NDARC Technical Report No. 273

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.

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 2000-2004 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. Funding for this methodology into 2006 has been provided by the Australian Government Department of Health and Ageing.

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 justice-related fields. Of these individuals, 6 reported on groups that predominantly used opioids, 13 on cannabis, 16 on groups primarily using methamphetamine (4 key experts commented on two distinct drug-using groups).

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 B and C incidence data, data from the National Drug Strategy Household Survey, 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 user (IDU) participants
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 (65%), and had an average age of thirty years. On average, participants had completed 10 years of education, and two-thirds (71%) were currently unemployed. One-third of participants had a previous prison history. Over half of the participants were involved in some sort of drug treatment at the time of interview. The majority of participants (56%) were injecting a few times per week, but not every day, with 37% injecting at least once per day. Opiates were the predominant drug of choice among the cohort (69%), similar to previous Tasmanian IDRS studies, except in 2005, in which only 54% reported an opiate as their drug of choice. Similarly, opiates were reported by 65% of the current cohort as the drug most injected in the preceding month, a rate higher than that reported in 2005 (51%), but similar to that among previous years’ samples.

Patterns of drug use among the IDU sample
The major trends identified in the 2006 Tasmanian IDRS report relate to indications of emerging changes in patterns of pharmaceutical opiate use amongst local IDU, along with the continuing trend toward coincident opioid and benzodiazepine (particularly alprazolam) use. Shifts within the local methamphetamine market have also been identified. Summaries of major trends for each drug class are reported below by drug type.

Heroin
Very few of the IDU consumers interviewed in the 2006 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 (9%) 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 state’s Needle Availability Program remained below 1% of all non-pharmacy client transactions in 2005/06.

Only one participant in the current study was able to provide information regarding price paid for recent heroin purchases. This purchase was between 2-3 ‘caps’ (~0.05-0.15g), at a cost of $200. This is consistent with prices in earlier studies ($100 per ‘cap’) where greater proportions reported recent use. 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, almost half of those reporting on availability (43%, n=3) had only used heroin 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 ‘medium’ in subjective purity in the preceding six months. The majority of indicators – such as a steadily declining proportion of use of heroin among clients of the state’s Needle Availability Program, findings such as the low median rate of use of heroin (six days in last six months amongst those who had used the drug) and that, of the 36% of the IDU sample that reported heroin as their drug of choice, only around two-fifths (22%) had recently used heroin – indicate that the low availability of heroin in the state, identified in earlier IDRS studies, has continued in 2006.

Methamphetamine
Over the past five 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 a substantial majority all of those surveyed in the current study using some ‘form’ of the drug in the six months prior to interview (83%), despite less than one-third (28%) nominating it as their drug of choice.

The market prices locally for all three presentations of methamphetamine appear to have remained relatively stable since those reported in the 2005 IDRS study, particularly in relation to ‘point’ (approximately 0.1g) amounts 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 price for gram purchases of crystal methamphetamine, falling from a median of $400 in 2004 to $340 in the 2005 and to $300 in the current survey. Consumers predominantly regarded the prices of each presentation of the drug as remaining stable in recent months.

IDU reports on subjective purity of powder methamphetamine were ‘low’ to ‘medium’ and participants reported fluctuating purity in recent months. ‘Base’ was considered by consumers to fluctuate between ‘medium’ to ‘high’ subjective purity, with potency fluctuating in recent months. Consumers considered crystalline methamphetamine used locally as ‘high’ in subjective purity, with this fluctuating to increasing in purity in recent months.

