EXECUTIVE SUMMARY

The Centre for Population Health (CPH) at the Macfarlane Burnet Institute for Medical Research and Public Health conducted the Melbourne arm of the 2011 IDRS study between June and September 2011.

Demographics of the sample
One hundred and fifty PWID were interviewed for the 2011 Victorian IDRS. The mean age was 36.7 and 75% of the sample was male. Eighty-nine percent of survey participants were born in Australia and 10% reported that they were Aboriginal and/or Torres Strait Islander. Eighty-seven percent of respondents were not employed at the time of the interview and 51% resided in stable accommodation.

Consumption pattern results
Current drug use
The mean age at which survey participants reported their first injection of a drug was 18 years, with the first drug usually being amphetamine (56%) or heroin (39%). This was a significant change (both p<0.01) from the previous year, when 58% reported heroin as their first drug injected and 39% reported amphetamine.

The sample’s main drugs of choice were heroin, methamphetamine or cannabis and the most commonly injected drugs of the preceding month were heroin, methamphetamine and buprenorphine.

Heroin
Heroin continues to be the most commonly used injectable illicit drug among the IDRS survey participants, with 81% reporting use within the six months preceding interview. Sixty percent of survey participants reported that heroin was their drug of choice compared with 68% of survey participants in 2010.

The prevalence of recent heroin use among the sample was comparable to previous years (85% in 2010 and 79% in 2009); however, the frequency of heroin use decreased from a median of 74 days in the six months preceding interview in 2010 to 63 days in 2011. This figure has fluctuated over the past few years, with no clear trend.

Among the 121 survey participants reporting recent heroin use, all had injected, with only small numbers of survey participants reporting recent heroin smoking. As in past years, PWID reported most commonly using white or off-white rock heroin.

Methamphetamine
The IDRS currently collects information on the use, price, purity and availability of the three main forms of methamphetamine: ‘speed’, crystal methamphetamine and ‘base,’ as well as amphetamine liquid and pharmaceutical stimulants such as dexamphetamine.

Reports of any recent methamphetamine use among the 2011 IDRS sample were frequent (65% of survey participants); however, patterns of use varied between different methamphetamine types. In particular the prevalence of recent crystal methamphetamine use increased in comparison to 2010 (53% vs. 36%). The frequency of recent methamphetamine use was relatively stable compared with previous years.

Cannabis
Cannabis was the most widely used illicit drug in the 2011 IDRS sample, similar to previous years. Ninety-eight percent of survey participants in 2011 reported using the drug in their lifetime and 85% in the preceding six months. Frequency of reported cannabis use was 120 days in the preceding 180, with 44% of respondents reporting daily use. Hydroponic cannabis was again the most commonly recorded type of cannabis used.

Other drugs
Other opioid use was common in the 2011 IDRS sample, as in previous years, but the type of opioid varied amongst the survey participants.

Fifty-two percent of respondents reported recent methadone use and 21% recent illicit methadone use. Nine percent reported recent injection of methadone, which occurred on a median of five days.

Twenty-five percent of respondents reported recent buprenorphine use and 18% reported recent illicit buprenorphine use. Recent buprenorphine injection was reported by 21% of survey participants and injection of any form of buprenorphine on a median of 48 days.

Buprenorphine-naloxone use in the preceding six months was reported by 43% of the sample and 29% reported recent illicit use. Recent injection of this drug was reported by 25%, an increasing trend mostly likely representing the expanding percentages of patients prescribed this drug in the community over time. Either licit or illicit buprenorphine-naloxone was recently injected on a median of 14 days.

Thirty-four percent of survey participants reported recent use of morphine, with the majority reporting recent illicit use (33%) versus licit use (3%). Thirty-three percent of the sample had injected either licit or illicit morphine recently on a median of five days. More prevalent reports of morphine as the last drug injected (1%, 5%, 1%) and drug most often injected (1%, 7%, 1%) had returned to 2009 levels following spikes in 2010 (numbers reported in brackets are 2009, 2010, 2011 respectively).

Oxycodone use (combined licit and illicit) had increased slightly compared to 2010 with 41% of the sample indicating recent use (31% in 2010) and 36% recent injection (29% in 2010) on a median number of four days. Similarly to morphine, more of the sample reported illicit versus licit use (37% versus 8%).

