Effects of a sustained heroin shortage in three Australian States

BACKGROUND: In early 2001 in Australia there was a sudden and dramatic decrease in heroin availability that occurred throughout the country that was evidenced by marked increases in heroin price and decreases in its purity. AIM: This study examines the impact of this change in heroin supply on the following indicators of heroin use: fatal and non-fatal drug overdoses; treatment seeking for heroin dependence; injecting drug use; drug-specific offences; and general property offences. The study was conducted using data from three Australian States [New South Wales (NSW), Victoria (VIC) and South Australia (SA)]. METHODS: Data were obtained on fatal and non-fatal overdoses from hospital emergency departments (EDs), ambulance services and coronial systems; treatment entries for heroin dependence compiled by State health departments; numbers of needles and syringes distributed to drug users; and data on arrests for heroin-related incidents and property-related crime incidents compiled by State Police Services. Time-series analyses were conducted where possible to examine changes before and after the onset of the heroin shortage. These were supplemented with information drawn from studies involving interviews with injecting drug users. RESULTS: After the reduction in heroin supply, fatal and non-fatal heroin overdoses decreased by between 40% and 85%. Despite some evidence of increased cocaine, methamphetamine and benzodiazepine use and reports of increases in harms related to their use, there were no increases recorded in the number of either non-fatal overdoses or deaths related to these drugs. There was a sustained decline in injecting drug use in NSW and VIC, as indicated by a substantial drop in the number of needles and syringes distributed (to 1999 levels in Victoria). There was a short-lived increase in property crime in NSW followed by a sustained reduction in such offences. SA and VIC did not show any marked change in the categories of property crime examined in the study. CONCLUSIONS: Substantial reductions in heroin availability have not occurred often, but in this Australian case a reduction had an aggregate positive impact in that it was associated with: reduced fatal and non-fatal heroin overdoses; reduced the apparent extent of injecting drug use in VIC and NSW; and may have contributed to reduced crime in NSW. All these changes provide substantial benefits to the community and some to heroin users. Documented shifts to other forms of drug use did not appear sufficient to produce increases in deaths, non-fatal overdoses or treatment seeking related to those drugs.     

Evaluating explanations of the Australian 'heroin shortage'

AIMS: In this paper we outline and evaluate competing explanations for a heroin shortage that occurred in Australia during 2001 with an abrupt onset at the beginning of 2001. METHODS: We evaluated each of the explanations offered for the shortage against evidence from a variety of sources: government reports, police and drug law enforcement documents and briefings, key informant (KI) interviews, indicator data and research data. RESULTS: No similar shortage occurred at the same time in other markets (e.g. Vancouver, Canada or Hong Kong) whose heroin originated in the same countries as Australia's. The shortage was due most probably to a combination of factors that operated synergistically and sequentially. The heroin market had grown rapidly in the late 1990s, perhaps helped by a decline in drug law enforcement (DLE) in Australia in the early 1990s that facilitated high-level heroin suppliers in Asia to establish large-scale importation heroin networks into Australia. This led to an increase in the availability of heroin, increasingly visible street-based drug markets, increased purity and decreased price of heroin around the country. The Australian heroin market was well established by the late 1990s, but it had a low profit margin with high heroin purity, and a lower price than ever before. The surge in heroin problems led to increased funding of the Australian Federal Police and Customs as part of the National Illicit Drug Strategy in 1998-99, with the result that a number of key individuals and large seizures occurred during 1999-2000, probably increasing the risks of large-scale importation. The combination of low profits and increased success of law enforcement may have reduced the dependability of key suppliers of heroin to Australia at a time when seized heroin was becoming more difficult to replace because of reduced supplies in the Golden Triangle. These factors may have reduced the attractiveness of Australia as a destination for heroin trafficking. CONCLUSIONS: The Australian heroin shortage in 2001 was due probably to a combination of factors that included increased effectiveness of law enforcement efforts to disrupt networks bringing large shipments of heroin from traditional source countries, and decreased capacity or willingness of major traffickers to continue large scale shipments to Australia.     