Consumers interviewed regarded powder and ‘base/paste’ methamphetamine as ‘easy’ to ‘very easy’ to access, with availability stable in recent months. This was not the same for crystal methamphetamine: while most who had used crystal methamphetamine also reported it as ‘easy’ or ‘very easy’ to access in recent months, one-quarter of participants considered it as ‘very difficult’ or ‘difficult’ to access, and most had not noted any recent change in availability for this form.
Previous years have seen major upheavals in methamphetamine markets in Hobart. Between 2001 and 2005 there have been steady increases in the use of methamphetamine both among the IDRS IDU cohort (85% using the drug in the preceding six months in 2001, 95% in 2005) and among clients of the state’s Needle Availability Program (30% reporting it as the ‘drug most often injected’ in 2000/01, 59% in 2004/05). Within these markets, shifts have also occurred: among IDRS IDU cohorts, use of the powder form has been steadily increasing (39% in 2002; 76% in 2005), and the predominantly used form, base/paste methamphetamine, was briefly overshot by a marked increase in local availability of crystal methamphetamine in 2003. In subsequent years, crystal methamphetamine availability returned to lower levels than for the other two forms of the drug. Trends in 2006 represent subtle changes both for the methamphetamine market overall (for the IDU demographic) and within it: there are possible indications of a decline in use of methamphetamine among IDU both amongst the IDRS IDU cohort (95% in 2005, 83% in 2006) and clients of the state’s Needle Availability Program (59% in 2004/05, 56% in 2005/06). Amongst IDU consumers who report recent use of methamphetamine, reductions in the proportion reporting use of the most common powder and base/paste forms (falling from 78% to 62% recently using powder and 81% to 63% recently using base/paste between 2005 and 2006 respectively), and a shift to half-gram rather than ‘points’ as the most common purchase amounts, are suggestive of decreased or unreliable purity of the product available to this demographic. While, in contrast, use of crystal methamphetamine appears to have slightly increased amongst IDRS IDU cohorts (52% in 2005, 64% in 2006), this remains infrequent (approximately monthly on average) and not commonly the methamphetamine form most used amongst this group.

Consumers anecdotally noted a change in the local drug culture developing, with methamphetamine being used at greater frequency by existing users, and the drug increasingly used among different – not necessarily IDU – demographic groups: younger teenage groups, equally used by males and females, as well as a wider range of socio-economic groups (a finding supported by the 2006 Tasmanian EDRS study (Matthews & Bruno, 2007). Service providers also anecdotally noted the impact of increasing polydrug use and methamphetamine use on clients seeking their services, and reported concern about the multiple health and social problems experienced by this client group within Tasmania.

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, with use of the drug amongst clients of the state's Needle Availability Program virtually non-existent (less than 0.1% of non-pharmacy equipment transactions). Only a very small proportion of the IDRS IDU participants reported recent use of the drug (12%), which was predominately 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 purchased locally; however, one-quarter of participants who were able to comment reported that they purchased cocaine from other Australian jurisdictions. There have been no seizures of cocaine made by Tasmania police between 2001 and 2005. These patterns of low levels of availability and use in these cohorts appear to have remained reasonably stable over the past few years. However, there has been an increase in the level of use of the drug in different local consumer populations (Matthews & Bruno, 2007) which may provide early indications of emerging changes in local markets for the drug.

Cannabis
Among the IDU consumers 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.

Consumers reported purchasing a median of 1.7g of outdoor-cultivated cannabis or a median amount of 1g of indoor-cultivated cannabis in a traditional $25 ‘deal’ of the drug.

When accessing outdoor-cultivated cannabis, consumers typically purchased in quarter-ounce or ounce amounts. While the price of a quarter-ounce purchase had remained stable between 2005 and 2006 (median $60), the median price for an ounce of outdoor-cultivated cannabis decreased from $200 in 2005 to $170 in 2006. The majority of consumers reported no change in price, whilst a minority reported prices decreasing in the preceding six months.

Prices for indoor-cultivated cannabis were higher than for outdoor-cultivated cannabis, at a median of $90 per quarter-ounce and $250 per ounce. In comparison to prices identified in 2005, modal purchase prices for ounce purchases had declined by $50. Consumer reports reflect general stability in prices paid for the most commonly purchased amount: quarter-ounces. Consumers overwhelmingly reported that both indoor- and outdoor-cultivated cannabis was ‘easy’ or ‘very easy’ to obtain in 2006, with this situation remaining stable for both forms of cannabis. However, there were indications of somewhat increased availability (a greater proportion of consumers reporting either form as ‘very easy’ to access) in comparison to the trends identified in the 2005 IDRS survey, following indications of relatively decreased availability between 2003 and 2004.

Similar to previous years, consumers described the subjective potency of outdoor-cultivated cannabis as ‘medium’, with this level generally considered stable to fluctuating in the preceding six months. Indoor-cultivated cannabis was regarded as ‘high’ to ‘medium’ in subjective potency by consumers, with this level regarded as stable or fluctuating to increased potency in recent months. Those 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 in 2004), and from a slowly decreasing rate of use in Hobart IDRS IDU samples, particularly in regard to the proportion of daily cannabis smokers.