Use of other opioids (and in particular injection of these) was limited. Thirty-nine percent of the sample reported using over the counter (OTC) codeine recently on a median of eleven days but only one participant reported recent injection. The ibuprofen-codeine combination product Nurofen Plus® was the main brand used by participants.

Thirty-seven percent of participants reported recent use of ‘other’ opioids with three participants reporting recent injection. Panadeine Forte® was the main ‘other’ opioid that was used by the sample.

Participants of the Victorian IDRS frequently report poly-drug use. Thus use of additional prescription and non-prescription drugs which were not opioids was also common in the 2011 sample.

For example, almost all of the IDRS survey participants reported lifetime use of both alcohol and tobacco, with 70% reporting alcohol and 95% tobacco use in the past six months. The majority of recent tobacco users were daily smokers (96%), while alcohol was consumed approximately once a week (median=24 days in the previous six months).

Similarly, 71% of the sample reported recent use of benzodiazepines, although a much smaller proportion reported recent injection (2%). Illicit recent use of benzodiazepines (excluding alprazolam) was reported on a median of 10 days, whereas recent illicit use of alprazolam was reported on a median of 13 days. Sixty-nine percent of the sample reported recent use of illicit alprazolam, the highest single report in the Victorian IDRS of illicit use of a prescribed medication. Diazepam and alprazolam were the main benzodiazepines used by respondents.

In the 2010 and 2011 Victorian IDRS survey, participants were informally asked about their use of Unisom® capsules (diphenhydramine hydrochloride), given indications of use raised by KE previously. Whereas, in 2010, 10% reported using it in the previous six months, 11% reported doing so in 2011.

The sample were asked for the first time about licit and illicit quetiapine use (Seroquel®). Sixty-four percent had ever used quetiapine (licit or illicit), with 30% having used illicit quetiapine in the last six months on a median of five days. There were almost no reports of injection of quetiapine. The main form of administration was by swallowing the drug.

Pharmaceutical stimulants continued to be used by small numbers of survey participants in the 2011 sample; however, almost all use was of illicit and not licit forms of these drugs. Sixteen percent reported use in the last six months with 10% citing recent injection of illicit pharmaceutical stimulants on a median of two days.

Reports of recent cocaine use among the IDRS sample remained infrequent, with 17% of survey participants reporting having used cocaine during the six months preceding interview and 13% injecting the drug. Among those reporting recent use, the frequency of use remained low (median=three days).

Few IDRS participants reported using hallucinogens and ecstasy. Seven percent of respondents reported recent use of hallucinogens but only small numbers (<5) reported recent injection, whilst 11% reported recent ecstasy use and 3% recent injection of this drug.

Drug market: Price, purity, availability and purchasing patterns
Heroin
The median price for a ‘cap’ of heroin was roughly stable at $50; however, the reported price per gram had dropped to $250. Heroin was reported as easy or very easy to obtain and the purity low to medium. The source was generally a known dealer at an agreed public location. The average purity of seizures by Victorian police in 2010-11 of 18% was lower than that found in 2009-10 (26.5%).

Methamphetamine
The median reported prices of points of speed and crystal methamphetamine were $50 and $100 respectively. Grams of speed were priced at $200 and grams of crystal methamphetamine at $800. Methamphetamine types in general were considered easy to obtain. The drug was generally sourced through known dealers or friends and purity varied from low to medium if speed through to medium to high if crystal methamphetamine. The average purity of seizures by Victorian police was 39%, which was higher than in the preceding year (21%).

Cocaine
Only a small number of survey participants were able to report on the price, purity and availability of cocaine. These participants suggested a stable price of $400 for a gram. Current purity was reported to be variable with variable ease of access by the respondents. The mean purity of cocaine seizures was 26%, which is much lower than the previous year’s figure of 42%.

Cannabis
Prices remained remarkably stable for cannabis with $20 per gram being proposed for both hydroponic and bush cannabis. An ounce was reported to cost $250 for hydroponic and $210 for bush cannabis. Both types of cannabis were reported to be easy or very easy to obtain and commonly purchased from known dealers or friends. Potency was medium to high and stable.

Methadone
A limited number of survey participants were able to give purchasing details for illicit methadone. The price was described as stable. Availability was reported as easy to obtain and stable.

Buprenorphine
The cost of illicit buprenorphine was reported to be $20 for an eight milligram tablet. There were a variety of responses to the question of accessibility but it was most commonly described as easy to obtain.