Decreased heroin availability in Sydney in early 2001

Aim To examine the veracity of reports of a substantial decrease in the availability of heroin in Sydney in January 2001. Design Cross‐sectional survey. Setting Sydney, Australia. Participants Forty‐one injecting drug users (IDUs) and 10 key informants (KIs). Findings Almost all IDUs (93%) reported that heroin was harder to obtain at the time of interview (mid‐February 2001) than it was before Christmas 2000 and KIs concurred. IDUs (83%) and KIs (70%) also reported that the price of heroin had increased since Christmas, and that the purity of heroin had decreased (IDUs 73%; KIs 80%). Almost all IDUs reported a reduction in their heroin use and a subsequent increase in other drug use, particularly cocaine, benzodiazepines and cannabis. Similar reports about IDUs came from nine of the 10 KIs. Over half the KIs reported an increase in both property and violent crime as a result of the heroin shortage. This crime was reportedly occurring mainly between heroin suppliers and/or IDUs. Reports from other Australian jurisdictions suggest that the shortage was not specific to Sydney. Conclusions The reduction in the availability of heroin provides a unique opportunity to investigate the impact of supply reduction.     

Changes in Canadian heroin supply coinciding with the Australian heroin shortage

AIMS: Previous studies have largely attributed the Australian heroin shortage to increases in local law enforcement efforts. Because western Canada receives heroin from similar source nations, but has not measurably increased enforcement practices or funding levels, we sought to examine trends in Canadian heroin-related indices before and after the Australian heroin shortage, which began in approximately January 2001. METHODS: During periods before and after January 2001, we examined the number of fatal overdoses and ambulance responses to heroin-related overdoses that required the use of naloxone in British Columbia, Canada. As an overall marker of Canadian supply reduction, we also examined the quantity of heroin seized during this period. Lastly, we examined trends in daily heroin use among injection drug users enrolled in the Vancouver Injection Drug Users Study (VIDUS). RESULTS: There was a 35% reduction in overdose deaths, from an annual average of 297 deaths during the years 1998-2000 in comparison to an average of 192 deaths during 2001-03. Similarly, use of naloxone declined 45% in the period coinciding with the Australian heroin shortage. Interestingly, the weight of Canadian heroin seized declined 64% coinciding with the Australian heroin shortage, from an average of 184 kg during 1998-2000 to 67 kg on average during 2001-03. Among 1587 VIDUS participants, the period coinciding with the Australian heroin shortage was associated independently with reduced daily injection of heroin [adjusted odds ratio: 0.55 (95% CI: 0.50-0.61); P < 0.001]. CONCLUSIONS: Massive decreases in three independent markers of heroin use have been observed in western Canada coinciding with the Australian heroin shortage, despite no increases in funding to Canadian enforcement efforts. Markedly reduced Canadian seizure activity also coincided with the Australian heroin shortage. These findings suggest that external global heroin supply forces deserve greater investigation and credence as a potential explanation for the Australian heroin shortage.     

Street-level drug law enforcement and entry into methadone maintenance treatment

Aims. To test the hypothesis that drug law enforcement encourages entry into methadone maintenance treatment. Design. Survey conducted as face-to-face interviews in methadone clinics, at needle exchange centres and on the street, in areas of widespread heroin dealing and use. Setting. Sydney, Australia. Participants. Heroin users. Measurements. Self-reported data on personal characteristics, and experience of drug law enforcement and methadone maintenance treatment. Findings. Although keeping their relationship/family together emerged as the most important reason given by respondents for entering treatment, avoiding more trouble with police/courts was also rated by the majority of respondents as an important or very important reason for entering treatment. The results of logistic regression analysis show that, after controlling for other factors, heroin users who have had a friend or family member imprisoned are more likely to have tried methadone maintenance treatment. A heroin user's own experience of arrest and imprisonment was also found to increase the likelihood of having tried treatment but only when age and length of time as a regular user (which were related to the user's experience of arrest and imprisonment) were excluded from the set of control variables. Despite having extensive histories of contact with the police and criminal justice system, however, Asian, Middle Eastern and Aboriginal respondents showed less proclivity to enter treatment than Caucasian respondents. Conclusion. Drug law enforcement may have a role to play in heroin demand reduction but its effects are not evident for all ethnic groups and the separate effects of contact with police, age and time spent in the heroin market remain unclear.     

