Executive summary

Demographic characteristics of participants

In 2011, 98 people who inject drugs (PWID) were interviewed for the IDRS in the Australian Capital Territory (ACT). The majority of participants were male (63%) and on average 38 years old (ranging from 17 to 65 years). In terms of education, participants had completed an average of 10 formal school years, 29% of respondents had trade or technical qualifications, and 11% reported having university or other tertiary qualifications. Fifty-three percent had a previous prison history. Just over half (58%) reported currently participating in some form of drug treatment. The most common form of drug treatment was methadone maintenance treatment with 43% of those in treatment engaged in buprenorphine maintenance treatment and buprenorphine-naloxone maintenance treatment at 6%. The demographic characteristics of the 2011 sample were very similar to those of the 2010 sample.

Patterns of drug use among participants
In terms of the injection history of respondents, the mean age of first injection was 18 years (ranging from 10 to 39 years). Heroin and speed were the drugs first injected by the majority of the 2011 sample. Heroin was the drug of choice for the majority of respondents (65%), followed by ice/crystal methamphetamine (12%). The drug injected most often by participants in the month preceding the interview was heroin (50%). Heroin was also the last drug injected by 49% of respondents, followed by ice/crystal methamphetamine (14%). In 2011, there was a 50% decrease in the proportion of the ACT sample reporting methamphetamine as their drug of choice; however, the drug injected most often in the past month slightly increased. In 2011, the number of participants reporting cannabis as the drug of choice decreased by more than half.

In 2011, 38% of the sample reported a discrepancy between their drug of choice and the drug they injected most often in the previous month. Of those that reported a discrepancy (n=36), most respondents reported that this was due to availability (28%), price (22%), or their drug of choice being non-injectable (17%). The most common drug used on the day prior to the interview was cannabis (63%).

Participants reporting daily or more frequent drug injection in the month preceding the IDRS survey remained stable in 2011 at 41% (44% in 2010).

Heroin
The proportion of participants reporting use of heroin in the six months preceding interview was 79%, almost identical to 2010 (see Table 1). Almost all (97%) participants who had used heroin in the preceding six months reported injecting it, whilst 8% had also recently smoked it. In terms of the frequency of use, patterns varied from once to daily use. In the six months preceding interview, the median days of heroin use was 66 (two to three times a week); this increased from 60 days in 2010.

In 2011, participants were asked to comment on the colour and form of heroin used in the previous six months. The majority of participants reported that they had used heroin that was a powder and off-white or white (77%) in colour. Fifteen percent of participants reported using powder that was brown or beige coloured in the previous six months which decreased from 28% in 2010. Almost over half (52%) reported using white or off-white rock, 8% of participants reported recently using brown or beige coloured rock heroin which dropped from 14% in 2010.

Methamphetamine
The IDRS survey collects data on three different forms of methamphetamine: methamphetamine powder (speed), methamphetamine base (base) and crystal methamphetamine (crystal). A summary of the 2011 findings is presented in Table 1 for the three forms of methamphetamine. In 2011, 94% of participants reported lifetime use of any form of methamphetamine and 73% of the sample reported the recent use of some form of methamphetamine, which was an increase from 2010 (59%).

Speed
Almost half (46%) of the sample reported the recent use of speed, which was similar to 2010 (48%). The majority of recent speed users had used infrequently in the six months prior to interview, with a median of 9.5 days of use reported during this period. No one reported daily use of speed. Injection was the most common route of administration, with almost all (89%) of recent speed users having injected in the six months preceding interview.

Base
Methamphetamine base was the least used form of methamphetamine among the 2011 sample, with 17% reporting recent use (18% in 2010). The median number of days that base was used in the six months preceding the interview remained stable (less than weekly) from five in 2010 to 6.5 in 2011. As with speed, injection was the most common form of base administration, with all recent base users reporting injection as a route of administration for them.

Crystal
The use of crystal increased from 48% in 2010 to 57% in 2011 (identical to that of 2009). Ninety-five percent of recent crystal users had injected it while the number of participants who had smoked it in the six months preceding interview doubled to 38% in 2011 from 19% in 2010. Use remained infrequent but still almost doubled with recent crystal users reporting a median of 12 days of use in the six months prior to the interview (6.5 in 2010). In 2011, one participant reported daily use of crystal.

Cocaine
Recent cocaine remained stable at 6% of participants in 2010 and 8% in 2011. Among those who had recently used cocaine in the ACT, the frequency of use remained low although increased slightly, with a median of eight days of use in the six months prior to interview (i.e. approximately once a month). Among the participants who reported recent cocaine use, the most common route of administration was injection.

Cannabis
Cannabis use was widespread and frequent amongst the sample in 2011; this was consistent with reports from KE. All participants in the sample had tried cannabis at least once in their life and 87% reported the recent use of cannabis. The majority of the sample used cannabis frequently in the six months preceding interview with a median of 180 days of use (i.e. daily use), which was equivalent to 2010.