Buprenorphine-naloxone
The median price for buprenorphine-naloxone combination was five dollars for a two milligram tablet. The median price of eight milligrams was $20. Illicit buprenorphine-naloxone was reported to be very easy or easy to obtain and access to illicit supplies of the drug stable.

Morphine
The most commonly reported purchased amount and brand of morphine was 100 milligram tablets of MS Contin®. These were reported to cost a median of $50 and the price was stable compared to 2010. Perceptions of availability varied widely; however, most survey participants reported stability in ease of access to illicit forms of morphine. Morphine was more likely to be purchased from friends (51%) than street dealers (20%).

Oxycodone
Eighty milligrams of OxyContin® was the most commonly reported dose and brand of oxycodone reported to be purchased by respondents. These tablets cost a median of $40 which was stable in comparison to 2010. Similarly to morphine, perceptions varied over ease of availability to this drug illicitly amongst the sample; however, again it was agreed that ease of such access had remained stable. Again, like morphine, the drug was most frequently purchased through friends (46%).

Health-related trends associated with drug use
Overdose and drug-related fatalities
More than half the survey participants reported an overdose of heroin in their lifetime (59%) but overdose in the preceding twelve months was limited to 16% of respondents. There were 1,088 non-fatal heroin overdoses attended to by Ambulance Victoria during 2010. Only seven survey participants reported overdosing on other drugs in the year preceding interview with no clear pattern in the drugs implicated.

Drug treatment
During the 2010-2011 financial year, 54,457 courses of treatment were delivered to 28,207 clients2 in Victorian specialist alcohol and drug services. Alcohol was the most frequent drug of concern, followed by cannabis and then heroin.

During 2011, DirectLine responded to 40,101 calls; a drug of concern4 was identified in 52% of these calls and the distribution of these calls was similar to 2010. Heroin was identified as a drug of concern in 12% of all drug-identified calls. Other opiates were indicated in an additional 32% of all drug-identified calls. Eight percent of all drug-identified calls indicated amphetamine as the drug of concern. Cannabis accounted for a further 12% of drug-identified calls whilst, similarly to previous years, cocaine only accounted for a very small percentage of such calls of concern (1%).

According to the Victorian Department of Health, in 2011 13,763 clients were recorded as being on pharmacotherapy programs, with the largest percentage prescribed methadone (66%, n=9,030). Around one-third of pharmacotherapy clients were prescribed buprenorphine-naloxone (30%, n=4,078) and the remainder of clients were receiving buprenorphine (5%, n=655).

Hospital separations
Hospital admissions for opioids in Victoria have remained stable compared to previous years; however, these continue to account for the highest proportion of drug-related admissions. The highest ever number of hospital admissions relating to amphetamines was recorded during 2008-09. Admissions relating to cocaine and cannabis have remained stable.

Injecting risk behaviours and health problems
Eleven percent of Victorian IDRS 2011 survey participants reported borrowing a used needle in the preceding month and 22% reported lending a used needle to someone else. Reports of recently lending and borrowing needles were roughly similar to previous years but reports of sharing any other injecting equipment decreased across all categories from 2010.

Blood-borne viral infections attributable to illicit drug use were fairly stable in Victoria in 2010, although hepatitis C remains highly prevalent among PWID. Other injection-related health problems, such as skin problems and infections, were generally reported more frequently by the 2011 cohort than in 2010.

KE noted particular issues with regards to injection-related skin problems and infections requiring significant primary care. These issues were noted as being compounded by the ageing of the PWID population.

Mental health problems and psychological distress
Seventy-nine percent of the sample reported that they had experienced a mental health problem in the six months preceding the interview with most reporting experience of high prevalence disorders such as depression and anxiety. There were, however, some significant percentages of respondents reporting lower prevalence conditions such as schizophrenia and bipolar disorder (both 9%).

Driving risk behaviour
Of the 62 respondents who reported recently driving a vehicle, 19% reported having driven under the influence of alcohol and 73% after taking illicit drugs. Of the respondents who commented on the self-perceived effect of illicit drugs on their driving ability, the majority (71%) reported that they believed it had no effect or slightly improved their driving skills.

Law enforcement-related trends associated with drug use
Reports of criminal activity
Forty-six percent of survey participants reported being arrested in the 12 months preceding the IDRS study, with the largest proportion being related to property crime. Forty-seven percent reported engaging in any crime in the preceding month and 63% reported ever having been to prison.

