Changes in patterns of drug use among injecting drug users following changes in the availability of heroin in New South Wales, Australia

The aim of this study was to examine changes in drug use patterns among groups of injecting drug users (IDU) who remained in the drug market during a period of reduced heroin availability in NSW, Australia. Cross-sectional data collected from regular IDU interviewed as part of the NSW Illicit Drug Reporting System (IDRS) between 1996 - 2003 were analysed. Drug use patterns, reported drug availability and price were assessed. There was a marked decrease in the frequency of heroin use during the period of reduced availability in 2001, with some increase in 2002 and 2003. Heroin availability and frequency of use have not returned to levels reported prior to 2001; however; even at the peak of the reduction in supply, users continued to access heroin. There was a significant shift among IDU from heroin to cocaine during 2001, which subsequently reversed. The availability of cocaine has fluctuated in recent years, but the price has remained stable. The price of heroin appeared to be more responsive to market fluctuations, and co-varied with heroin availability. IDU used cocaine when heroin was less available; however, patterns of cocaine use were not maintained. The frequency of heroin use remained lower, which may be indicative of a less consistent supply, increased price or increased numbers of IDU entering treatment. The reduced supply of heroin in 2001 highlighted the adaptable nature of IDU patterns of use, indicative of the need for a commensurate treatment response. It also highlighted the importance of the ongoing monitoring of drug trends in Australia. [Roxburgh A, Degenhardt L, Breen C. Changes in patterns of drug use among injecting drug users following changes in the availability of heroin in New South Wales, Australia. Drug Alcohol Rev 2004;23:287-294]     

Documenting the heroin shortage in New South Wales

Australian heroin markets have recently undergone dramatic change, sparking debate about the nature of such markets. This study aimed to determine the onset, peak and decline of the heroin shortage in New South Wales (NSW), using the most appropriate available methods to detect market level changes. The parameters of the heroin shortage were determined by reviewing: reports of heroin users about availability and price (derived from the existing literature and the Illicit Drug Reporting System); qualitative interviews with injecting drug users, and health and law enforcement professionals working in the illicit drug field; and examining data on heroin seizures over the past decade. There was a marked reduction in heroin supply in NSW in early 2001. An increase in the price of heroin occurred in 2001, whereas it had decreased steadily since 1996. A reduction in purity also occurred, as reported by drug users and heroin seizures. The peak period of the shortage appears to have been January to April 2001. The market appears to have stabilised since that time, although it has not returned to pre-2001 levels: heroin prices have decreased in NSW for street grams, but not to former levels, and the price of 'caps' (street deals) remain elevated. Heroin purity in NSW has remained low, with perhaps a 10% increase above the lowest recorded levels. These data support the notion that the heroin market in NSW underwent significant changes, which appear to have involved a lasting shift in the nature of the market. [Day C, Degenhardt L, Hall W. Documenting the heroin shortage in New South Wales. Drug Alcohol Rev 2006;25:297 - 305]     

Crystal methamphetamine smoking among regular ecstasy users in Australia: increases in use and associations with harm

Introduction. This study examined (a) changes in crystal methamphetamine use among regular ecstasy users (REU) in Australia and (b) associations of crystal use and smoking with demographics, drug use and harm. Design and Methods. Cross-sectional surveys (2000 - 06) of REU in three Australian capital cities, and in 2006, 750 REU in all Australian capital cities. The interview included: demographics, drug use, risk behaviour, recent criminal activity and methamphetamine dependence using Severity of Dependence Scale. Results. There was little change in overall methamphetamine use, but a marked increase in crystal methamphetamine smoking. Among recent methamphetamine users in 2006 (n = 606), crystal methamphetamine users (n = 364) reported more frequent methamphetamine use and higher levels of dependence. Compared with those who had used only other forms of methamphetamine, recent crystal methamphetamine users were more likely to 'binge' on drugs for ≥48 hours, engage in crime and experience financial and legal problems related to drug use. Non-smoking crystal methamphetamine users (n = 78) more often reported recent injecting and heroin use. Recent smokers were more likely to have: greater polydrug use, recently overdosed on a 'party drug', and accessed medical services for their drug use. Many of these associations were accounted for by their injecting and heavier methamphetamine use, rather than smoking per se. Conclusions. Crystal methamphetamine smoking among REU has increased markedly and is associated with significant harm. This appears related to smokers' heavier levels of methamphetamine use. Effective harm reduction strategies should be tailored to these specific risks. [Kinner SA, Degenhardt L. Crystal methamphetamine smoking among regular ecstasy users in Australia: Increases in use and associations with harm. Drug Alcohol Rev 2008;27:292-300]     