Other opioids
Morphine
Morphine was reported to cost a median of $80 per 100mg, or $50 per 60mg (MS Contin), an increase of $10 for 100mg tablets from prices reported in 2005, with prices considered by respondents as being stable to increasing 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. Two-thirds of the sample (62%) had used morphine in recent months. MS Contin remains the predominant preparation used by this group, followed by Kapanol and Ordine (liquid morphine). Recent IDRS studies have shown a decreasing median frequency of use and proportion of consumers reporting recent morphine use; however, in 2006, this trend has been reversed, with 62% of participants reporting recent use (58% in 2005) and a median frequency of use of 21 days (11 days in 2005) in the preceding six months. Similar trends are also apparent in data from the state’s Needle Availability Program. However, the measures of morphine use in the 2006 IDRS IDU cohort remain markedly lower than those from earlier local IDRS studies (for example, in 2000, 77% had recently used the drug, with a median frequency of 52 days).

Methadone syrup
Diverted methadone syrup was reported to cost a median of approximately $1.00 per milligram in 2006, a price higher than that reported by 2005 participants ($0.80 per mg), but the same as prices reported during 2001 through 2004. The majority of participants who commented reported prices to be stable in recent months. Most commonly, participants reported that methadone syrup was ‘easily’ accessed, with over half reporting stable availability of the drug in the preceding six months (although a minority reported decreased availability). Methadone syrup is most frequently purchased from friends or acquaintances, and this is generally carried out in an agreed-upon public location. Predominantly, those participants reporting purchasing diverted methadone syrup were themselves receiving methadone maintenance treatment. There have been increasing reports of consumers injecting combinations of alprazolam and methadone syrup in the past four IDRS studies, a practice that carries an increased risk of overdose, injection-related harms, and adverse social or legal consequences because of the particular disinhibitive effects of this combination, which both consumers and key experts noted as concerns in regard to this trend.

Physeptone
Diverted Physeptone tablets of methadone were regarded as costing a mode of $10 per 10mg (as has been reported in the past six years of the IDRS), with prices regarded by consumers considered stable or increasing in recent months. Physeptone was regarded as ‘difficult’ to access, with this level of availability remaining stable or declining somewhat in the preceding six months. The proportion of the consumer sample reporting recent Physeptone use rose slightly in 2006 to 49%, after a decline in the three preceding years (64% in 2003, to 52% in 2004 and 41% in 2005).

Oxycodone
Oxycodone use among local IDU samples appears to have increased 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 ($0.63 per milligram for 40mg and 80mg oxycodone tablets). According to consumer reports, median prices for both 40mg and 80mg tablets have increased since 2005 (by $5 to $25 40mg tablets; and by $10 to $50 for 80mg tablets). Consumers reported that prices were stable to increasing over the preceding six months. Availability reports were mixed, with two-fifths of those who commented reporting ‘easy’ access, and one-third reporting access as ‘difficult’, a situation regarded as stable by most participants. While the drug remains somewhat difficult to access illicitly, the rapidly increasing rate of prescription of oxycodone, and its perceived similarity amongst consumers to morphine render it likely that oxycodone use may expand within the local IDU market. Given the high relative potency of oxycodone and its possible synergistic effects with other opiates, this is an issue that merits continued careful monitoring.
It is important to note also that the opioids used by this group are not coming from direct doctor-shopping by IDU, as the vast majority report obtaining them ‘illicitly’, i.e. not on a prescription in their name.

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 benzodiazepines remains an ongoing part of the local drug culture, with Tasmanian IDU consumers continuing to inject at rates higher in comparison to that identified in other Australian jurisdictions. As noted in the 2003 to 2006 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 2006 studies, the proportion of the IDU samples reporting recent injection of alprazolam had more than doubled (from 11% among the 2003 IDU cohort to 27% in 2006). 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, and the highly variable half-lives across different benzodiazepine types. 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 0.3% in 2005/06. However, all IDRS studies in Hobart have suggested that 3-10% 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 13% of the 2006 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 0.6% in 2005/06). In contrast, one in four of IDU consumers interviewed in the current study had shared injecting equipment such as tourniquets, spoons or water in the month prior to interview.

Alarmingly, almost half of the consumers reported re-using injecting equipment from a shared sharps disposal bin, and one in four did not use bleach to clean this equipment. Almost half of the consumers interviewed reported re-using their own injection equipment in the month prior to interview (a reduction from two-thirds of the cohort reporting this in 2005), with the majority of these participants re-using on one occasion in this time. These are harmful injection practices: 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. The equipment most frequently re-used included 20ml barrels, 1ml barrels and winged infusion sets (‘butterflies’). This was typically reported as being due to NAP outlets being inaccessible (either due to distance or equipment being required outside of business hours).