Arrests
The number of heroin-related arrests remained stable in 2009-2010 compared to the previous reported year; however, arrests related to methamphetamine (3,590-3,223) dropped slightly and arrests related to cannabis (6,884-7,066) and cocaine (148-196) increased.

Expenditure on illicit drugs
The median amount spent by Victorian IDRS respondents the day prior to the survey was $20 (an amount which includes those respondents who reported not spending any money the day before).

Special topics of interest
Heavy Smoking Index for nicotine dependence
In the Fagerstrom test for nicotine dependence, a score of 3 is equivalent to very low dependence on tobacco. The mean score of IDRS participants was 3.1. One-fifth of daily smokers recorded a score of five or above indicating high nicotine dependence.

Alcohol Use Disorders Identification Test (AUDIT-C)
In the AUDIT-C test, a cut-off score of five or above indicates that further assessment is required for problems with alcohol dependence and risky drinking. The mean score for the 2011 survey participants was 6.1 and 60% of the sample scored five or more.

Pharmaceutical opioids
Fifty-three percent of IDRS participants reported using pharmaceutical opioids in the past six months, with common reasons being to relieve pain or to seek an opioid effect. Most of those using pharmaceutical opioids had only ever sought them from illicit sources (63%).

Over the counter codeine
Thirty-seven percent of participants reported using over the counter codeine to relieve pain in the last six months, generally acute short-term pain (for example, a headache or toothache). The most common brand used was Nurofen Plus®.

Injecting equipment use in the last month
Victorian IDRS participants most commonly utilised 1ml needle/syringes for their injecting drug use. These items were also the most commonly identified by participants as having been cleaned and re-used.

Physical and mental health (SF-12)
Participants scored lower on the physical component score (PCS) and mental component score (MCS) than Australian norms, indicating poorer physical and mental health among this sample of PWID.

Health service usage
GPs were the most commonly accessed health service by PWID; however, 17% of respondents had visited a hospital ED in the last four weeks. This concords with literature which suggests PWID have an over-dependence on acute crisis and emergency interventions (Kerr, Wood et al. 2004).

Online activity
More than half of participants reported that they had not used the internet in the past six months. Of those who said they had, very few had utilised the internet to obtain information about drugs or to buy drugs (10%). Nineteen percent of participants described text messaging as their preferred method of obtaining drugs.

Policy
Ninety-nine percent of participants support needle and syringe programs, as compared with between 67% and 80% of the general population in Australia. Similarly high numbers of the PWID sample also indicated support for methadone and buprenorphine programs, regulated injecting rooms and a trial of prescribed heroin. Participants generally had higher levels of support for these initiatives than the general population. Participants generally supported the legalisation of various drugs for personal use at higher rates than the general population and supported increased penalties for the sale and supply of illicit drugs at lower rates than the general population.

Conclusions
The results of the 2011 Victorian IDRS study indicate that the majority of illicit drug markets in Melbourne have remained stable over the last 12 months.

Key changes detected in the 2011 IDRS were:

Heroin was once again reported to be the main drug of choice, similar to the 2010 sample but in contrast to the 2009 sample (where it was reported to be methamphetamine).
A significant drop in the price paid per gram of heroin (from $325 to $250).
Differing patterns of use of the three main types of methamphetamines were noted, with speed use declining and ice and base use increasing. Overall, methamphetamine use increased from 2010 levels but did not equal the high levels seen in 2009.
The continuing emergence of illicit markets and inappropriate use of other ‘licit’ medications, aside from benzodiazapines, including opiate replacement drugs such as buprenorphine-naloxone, prescription opioids such as oxycodone and antipsychotics such as quetiapine.
A significant decrease in sharing of injecting equipment besides needles and syringes.
An increase in injection-related injury and disease requiring significant wound management and, in some cases, hospitalisation.
An increase in problem drinking behaviours among PWID.
A range of issues relating to the ageing of the PWID population.

On the basis of these findings, we recommend:

Continued monitoring of illicit drug markets for trends in price, purity, availability, patterns of drug use and related outcomes;
Further research on the impact on ageing on the PWID population, with particular attention paid to the types of primary and secondary health services required to effectively service this population;
Closer monitoring of illicit alprazolam, quetiapine and buprenorphine-naloxone use and potential associated health impacts;
Funding for needle and syringe program consumables which help to prevent injection-related injury and disease (e.g. sterile water, wheel filters);
Research on alcohol consumption patterns amongst PWID and impact on overall health, particularly with regard to the high prevalence of hepatitis C in this population.