Patterns of illicit drug use in NSW,Australia following a reduction in heroin supply

Objective:To examine whether a reduction in the availability of heroin in New South Wales (NSW) in 2001 was associated with community level changes in heroin and other drug use.Method:Data from the NSW Alcohol and Drug Information Service (ADIS) on the number of persons calling about different drug types were used to examine NSW trends in calls of concern about heroin and other drugs. ADIS is a 24-h telephone information and counselling service in NSW; data from ADIS has previously been shown to be related to trends in drug use. Data from an inner Sydney needle and syringe program on drugs injected by clients were also used to examine time trends among a sentinel group of injecting drug users (IDU). Time series analysis was used to model the series.Results:There was a significant reduction in calls regarding heroin associated with the reduction in heroin supply. Increases in calls about cocaine and methamphetamine were also associated with the heroin shortage. The reduction in calls about heroin appeared to be sustained, whereas the increases in calls about cocaine and methamphetamine were not.Conclusions:Decreases in heroin supply were associated with sustained decreases in the use of heroin at a community level. Substitution of other drugs probably occurred among some users, such substitution did not appear to be sustained, as the number of calls returned to pre-shortage levels.Implications:Drug supply reduction may lead to increases in use of other drug types. The health implications of such changes need to be borne in mind by law enforcement and health services.     

Changes in patterns of drug injection concurrent with a sustained reduction in the availability of heroin in Australia

Between 1996 and 2000, heroin was the drug most frequently injected in Australia, and viable heroin markets existed in six of Australia's eight jurisdictions. In 2001, there was a dramatic and sustained reduction in the availability of heroin that was accompanied by a substantial increase in its price, and a 14% decline in the average purity of seizures analysed by forensic laboratories. The shortage of heroin constitutes a unique natural experiment within which to examine the impact of supply reduction. This paper reviews one important correlate of the shortage, namely changes in patterns of illicit drug injection. A number of studies have consistently suggested that between 2000 and 2001, there was a sizeable decrease in both prevalence and frequency of heroin injection among injecting drug users. These changes were accompanied by increased prevalence and frequency of stimulant injection. Cocaine was favoured in NSW, the sole jurisdiction in which a cocaine market was established prior to the heroin shortage; whereas methamphetamine predominated in other jurisdictions. Some data suggest that, at least in the short-term, some drug injectors left the market altogether subsequent to the reduced heroin availability. However, the findings that (1) some former heroin users switched their drug preference to a stimulant; and (2) subsequently attributed this change to the reduced availability of heroin, suggests that reducing the supply of one drug may serve to increase the use of others. Given the differential harms associated with the use of stimulants and opiates, this possibility has grave implications for Australia, where the intervention and treatment system is designed primarily to accommodate opiate use and dependence.     

Trends in methamphetamine use in young injection drug users in San Francisco from 1998 to 2004: the UFO Study