A substantial proportion of IDU surveyed experienced injection-related health problems. Scarring and bruising, 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 most common 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 re-use of injection equipment.
Around two-thirds of the consumers sampled that had driven a car in the past six months had done so within an hour of using non-prescription drugs on at least one occasion. Methamphetamine, methadone and cannabis were most commonly involved. This level of self-reported drug driving has remained stable when compared with that among the 2005 IDRS study participants, although the proportion reporting driving while affected by cannabis has declined slightly in this time.
More than one-third 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 depression and anxiety-related issues. Despite increases in the use of high-potency methamphetamines, rates of psychotic-type syndromes (schizophrenia, paranoia) have remained stable in recent IDRS IDU surveys, albeit at a higher level than seen in general community cohorts.

Implications
The findings of the Tasmanian 2006 IDRS suggest the following areas for further investigation and possible consideration in policy:

1.Interventions to improve injection practices and injection-related health
The detailed face-to-face interviews in the current study identified a high level of extremely risky injection practices amongst the consumer cohort that have not been identified in other data sources (such as NAP data or the NSP study). For example, one in ten participants had given a used needle to another individual in the month prior to interview, and four in ten had themselves re-used injecting equipment from shared disposal bins without appropriately cleaning this equipment. Given the increasing identification of infections and endocarditis, both among the current IDU sample and by key experts interviewed in the current study – all of which are associated with the introduction of bacteria into the bloodstream (which is possible through the use of non-sterile injecting equipment) – this is clearly an emerging issue which demands urgent intervention.

The high level of re-use and sharing of injection equipment requires the attention of the Needle Availability Program, as a priority, to identify whether systemic barriers exist which may be hampering access to sterile injecting equipment.

In the short-term, information on procedures for cleaning injection equipment, and the harms associated with use of non-sterile equipment, should be actively provided to consumers. Continued emphasis on targeted strategies to reduce the rates of sharing of needles/syringes and other injection equipment (such as tourniquets, filters and mixing containers), and to improve awareness and adoption of safe injection practices and vein care among IDU, is clearly warranted.

2. Monitoring and application of region-specific drug trend information

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.

It would be beneficial to extend the methodology of the IDRS into the other regions of the state (such as Launceston and the North-West coast) to form a state-wide drug trend monitoring framework. There has been little specific research examining patterns of drug use within these areas, and, similarly, there is a paucity of available indicator data that is available on a region-specific basis. Due to their access to air and sea ports and establishment of organised motorcycle group headquarters, availability and use of illicit substances may differ substantially in these regions from patterns seen in Hobart. An initial study in 2003 has provided evidence suggesting that there are clear distinctions between the drug markets in these regions (Bruno, 2004b [unreleased]). As such, it may not be appropriate to infer similarity between drug trends and emergent issues identified in Hobart-based studies to these regions.

3. Development of specialist training and interventions for methamphetamine
As availability of the higher potency forms of methamphetamine appears to be relatively stable, 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, 2006, 2007). 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 frontline health intervention workers and emergency services workers. Similarly, investigation into the requirement for specialist treatment programs and/or services for primary consumers of these drugs is warranted.

4. Implementation of harm-reduction approaches to reflect the needs of methadone pharmacotherapy clients
With the entrenchment 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 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.

5. Proactive harm-reduction interventions targeted to injectors of pharmaceuticals
Tasmania, like a number of other regions removed from heroin distribution networks (such as the Northern Territory and New Zealand) has a long-established culture of injection of opioid-based pharmaceuticals. As such, research into factors that would reduce the harms associated with the tablet preparations 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, are necessary.

For example, despite clear evidence that injection of tablets are associated with the development of granulomas in internal organs (Roberts, 2002; Gotway et al., 2002) there has been no research into the effectiveness of commercially available pill or biological filters on reducing the harms associated with intravenous use of these drugs. As an interim harm-reduction measure, however, given the existing evidence in support of the potential benefit offered by such filters in regard to the use of other drugs (Scott, 2005) it would be recommended that pill filters become more widely available, at a cost that is not unaffordable, and their use promoted by frontline workers, to local IDU consumers.