Back-projection estimates of the number of dependent heroin users in Australia

Aims. To plan an appropriate response to heroin use in Australia, good estimates are needed of the numbers of dependent heroin users, the group who are most in need of treatment, most at risk of fatal opioid overdose and most at risk of contracting and transmitting blood-borne viruses. Methods. Back-projection methods were used to estimate the numbers of people starting dependent heroin injecting in Australia between 1960 and 1997. Separate analyses were based on national opioid overdose deaths and numbers of new entrants to methadone treatment in New South Wales (NSW). Estimates of the rates at which dependent heroin users cease heroin use, commence methadone treatment or die from opioid overdoses were estimated from external data sources. Results. Back-projection estimates derived from opioid overdose deaths indicated that there were 104 000 (lower limit of 72 000 and upper limit of 157 000) people who were heroin dependent in Australia between 1960 and 1997. Of these it was estimated that 67 000 (39 000-120 000) were still heroin dependent at the end of 1997. Back-projection estimates based on numbers of new entrants to methadone treatment in NSW indicated that there were 108 000 (82 000-141 000) heroin-dependent people in Australia between 1960 and 1997, of whom 71 000 (47 000-109 000) were estimated to be heroin dependent at the end of 1997. Both analyses indicated that the number of heroin-dependent people in Australia has increased substantially from the early 1970s onwards. Conclusions. Back-projection estimates based on analyses of treatment entries and opioid overdose deaths provide an additional method for estimating the numbers of heroin-dependent people in the population. The addition of these methods to existing methods, using different data sources and statistical methods, should improve consensus estimates of the numbers of heroin-dependent people.     

The impact of illicit drug supply reduction on health and social outcomes: the heroin shortage in the Australian Capital Territory

Aims We seek to establish whether a substantial decline in the supply of heroin, as measured by indicators such as drug purity, is related to changes in drug‐related health indicators such as ambulance callouts to heroin overdoses and numbers participating in methadone treatment programmes, and to changes in levels of property crime. The guiding hypothesis is that reduced supply will result in positive health and social outcomes. Design Standard time‐series methods are employed to analyse official data from local law‐enforcement and heroin supply indicators and several health and social outcome indicators within the Australian Capital Territory (ACT), spanning the late 1990s to early 2002. Autoregressive moving average (ARMA) models are estimated to remove autocorrelation from these series. Cross‐correlation and autoregression models are then employed to identify the best predictive models. Findings When autocorrelation has been removed, a reduction in heroin purity predicts a large decline in heroin‐related ambulance callouts and an increase in methadone treatment programme enrolments. There is little evidence of an increase in negative outcomes due to heroin users switching to other drugs. A reduction in purity also predicts declines in robbery and burglary but not in theft. Conclusion The overall evidence indicates modest links between the declines in heroin supply and increases in positive health outcomes and decreases in crime, as predicted by a simple economic model. Due to the shortness of some of the series and consequent limitations in statistical power, these conclusions should be regarded as tentative.     

Prevalence and correlates of intravenous methadone syrup administration in Adelaide,Australia

Aims The aims of this study were to determine the prevalence of methadone syrup injecting in Adelaide, South Australia and to characterize methadone injectors, including their heroin use and risk behaviours associated with heroin overdose. Design Cross‐sectional design. Setting Community setting, principally metropolitan Adelaide. Participants Current heroin users (used heroin in the last 6 months), recruited through snowballing. Measurements Structured questionnaire. Findings Of 365 participants, 18.4% reported having ever injected methadone syrup and 11.0% had injected methadone in the last 6 months. Those that had injected methadone were more likely to be male, and were more likely to be receiving methadone maintenance. They were also maintained on higher doses of methadone than subjects not injecting methadone. A history of methadone injection was associated with more heroin overdose experiences and greater dependence on heroin. Methadone injectors were also more likely to engage in risky behaviours associated with heroin overdose, including using heroin when no other people were present, not trial‐tasting new batches of heroin and polydrug use. Conclusions Methadone syrup injectors appear to be at greater risk of a series of harms than subjects not injecting methadone. The prevalence of methadone syrup injecting in Adelaide, South Australia was 11%, which was lower than prevalence in Sydney, New South Wales, but higher than in Melbourne, Victoria. Jurisdictional differences concerning the prevalence of methadone syrup injecting may reflect differing policies by each state to methadone dispensing.     