Aims . To describe temporal trends in methamphetamine use among young injection drug users (IDU) in San Francisco. Design and Methods . Secondary analysis of cross‐sectional baseline data collected for a longitudinal study of young IDU from 1998 to 2004. Participants were 1445 young IDU (<30 years old) who reported injection in the previous month, English‐speaking, and recruited by street outreach methods. We examined trends for: lifetime (ever) and recent (30‐day) methamphetamine use, including injected and non‐injected, and by age group and sexual risk behaviour [men who have sex with men injecting drug users (MSM‐IDU), male IDU (non‐MSM) and female IDU]. Results . In 1998, 1999, 2000, 2001, 2003 and 2004 we interviewed 237, 276, 431, 310, 147 and 44 participants, respectively. Overall, median age was 22 years [interquartile range (IQR) 20–25], 30.3% were women and median duration of injecting was 4.4 years (IQR 2–7). Prevalence of methamphetamine use was high, with 50.1% reporting recent injection, but overall there were no temporal increases in reported ‘ever’ injected use. Recent methamphetamine injection (past 30 days) increased significantly, and peaked at 60% in 2003. MSM‐IDU had higher methamphetamine injection ever (92.3%) and recently (59.5%) compared to heterosexual male (non‐MSM) IDU (81.6% and 47.3%, respectively) and to female IDU (78.4% and 46.1%, respectively). Conclusions . Despite reports of ubiquitous increases in methamphetamine use, there were no significant increases in 6 years in ever injecting methamphetamine overall among young IDU. MSM‐IDU who reported the highest methamphetamine use overall reported some increases in recent injected use. The methamphetamine ‘epidemic’ was probably under way among young IDU earlier than other populations.     

Socio-demographic factors associated with methamphetamine treatment contact among dependent methamphetamine users in Sydney, Australia

Australia has a sizable population of dependent methamphetamine users, the majority of whom do not receive treatment for their drug use. The aim of the current study was to identify socio-demographic factors related to not having received treatment for methamphetamine use among dependent users of the drug in Sydney, Australia. A cross-sectional survey of methamphetamine users in Sydney was used to identify a sample of dependent methamphetamine users (n = 173). Dependence was defined as a score of four or greater on the Severity of Dependence Scale. Dependent methamphetamine users who had received treatment for their methamphetamine use (n = 57) were compared with those who had never received treatment for their methamphetamine use (n = 116) on socio-demographic characteristics and drug use. After adjusting for severity of methamphetamine dependence, socio-demographic factors that were predictive of not having received methamphetamine treatment included being female, being born outside Australia and being in full-time employment. Methamphetamine smokers were less likely to receive treatment than people who took the drug via other routes of administration, while primary heroin users who were concurrently dependent on methamphetamine were unlikely to receive treatment for their methamphetamine use. Further research is needed to understand the barriers to receiving methamphetamine treatment among these subgroups of dependent methamphetamine users. [McKetin R, Kelly E. Socio-demographic factors associated with methamphetamine treatment contact among dependent methamphetamine users in Sydney, Australia. Drug Alcohol Rev 2007;26:161 - 168]     

Impact of the heroin 'drought' on patterns of drug use and drug-related harms

Since late 2000, anecdotal reports from drug users and health professionals have suggested that there was a reduction in the supply of heroin in Adelaide in the first half of 2001, referred to as a heroin 'drought'. The aim of this paper was to critically review evidence for this, using data obtained from 100 injecting drug users surveyed for the 2001 Illicit Drug Reporting System (IDRS). This project is carried out annually in all Australian jurisdictions, and collects up-to-date information on the markets for heroin, methamphetamine, cocaine and cannabis. This paper also investigates the possible implications of this 'drought' on patterns of drug use and drug-related harms. The 2001 IDRS found consistent reports by users of an increase in the price of heroin, together with decreases in purity and availability. These factors resulted in a decrease in the frequency of self-reported heroin use among those surveyed in 2001, and a concomitant increase in the use of other drugs, in particular methamphetamine and morphine. The heroin 'drought' appears to have had a substantial impact on several indices of drug-related harm. There was a marked decrease in the number of opioid-related fatalities, and hospital data also showed reductions in heroin-related presentations. Treatment service data showed an increase in the number of admissions related to amphetamines. There is a need for health promotion and education on the adverse effects of methamphetamine use, and the development of improved treatment protocols for methamphetamine abuse and dependence. [Longo MC, Henry-Edwards SM, Humeniuk RE, Christie P, Ali RL. Impact of the heroin 'drought' on patterns of drug use and drug-related harms. Drug Alcohol Rev 2004;23:143 - 150]     

Gender differences among regular injecting drug users in Sydney, Australia, 1996-2003