6. Monitoring and dissemination of information in regard to emergent trends in use of diverted pharmaceuticals
Oxycodone prescriptions both locally and nationally have continued a rapid increase in recent years. With diverted oxycodone use increasing amongst local IDU consumers, but still infrequent, it may be the case that knowledge of the drug amongst the consumer community is still developing. Reviews of opioid equianelgesic dose ratios suggest that oxycodone is between 1.5-2.0 times the potency of morphine (Piereira, Lawlor, Vigano, Dorgan & Bruera, 2001). Moreover, oxycodone reaching systemic circulation after injection is more than twice that after oral or rectal administration (Leow, Smith, Watt, Williams & Cramond, 1992). While conducting interviews for the current study, it was apparent that many consumers were not aware that oxycodone, although similar in presentation and trade name (e.g. morphine – MS Contin; oxycodone – OxyContin), is not the same drug, and is indeed more potent that morphine, and that caution needs to be exercised in its use. Further, given the talc content of the tablets, careful preparation and filtering of the drugs is required to avoid granulomas (Roberts, 2002). Frontline workers need to be aware of these issues and to implement harm-reduction interventions with potential illicit consumers of this drug.

In other jurisdictions, diverted use (both oral and injecting) of buprenorphine (Subutex) and buprenorphine-naloxone (Suboxone) has been reported by substantial proportions of IDRS IDU cohorts (O’Brien et al, 2007). At the time of this report, Suboxone treatment is not yet available in the state; however, Subutex treatment is currently being provided to a relatively small number of people. In light of the harms associated with injecting this drug (vascular damage, infections and overdose) identified in other jurisdictions and internationally, continued monitoring is recommended as these treatments are expanded across the state.

Thirdly, research examining misuse of pharmaceutical products in populations other than IDU is warranted, as this has been a demographic identified in both key expert interviews in the current study and in associated local research (Fry, Smith, Bruno, O’Keefe & Miller, 2004; Bruno, 2004c) but not accessed within the methodology of the IDRS, and this population has, to date, been largely invisible in research or other data collections.

7. Continued monitoring and focused interventions to reduce the harms associated with benzodiazepine injection
Intravenous administration of benzodiazepines has proved resilient amongst local IDU: despite the removal of temazepam gel capsules from the market due to the harms associated with their use, alprazolam is clearly being used in similar ways by a substantial proportion of local consumers. Of particular concern is the combined injection of alprazolam and methadone syrup, as this is a practice that substantially increases the risk of overdose. There is considerable concern about this practice amongst consumers and service providers alike, and a targeted campaign to increase awareness of the potential harms of this combination, as well as provision of accurate, non-judgemental harm reduction information, would be timely and likely to lead to improved health outcomes for consumers.

8. Increased attention to substance dependence – mental health comorbid issues
While self-reported rates of experience of mental health issues are likely to under-represent the true extent of these issues, around two-fifths of the IDU sample reported recently attending a health professional for mental health concerns, a level substantially greater than that 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.

9. Expanded access to dental health services for IDU
Further focus needs to be placed on the dental health of injecting drug users, as anecdotal reports indicate numerous severe dental health problems experienced by this group, both amongst long-term methadone patients and among consumers of methamphetamine. For many of these individuals, accessing dental health services is problematic, partly due to long waiting lists to access public dental health treatment, and also the prohibitive cost of private dental care. Provision of regular, dedicated session times at public dental services for injecting drug users, or development of co-ordinated relationships between dental services and the holistic health services currently accessed by IDU, may be appropriate treatment options to service the needs of this demographic group.

10. 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 IDRS study reported driving while affected by drugs (two-thirds of those with access to a vehicle). This has remained unchanged in comparison to levels identified in the 2005 study, despite the implementation of roadside drug-testing by Tasmania Police and associated driver education campaigns. While reports of driving while affected by most drug types remained unchanged, there were declines in reports of driving under the influence of cannabis, the drug most focused on in media reports of this issue. This suggests that drug-driving interventions may indeed have an impact in this demographic and further monitoring and evaluation of these strategies among this group is recommended, particularly where this could be used to tailor campaigns to this particularly risky demographic.

Citation: de Graaff, B. & Bruno, R. (2007) Tasmanian Drug Trends 2006: Findings from the Illicit Drug Reporting System (IDRS). Sydney: National Drug and Alcohol Research Centre.

Resources

Date Commenced
24 Mar 2007
Resource Type
Technical Reports