The impact of a supervised injecting facility on ambulance call‐outs in Sydney,Australia

Aims Supervised injecting facilities (SIFs) are effective in reducing the harms associated with injecting drug use among their clientele, but do SIFs ease the burden on ambulance services of attending to overdoses in the community? This study addresses this question, which is yet to be answered, in the growing body of international evidence supporting SIFs efficacy. Design Ecological study of patterns in ambulance attendances at opioid‐related overdoses, before and after the opening of a SIF in Sydney, Australia. Setting A SIF opened as a pilot in Sydney's ‘red light’ district with the aim of accommodating a high throughput of injecting drug users (IDUs) for supervised injecting episodes, recovery and the management of overdoses. Measurements A total of 20 409 ambulance attendances at opioid‐related overdoses before and after the opening of the Sydney SIF. Average monthly ambulance attendances at suspected opioid‐related overdoses, before (36 months) and after (60 months) the opening of the Sydney Medically Supervised Injecting Centre (MSIC), in the vicinity of the centre and in the rest of New South Wales (NSW). Results The burden on ambulance services of attending to opioid‐related overdoses declined significantly in the vicinity of the Sydney SIF after it opened, compared to the rest of NSW. This effect was greatest during operating hours and in the immediate MSIC area, suggesting that SIFs may be most effective in reducing the impact of opioid‐related overdose in their immediate vicinity. Conclusions By providing environments in which IDUs receive supervised injection and overdose management and education SIF can reduce the demand for ambulance services, thereby freeing them to attend other medical emergencies within the community.     

The impact of borderline personality disorder on 12-month outcomes for the treatment of heroin dependence

AIMS: To determine the effects of borderline personality disorder (BPD) on 12-month treatment retention and outcomes for the treatment of heroin dependence. DESIGN: Longitudinal cohort study. Setting Sydney, Australia. PARTICIPANTS: A cohort of 495 heroin users enrolled in the Australian Treatment Outcome Study. FINDINGS: Criteria for BPD were met by 45% of the cohort. At baseline there were no differences in heroin use, but the BPD group had higher levels of polydrug use, crime, needle risk-taking, more injection-related health problems, higher levels of overdose, poorer psychological health and more extensive suicide histories. At 12 months there was no group difference in the cumulative number of treatment days received, but the BPD group had enrolled in more different treatment episodes. Within both groups reductions had occurred in drug use and drug-related problems, with no differences in heroin use, polydrug use or global physical health at 12 months. After taking into account the effects of treatment on outcome, however, BPD was associated independently with a higher level of needle sharing [odds ratio (OR) 3.21], more injection-related health problems (OR 1.90), a higher likelihood of heroin overdose (OR 1.92), poorer global psychological health (OR 2.43), higher levels of current major depression (OR 3.19) and a higher likelihood of attempted suicide (OR 3.89). While BPD participants showed similar reductions in heroin and other drug use to other patients at 12 months, they continued to exhibit higher levels of risk and harm across a range of outcomes. CONCLUSIONS: Screening would appear to be warranted to identify a group who may overtly respond to treatment in terms of drug use per se, but remain at substantially greater risk.     

Heroin‐Related Deaths in Sydney,Australia. How Common Are They?