Previous research has found that female injecting drug users (IDU) are younger and more likely to be involved in risky behaviours such as needle sharing and sex work than male IDU. Aboriginal female drug users, in particular, are over-represented in IDU and prison populations. These factors place female IDU at increased risk of health problems and complicate issues such as homelessness, unemployment and poverty. Although a substantial body of research exists, little trend analysis has been done in Australia and much of the previous literature has focused on treatment populations. Cross-sectional data from 1996 to 2003 from regular IDU in Sydney interviewed as part of Australia's drug monitoring system, the Illicit Drug Reporting System (IDRS) were examined for trends over time. The demographic characteristics, drug use patterns and self-reported risk behaviours of the most recent sample (2003) were analysed for gender differences. Female IDU were younger in all sample years. Female IDU were more likely to identify as Aboriginal or Torres Strait Islander (ATSI) and engage in sex work. There has been a steady increase in these proportions over time. Female IDU were less likely to have a prison history, although there has been an increase among both male and female IDU over time. There were no gender differences in drug use patterns or frequency of drug use. Larger proportions of females report lending needles. Reports of lending and borrowing needles have decreased over time among both male and female IDU. Female IDU may place themselves at greater risk than male IDU by being more likely to share injecting equipment and engage in sex work. Treatment and other measures to reduce harm may need to be targeted specifically at women and, in particular, indigenous women. [Breen C, Roxburgh A, Degenhardt L. Gender differences among regular injecting drug users in Sydney, Australia, 1996 - 2003. Drug Alcohol Rev 2005; 24:353 - 358]     

The relationship between initial route of heroin administration and speed of transition to daily heroin use

Introduction and Aims. The effect of heroin administration route on speed of transition to regular use is unknown. This paper aims to determine whether the speed of transition from initiation of heroin use to daily heroin use differs by route of administration (injecting, chasing/inhaling or snorting). Design and Methods. Privileged access interviewer survey of purposively selected sample of 395 current people who use heroin (both in and not in treatment) in London, UK (historical sample from 1991). Data on age and year of initiation, time from initiation to daily use and routes of administration were collected by means of a structured questionnaire. Generalised ordered logistic models were used to test the relationship between route of initial administration of heroin and speed of transition to daily heroin use. Analyses were adjusted for gender, ethnicity, daily use of other drug(s) at time of initiation, year of initiation and treatment status at interview. Results. After adjustment, participants whose initial administration route was injecting had a 4.71 (95% confidence interval 1.34–16.5) increase in likelihood of progressing to daily use within 1–3 weeks of initiation, compared to those whose initial administration route was non‐injecting. Discussion and Conclusions. The speed of transition from first use to daily heroin use is faster if the individual injects heroin at initiation of use. Those who initiate heroin use through injecting have a shorter time frame for intervention before drug use escalation. [Hines LA, Lynskey M, Morley KI, Griffiths P, Gossop M, Powis B, Strang J. The relationship between initial route of heroin administration and speed of transition to daily heroin use. Drug Alcohol Rev 2017;00:000‐000]     

The gendered context of initiation to injecting drug use: evidence for women as active initiates

This paper explores differences between women's and men's first experience of injecting in relation to socio-demographic context, drug use, and the role of others. We collected cross-sectional retrospective data from 334 recently initiated (≤5 years) injecting drug users in New South Wales and Queensland, Australia using a structured questionnaire in face-to-face interviews. Logistic regression was used to estimate crude and adjusted odds ratios (OR). Findings from the adjusted analysis show that women had a shorter duration of illicit drug use prior to initiation (adjusted OR 0.84, 95%CI: 0.74 - 0.94), and were more likely to have their romantic-sexual partner facilitate the initiation by paying for the drugs (adjusted OR 4.64, 95%CI: 1.21 - 17.73). Women also reported a greater likelihood of being initiated in groups of other women (adjusted OR 2.87, 95%CI: 1.24 - 6.67), suggesting that some women play an active role in their initiation experience rather than relying on, or being lead by, a romantic-sexual partner. These findings demonstrate the crucial role that romantic-sexual partners play in women's initiation experience, but also provide evidence for the way that women can be active participants in their own initiation and in initiating other women. [Bryant J, Treloar C. The gendered context of initiation to injecting drug use: evidence for women as active initiates. Drug Alcohol Rev 2007;26:]     