Other opioids
In this report, ‘illicit’ methadone use refers to the use of methadone that was prescribed for someone else. The recent use of illicit methadone among the ACT sample in 2011 remained stable at 19% of participants (24% in 2010). Among those who had recently used, the frequency of illicit methadone use was approximately monthly, with a median of six days of use in the previous six months (11 days in 2010). All participants who reported recent use of other opioids used swallowing as the most common route of illicit methadone administration.

‘Illicit’ buprenorphine use refers to the use of buprenorphine that was prescribed for someone else. The recent use of illicit buprenorphine among the ACT sample remained stable in 2011 at 21% (21% in 2010). The median days of illicit buprenorphine use in the six months prior to interview decreased from 72 days in 2010 to 60 in 2011. The most common route of administration for recent illicit buprenorphine use among the 2011 sample was injecting. Of those who had been prescribed licit oral buprenorphine, 56% reported having injected it at least once in the six months preceding interview.

In the 2011 IDRS survey, participants were asked about use of illicit morphine. Use of ‘illicit’ morphine refers to the use of morphine that was prescribed for someone else. Forty percent of participants reported that they had used illicit morphine at least once in their life. Twenty-one percent reported using illicit morphine in the preceding six months. The main route of administration for participants who had recently used illicit morphine was injection (87%). Participants reported using illicit morphine on a median of five (almost once every month) in the preceding six months.

In 2011, 47% of participants reported lifetime use of illicit oxycodone, an increase from 2010 (21%). Use of ‘illicit’ oxycodone refers to the use of oxycodone that is prescribed to someone else. Recent use of illicit oxycodone also increased from 13% of participants in 2010 to 23% in 2011. The median days of illicit oxycodone use remained low and stable at two and a half days in the six months preceding interview (approximately once every two months).

The recent use of ‘other opioids’ such as codeine by participants in the ACT increased from 6% in 2010 to 19% in 2011. The median number of days of use of other opioids decreased markedly from 31.5 in 2010 to 6 in 2011.

Patterns of other drug use
Eighty-one percent of participants reported lifetime use of benzodiazepines (85% in 2010) and 64% reported using benzodiazepines in the six months preceding interview (68% in 2010). The proportion of participants who reported recent use of licit benzodiazepines decreased from 47% in 2010 to 29% in 2011.

Thirty-four percent of participants reported recent use of illicit benzodiazepines, a decrease from 42% in 2010. The frequency of use for licit benzodiazepines was 180 days (daily) and five days for illicitly obtained benzodiazepines. The most common route of administration for recent users of both forms of benzodiazepines was reported to be swallowing (29% of participants for licit benzodiazepine and 34% for illicit benzodiazepine).

Participants were asked to comment on their use of pharmaceutical stimulants (or prescription amphetamines). This included drugs such as dexamphetamine and methylphenidate, which are medications most commonly prescribed for attention deficit hyperactivity disorder (ADHD). Twenty-five percent of the 2011 sample reported the recent use of illicit pharmaceutical stimulants. The median number of days of illicit pharmaceutical stimulant use in the preceding six months was five (i.e. less than monthly), similar to 2010 (four days). Seven percent of participants reported the use of licit pharmaceutical stimulants in the preceding six months (6% in 2010).

Over the counter (OTC) codeine was used in the previous six months by half (50%) of the sample (35% in 2010). Participants reported using OTC codeine on a median of six days (once every month).

Alcohol was recently used by more than two-thirds (70%) of the sample in the ACT in 2011. Recent alcohol users reported a median of 16 days (just over once a fortnight) of use in the six months prior to interview, down from 30 days in 2010. The majority of participants (96%) reported the recent use of tobacco, and 96% were daily smokers.

Patterns in price, purity and availability of drugs

Heroin
The reported price for a cap of heroin has remained stable in the ACT since 2001 at $50. In 2011 the reported price for a gram of heroin has remained stable at $300, which was equivalent to 2010. Respondents reported heroin to be very easy (48%) to easy (41%) to obtain, which was similar to 2010. There was a decrease in participants reporting heroin purity to be low from 57% in 2010 to 50% in 2011. In 2011, 31% reported heroin purity to be medium (up from 28% in 2010), and only 13% reported purity to be high (4% in 2010).

Methamphetamine

Speed
The reported price for a point of speed remained stable at $50. The median price reported for a gram of speed increased to $300 from $250 in both 2009 and 2010. Respondents reported speed to be very easy (34%) to easy (47%) to obtain in the ACT. In 2011, participants perceived the purity of speed to be low (38%) to medium (33%).

Base
In 2011, the number of participants reporting on the price of base was small so the following results should be interpreted with caution. The median price for a point of base was stable at $50 in both 2010 and 2011, as was the median price for a gram of base at $250. In 2011, respondents reported the availability of base to be very easy (41%) to obtain. There was an increase in the proportion reporting that base was easy to obtain from 18% in 2010 to 35% in 2011. There were mixed reports regarding the current purity of base, with 40% reporting purity to be medium, and 27% reporting purity to be equally low and high.