The objective of this article was to determine the number of recent deaths caused by accidental illicit drug overdoses seen at the NSW Institute of Forensic Medicine, Glebe (Sydney). All Forensic cases (3559) were reviewed during the period July 1995-February 1997. Any that were classified as accidental illicit drug overdose were followed up, and demographic and toxicological data were collected for analysis. Our results found that one hundred and forty three accidental illicit drug overdoses were identified from 3359 autopsies during the 20 month data collection period (4%). Male to female ratio was 5:1, but females predominated in the methadone toxicity group. Most of the cases were under 40 years of age. Toxicological results showed that 80% of the deaths were associated with morphine (heroin) levels in the toxic range, although 91% had morphine present at some level. Only 35% of cases had significant levels of bile morphine, suggesting "chronic" usage. In many cases, multiple illicit substances and/or alcohol were thought to be important contributing factors. Cocaine was found in 13% of cases, and all of these had morphine (heroin) in their blood. Methadone was found in 13% of cases, and 13/19 had toxic levels--9/19 also had morphine in their blood. Only two cases had amphetamines or methamphetamines in their blood. The authors conclude that Heroin overdose is by far the most common cause of accidental illicit drug overdose. Those at greatest risk are naive users and those who are not tolerant. There is an urgent need for increased awareness and further education concerning the dangers of heroin use, particularly of multiple drug use (including alcohol). Only about one-third of these cases appear to be "chronic" users.     

Morbidity associated with non-fatal heroin overdose

Aims To estimate the range and severity of heroin overdose related morbidity. Design Cross‐sectional survey. Setting Sydney, Australia. Participants 198 heroin users. Findings Sixty‐nine per cent had experienced a heroin overdose, 28% in the preceding 12 months. Of those who had overdosed, 79% had experienced at least one overdose‐related morbidity symptom. An ambulance had attended overdoses for 59% of subjects, 33% had required hospital treatment for overdose, and 14% had experienced overdose‐related complications of sufficient severity to be admitted to a hospital ward. Indirect overdose‐related morbidity included: physical injury sustained when falling at overdose (40%), burns (24%) and assault while unconscious (14%). Direct overdose‐related morbidity included: peripheral neuropathy (49%), vomiting (33%), temporary paralysis of limbs (26%), chest infections (13%) and seizure (2%). Conclusions There appears to be extensive morbidity associated with non‐fatal overdose. This is clearly an area that requires more research to document the prevalence and nature of these harms, and factors associated with them.     

Hair morphine concentrations of fatal heroin overdose cases and living heroin users

Aims To compare heroin and other opiate use of heroin overdose fatalities, current street heroin users and drug‐free therapeutic community clients. Design Hair morphine concentrations that assess heroin use and other opiate use in the 2 months preceding interview or death were compared between heroin overdose fatalities diagnosed by forensic pathologists (FOD) (n = 42), current street heroin users (CU) (n = 100) and presumably abstinent heroin users in a drug‐free therapeutic community (TC) (n = 50). Setting Sydney, Australia. Findings The mean age and gender breakdown of the three samples were 32.3 years, 83% male (FOD), 28.7 years, 58% male (CU) and 28.6 years, 60% male (TC). The median blood morphine concentration among the FOD cases was 0.35 mg/l, and 82% also had other drugs detected. There were large differences between the three groups in hair morphine concentrations, with the CU group (2.10 ng/mg) having concentration approximately four times that of the FOD group (0.53 ng/mg), which in turn had a concentration approximately six times that of the TC group (0.09 ng/mg). There were no significant differences between males and females in hair concentrations within any of the groups. Hair morphine concentrations were correlated significantly with blood morphine concentrations among FOD cases (r = 0.54), and self‐reported heroin use among living participants (r = 0.57). Conclusions The results indicate that fatal cases had a lower degree of chronic opiate intake than the active street users, but they were not abstinent during this period.     

