diverted methadone syrup was reported to cost a median of approximately $0.80 per milligram in 2005, a price lower than that to the 2004 participants ($1 per mg) but considered as stable in recent months by the consumers. A steadily declining proportion of consumers have found the drug easily accessed in recent years (82% in 2003, 74% in 2004 and 56% in 2005), with consumers reporting stable or decreasing availability of this drug in the preceding six months. Both IDU consumers and key experts note that the drug is generally only available where there is a standing arrangement with a person on the program, and is almost uniformly reported as being obtained from friends (82%). Moreover, the majority 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. However, there have been increasing reports of consumers injecting combinations of alprazolam and methadone syrup in the past three IDRS studies, a practice that carries an increased risk of overdose, injection-related harms, and adverse social or legal consequences from the particular disinhibitive effects of this combination, which both consumers and key experts noted as concerns in regard to this trend.
Diverted Physeptone® tablets of methadone were regarded as costing a mode of $10 per 10mg (as has been reported in the past five years of the IDRS), with prices regarded by consumers as stable or increasing in recent months. Physeptone® was regarded as difficult to access, with the level of availability remaining stable or declining somewhat in the preceding six months. Consistent with this, the proportion of the consumer sample reporting recent Physeptone® use has continued to decline in local IDRS studies, falling from 64% in 2003, to 52% in 2004 and 41% in 2005.
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 five individuals participating in the 2005 survey reporting illicit use of the drug (two of whom were also receiving legitimate buprenorphine prescriptions). All of those who had accessed buprenorphine illicitly in the preceding six months had injected the drug, but this use was infrequent (a median of three times in the preceding 180 days). 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.
Oxycodone use among local IDU samples appears to have risen in recent years, with one-third of the current cohort reporting use of the drug, predominantly OxyContin® tablets, in the preceding six months. Despite their higher relative potency than morphine tablets, these drugs are sold locally at lower comparative prices ($0.50 per milligram for 40 and 80mg oxycodone tablets), with consumers reporting stable prices in recent months. While the drug remains predominantly difficult for consumers to access currently (a situation regarded as stable by IDU), there are indications that oxycodone use may expand within the local market, which, given the high relative potency of oxycodone and its possible synergistic effects with other opiates, is an issue that merits continued careful monitoring.
One-fifth of the 2005 IDU consumer sample reported using some preparation of alkaloid poppies in the preceding six months, although such use was infrequent (a median of 3 days out of the preceding 180). This represents an increase in the proportion of the IDU consumer sample reporting such use when compared to recent IDRS studies (12-14% in the local studies between 2001 and 2004). However, the rates of use amongst the current consumer cohort were less than that seen in the 2000 IDRS survey (when one-third had recently used some alkaloid poppy preparation, at a median frequency of use twice that of the current sample), and the number of poppy thefts in 2004/05 were a quarter of those in that year (63,000 capsules stolen in 1999/00 compared to 16,000 in 2004/05). Moreover, the number of thefts from poppy crops has fallen one-third from the previous financial year (from 24,000 capsules in 2003/04 to 16,000 in 2004/05).
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 benzodiazepines remains an ongoing part of the local drug culture, with local IDU consumers continuing to inject at rates relatively higher in comparison to that identified in other Australian jurisdictions. As noted in the 2003 and 2004 studies, 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 2005 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 19% and a median frequency of 24 days in 2005), and there are anecdotal reports of increased demand for 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, 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 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 2004/05. 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. Additionally, there are indications of increasing sharing rates in the past two IDRS surveys (using the proxy measure of whether consumers had lent their used needles to another consumer in the preceding month, reported by 14% of the 2005 participants). 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 2004/05). However, a more stringent examination of such practices in the IDRS study suggests that there is still the potential for blood-borne viral infections (BBVI) in the injection practices adopted by a substantial proportion of those regular consumers interviewed, with two-fifths sharing some sort of injecting equipment in the preceding month (most commonly sharing mixing containers, 26%; water, 27%; or tourniquets 15%; albeit in most cases in situations where both people were using sterile injection equipment).
Almost two-thirds of the consumers interviewed reported re-using their own injection equipment in the month prior to interview, with the majority of these participants re-using on multiple occasions in this time. This is not a recommended practice as repeated use of needles leaves them blunt, which could cause damage to the venous system, and use of non-sterile equipment can lead to the introduction of bacteria into the bloodstream, which can lead to infections, septicaemia or endocarditis. Butterflies and 1mL insulin syringes were the equipment most commonly re-used, and this was typically reported as being due to NSP outlets being inaccessible (either due to distance or equipment being required outside of business hours).
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, one-fifth of the 2005 IDU cohort did not always self-inject, with those that did not always self inject being significantly younger and more likely to be female. Secondly, half 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 almost half of these cases participants did not report washing their hands between injections clearly a behaviour that increases the exposure risk to blood-borne viral infections.
A substantial proportion of IDU surveyed experienced 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) were the commonest injection-related problems experienced by the current IDRS IDU cohort. Multiple key experts noted recent increases in experiences of bacterial infections associated with injecting drug use in recent months, likely related to injection of non-sterile solutions or of re-use of injection equipment.
In 2005, 6% of the consumers interviewed reported experiencing a non-fatal opioid overdose in the preceding year, and one-quarter of the sample had witnessed such an overdose in this time. This rate of overdose experience is a decline from that seen amongst the 2004 cohort. However, multiple key experts and consumers provided anecdotal reports of an increase in the numbers of overdoses in the preceding six months, which were attributed in particular to coincident use of multiple CNS depressant drugs (opioids and benzodiazepines in particular).
More than two-fifths 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 steadily increasing rate of individuals presenting for anxiety-related issues (consistent with an increasing use of methamphetamine in these cohorts over time).
The findings of the Tasmanian 2005 IDRS suggest the following areas for further investigation and possible consideration in policy:
Citation: Bruno, R. (2006) Tasmanian Drug Trends 2005: Findings from the Illicit Drug Reporting System, Sydney: National Drug and Alcohol Research Centre.