Illicit tranquilliser use and dependence among female opiate users

This study determined the predictors of 12-month dependence on illicit tranquillisers among female opiate users attending three services in Glasgow, Scotland, UK. Twelve-month drug dependence was measured using the Diagnostic Interview Schedule. The Revised Clinical Interview Schedule (CIS-R) measured current neurotic symptoms. 60% (159/266) had used illicit tranquillisers in the past 30 days, and 50% (132/266) met criteria for 12-month dependence on illicit tranquillisers. Polydrug use, injecting drug use, childhood and adulthood abuse, adverse life experiences and current and previous mental health problems were associated with 12-month dependence on illicit tranquillisers. Using multiple logistic regression, polydrug use in last 30 days (OR 3.2, 95% CI 1.5 - 7.0), history of deliberate self-harm (OR 2.5, 95% CI 1.4 - 4.4), history of injecting drug use (OR 2.5, 1.2 - 5.2) and likely to need treatment for current neurotic symptoms (CIS-R ≥ 18) (OR 2.4, 95% CI 1.3 - 4.4) predicted 12-month dependence on illicit tranquillisers. Drug users in general and female drug users in particular who are using illicit tranquillisers are also particularly likely to have psychiatric symptoms requiring treatment. Mental health problems should be assessed and monitored among this client group and counselling and psychosocial support should be provided when indicated. [Gilchrist G, Atkinson J, Gruer L. Illicit tranquilliser use and dependence among female opiate users. Drug Alcohol Rev 2006;25:459 - 461]     

Age differentials in the impacts of reduced heroin: effects of a "heroin shortage" in NSW, Australia

BACKGROUND: This paper uses a unique event, the Australian heroin shortage, to see whether an abrupt, substantial and sustained change in heroin supply had different effects on harms related to heroin use among younger and older heroin users. METHOD: Indicator data were examined by age group on the number of persons entering treatment for heroin and amphetamine dependence, arrests for heroin use/possession and number of drug related deaths in NSW, Australia. Data were analysed using times series analysis. RESULTS: There was a 41% reduction in the number of new registrations for opioid pharmacotherapy per month among 25-34 year olds, and a 26% reduction among 15-24 year olds, but no apparent changes among older age groups. Similarly, reductions in the number of non-pharmacological heroin treatment episodes were most pronounced among younger age groups. There was a 49% reduction in the number of heroin possession/use offences among those aged 15-24 years, compared to declines of 31-40% among older age groups. Declines in heroin related deaths were greatest among 15-24 year olds (65% reduction). There was no change in other drug related deaths in any age group. CONCLUSIONS: A reduction in heroin supply was followed by greater reductions in heroin related harms among younger than older people, across a number of outcome domains.     

The association between cocaine use and short-term outcomes for the treatment of heroin dependence: findings from the Australian Treatment Outcome Study (ATOS)

The aim of this study was to determine the prevalence of cocaine use among individuals presenting for treatment for heroin dependence, describe the clinical profile of heroin users who also use cocaine and to establish the effects of cocaine use on short term outcomes for the treatment for heroin dependence. A longitudinal follow-up of 549 heroin users recruited in Sydney for the Australian Treatment Outcome Study was conducted at 3-month post-baseline interview. At baseline, current cocaine use was common (39%) and was associated with increased drug use, needle risk taking and criminality. The 3-month prevalence of cocaine use declined significantly to 19%. Thirty-five per cent of those who had used cocaine at baseline continued to use at 3 months, while 9% of the sample had commenced cocaine use. Those who entered residential rehabilitation at baseline were less likely than other treatment entrants and the non-treatment group to have used cocaine at follow-up. Treatment retention was not affected by baseline cocaine use status; however, baseline cocaine users (CU) displayed higher levels of heroin use, polydrug use and drug-related problems. A poorer outcome was associated with the commencement or continuation of cocaine use, while cessation of cocaine use resulted in significant improvements on these measures. Cocaine use was common among individuals seeking treatment for heroin dependence and was an important moderator of treatment outcome. It appears that cocaine use has a strong negative effect on treatment outcome over and above that caused by polydrug use generally. [Williamson A, Darke S, Ross J, Teesson M. The association between cocaine use and short-term outcomes for the treatment of heroin dependence: findings from the Australian Treatment Outcome Study (ATOS). Drug Alcohol Rev 2006;25:141 - 148]     