The relationship between suicide and heroin overdose among methadone maintenance patients in Sydney, Australia

Aims . To examine the relationship between attempted suicide and non-fatal heroin overdose among methadone maintenance patients.
Design . Cross-sectional survey.
Setting . Sydney, Australia.
Participants . Two hundred and twenty-three methadone maintenance patients.
Findings . Forty per cent of participants reported a history of at least one suicide attempt. Females were significantly more likely than males to have attempted suicide (50% vs. 31%), and to have done so on more than one occasion (28% vs. 15%). There was a large difference between males and females in the onset of attempted suicide. Females reported an initial attempt, on average, 6 years earlier than males (18.3 vs. 24.7 years), and were significantly more likely than males to have attempted suicide prior to the onset of heroin use (69% vs. 11%). While heroin overdose was common among the sample (66%), the most common methods employed for suicide attempts were overdose of a non-opioid drug (21%) and slitting of wrists (20%). A deliberate heroin overdose as a means of attempted suicide was reported by 10% of participants. Heroin overdoses appeared overwhelmingly to be accidental. Ninety-two per cent of those who had overdosed reported that their most recent overdose was accidental.
Conclusions . Attempted suicide presents a major clinical problem to staff at drug treatment programmes, but one distinct from heroin overdose. While both overdose and suicide present increasing clinical problems, they are separate problems, and require different responses.     

Recent life problems and non-fatal overdose among heroin users entering treatment

AIMS: To investigate the role of recent life problems in non-fatal overdose among heroin users entering various drug treatment settings. DESIGN: Cross-sectional data from a longitudinal study investigating drug treatment effectiveness. SETTING: Five prison drug treatment services, three residential rehabilitation units, three residential detoxification units and 21 community drug treatment services located in rural, urban and inner-city areas of Scotland. PARTICIPANTS: Of a total of 793 primary heroin users commencing drug treatment during 2001-02, 337 (42.5%) were prison drug service clients; 91 (11.5%) were residential rehabilitation clients; 97 (12.2%) were residential detoxification clients; and 268 (33.8%) were community drug treatment clients. MEASUREMENTS: Univariate and stepwise multivariate logistic regression analyses examined associations between overdosing in the 90 days prior to treatment entry and basic demographic characteristics, recent drug use and recent life problems. FINDINGS: Ninety-one study participants (11.5%) reported at least one overdose and 19 (2.4%) reported more than one overdose in the 90 days prior to treatment entry. A chi2 test revealed no significant difference in rates of recent overdosing between the four treatment settings (P = 0.650). Recent drug use and recent life problems-but not demographic characteristics-were associated independently with recent overdosing. However, recent life problems were not associated independently with recent overdosing among clients entering prison, clients entering residential rehabilitation or with multiple recent overdosing. CONCLUSIONS: Associations between recent life problems and recent overdose were evident, but varied by treatment setting. Treatment providers should identify and address heroin users' life problems as part of a broad strategy of overdose prevention.     

Police and Illicit Drug Markets: Some Economic Considerations*

The role and effects of police activity in the enforcement of drug laws are examined using the economic tools of supply and demand analysis. In view of the epidemic nature of the drug abuse problem and its obvious economic aspects, the infrequent application of economic analysis in the area seems an anomaly. This analysis suggests that some of our current enforcement practices are apparently futile. It is clear, however, that no simple solution to illicit drug abuse exists because of the interdependence of the markets for different drugs, because of the interplay between the supply and demand sides of most clandestine drug markets, and because of changing social mores and legal standards. Several important implications for the activities of police are evident. Vigorous drug law enforcement by police appears to be counterproductive and dysfunctional when it is: (1) directed at drugs such as heroin which are addictive in nature and which have price inelastic (unresponsive) demands; and (2) directed primarily at the supply side of the market. Supply-reducing law enforcement activities will apparently not be counterproductive and will not greatly increase the number and character of crimes if it is directed at drugs which are nonaddictive in nature (for example, marihuana), and which have price elastic (responsive) demands. Demand-reducing policies are more appropriate for addicting drugs such as heroin. Demand-reducing polices analysed include; (1) education; (2) rehabilitative incarceration; and (3) drug substitutes such as methadone. The role of police in demand-reducing policies is probably smaller, however, than their corresponding role in supply-reducing policies. The role of police in a medically-oriented approach similar to that existing in Geat Britain is also minimal.