Estimating national-level syringe availability to injecting drug users and injection coverage: Switzerland, 1996-2006

Background

Measuring syringe availability and coverage is essential in the assessment of HIV/AIDS risk reduction policies. Estimates of syringe availability and coverage were produced for the years 1996 and 2006, based on all relevant available national-level aggregated data from published sources.

Methods

We defined availability as the total monthly number of syringes provided by harm reduction system divided by the estimated number of injecting drug users (IDU), and defined coverage as the proportion of injections performed with a new syringe, at national level (total supply over total demand). Estimates of supply of syringes were derived from the national monitoring system, including needle and syringe programmes (NSP), pharmacies, and medically prescribed heroin programmes. Estimates of syringe demand were based on the number of injections performed by IDU derived from surveys of low threshold facilities for drug users (LTF) with NSP combined with the number of IDU. This number was estimated by two methods combining estimates of heroin users (multiple estimation method) and (a) the number of IDU in methadone treatment (MT) (non-injectors) or (b) the proportion of injectors amongst LTF attendees. Central estimates and ranges were obtained for availability and coverage.

Results

The estimated number of IDU decreased markedly according to both methods. The MT-based method (from 14,818 to 4809) showed a much greater decrease and smaller size of the IDU population compared to the LTF-based method (from 24,510 to 12,320). Availability and coverage estimates are higher with the MT-based method. For 1996, central estimates of syringe availability were 30.5 and 18.4 per IDU per month; for 2006, they were 76.5 and 29.9. There were 4 central estimates of coverage. For 1996 they ranged from 24.3% to 43.3%, and for 2006, from 50.5% to 134.3%.

Conclusion

Although 2006 estimates overlap 1996 estimates, the results suggest a shift to improved syringe availability and coverage over time.     

Characteristics and harms associated with injecting versus smoking methamphetamine among methamphetamine treatment entrants

Introduction and Aims. To compare the characteristics and harms associated with injecting and smoking methamphetamine among methamphetamine treatment entrants. Method and design. A structured face-to-face interview was used to assess demographics, drug use patterns and harms [physical and mental health, psychological distress, psychotic symptoms, crime and human immunodeficiency virus (HIV) risk behaviour] among 400 methamphetamine treatment entrants in Sydney and Brisbane, Australia. Participants who had injected but not smoked methamphetamine in the month before treatment (n = 195, injectors) were compared to participants who had either: (a) injected and smoked (n = 90, injectors who smoke), or (b) smoked but not injected (n = 73, smokers), during this time. Results. In comparison with injectors, smokers were primarily non-injecting drug users, who were younger, more likely to be female and use ecstasy rather than heroin. After adjusting for these differences smokers were less dependent on methamphetamine than injectors, but they took the drug as often and had similarly high levels of psychological distress, poor physical and mental health, psychotic symptoms, sexual risk behaviour and criminal involvement. Injectors who smoked had a similar demographic and clinical profile to injectors, including comparable levels of needle sharing, but they used methamphetamine more often and had greater criminal involvement. Conclusion. Within this treatment sample, smoking methamphetamine occurred among both long-standing injecting drug users and a comparatively younger group of non-injecting drug users. It was associated with less severe methamphetamine dependence than injecting, but more intense use patterns and similar levels of other harms. [McKetin R, Ross J, Kelly E, Baker A, Lee N, Lubman DI, Mattick R. Characteristics and harms associated with injecting vs. smoking methamphetamine among methamphetamine treatment entrants. Drug Alcohol Rev 2008;27:277-285]