Crystal
The median price for a point of crystal increased significantly to $92.50 from $50 in 2010. The price for a gram increased by more than 100% to $600 in 2010 from $275 in 2010; however, only a very small number of participants reported on the price of this quantity in 2011 so results should be interpreted with caution. There were mixed reports on crystal availability: 42% reported crystal to be easy to obtain while 38% reported that it was very easy. The majority of participants in 2011 reported that crystal purity was medium (27%) or high (31%). There was a small increase in the proportion of participants who reported that crystal was low in purity (27%; 22% in 2010).

Cocaine
In 2011, 10 participants commented on the price, purity and availability of cocaine. Of those who commented, half believed that cocaine purity was currently medium, while 20% reported purity as high and 20% low. The majority (80%) of participants report the availability of cocaine as reported as easy or very easy to obtain.

Cannabis
The median reported price of a gram of hydro or bush in 2011 remained stable compared to 2010 at $20. The median price for an ounce of hydro increased to $300 in 2011, while the median price for an ounce of bush remained stable at $250. The majority of participants perceived hydro to be very easy (57%) to easy (38%) to obtain. There were mixed reports on the availability of bush cannabis although the majority reported that it was very easy (61%) to easy (27%) to obtain. Participants reported that the availability of both hydro and bush cannabis had remained stable in the six months preceding interview. (Table 2).

Health-related trends

Overdose
Almost half (46%) of the sample reported having overdosed on heroin at least once at some point in their lives. Twenty-one percent of the sample reported having overdosed on heroin in the last 12mths.

Drug treatment
Over half (58%) of respondents reported that they were currently receiving drug treatment. The most commonly reported drug treatment was methadone or biodone syrup.
In the ACT, indicator data from the Australian Institute of Health and Welfare on the total number of clients registered in opioid substitution treatment remained relatively stable between 2009 and 2010. The majority of clients were being prescribed methadone, followed by buprenorphine-naloxone and buprenorphine.

Hospital admissions
The number of opioid-related hospital separations nationally decreased between 2007/08 and 2008/09, the most recent data available at the time of publication. The number of amphetamine hospital admission per million persons decreased slightly between 2007/08 and 2008/09. Cocaine-related hospital separations remained low relative to those for heroin and methamphetamine. Cannabis-related separations decreased between 2007/08 and 2008/09. At the time of print the 2009/10 data for hospital admissions was not available.

Injecting risk behaviour
Thirteen percent of participants reported that they had injected with a syringe after someone in the past month (11% in 2010); 13% of participants reported that they had lent a syringe in the past month, compared to 16% in 2010. The proportion of participants that reported sharing injecting equipment (e.g. spoons, mixing containers, water and swabs) decreased from 32% in 2010 to 22% in 2011, with levels of injection-related risk-taking behaviour remaining high. Given these levels of injection-related risk-taking behaviour, risk of transmission of hepatitis C virus (HCV) remains a concern.

Blood-borne viral infections
Indicator data from the National Notifiable Diseases Surveillance System (NNDSS) reported a total of 191 cases of HCV in the ACT in 2011, a decrease from 224 in 2010. There were no positive cases of HIV identified in the ACT sample surveyed for the annual NSP) survey conducted by The Kirby Institute (formally the National Centre in HIV Epidemiology and Clinical Research) in 2010.

Mental health problems and psychological distress
In the 2011 ACT IDRS sample, 39% reported experiencing mental health problems in the six months preceding interview. The most commonly reported mental health problems were depression and anxiety. Of those who reported a mental health problem, 61% had seen a mental health professional in the past six months. Participants were also administered the Kessler Psychological Distress Scale (K10). One-quarter (26%) scored at levels indicating high distress and a further 31% scored at levels indicating very high distress. The scores amongst this sample were much higher than those of the general population.

Driving risk behaviour
Participants were asked about driving while under the influence of drugs. Of those who had driven in the previous six months (n=34), 18% reported driving under the influence of alcohol and 82% reported driving under the influence of drugs during that period. Participants most commonly reported driving while under the influence of heroin and cannabis.

Law enforcement-related trends
The proportion of participants who reported having been arrested in the last year remained stable at 20% (22% in 2010). In 2011, the proportion of participants reporting committing at least one crime in the month preceding interview increased slightly (33%; 26% in 2010). The most common crimes committed, as reported by participants in the month prior to interview, were dealing and property crime.

The most recent indicator data available on consumer and provider arrests were for the financial year 2009/10. These data indicated that the number of drug-specific arrests made by ACT police remained fairly steady from the previous year. A total of 386 arrests were made, with 332 of these being consumer arrests and the remaining 54 being provider arrests. Of the 386 arrests made, 224 were related to cannabis.

Special topics of interest

Heavy Smoking Index/nicotine dependence
Daily smokers were asked two questions from the Fagerstrom test (known as the Heavy Smoking Index of HSI). Among those who reported daily smoking, half reported having their cigarette within the first five mins of waking. Over half (54%) of daily smokers reported smoking between 11-20 cigarettes a day. The mean HSI score was 3.1 among daily smokers. Forty percent of daily smokers scored five or above indicating high nicotine dependence.

Alcohol Use Disorders Identification Test-Consumption
In 2011 IDRS participants were asked to respond to the AUDIT-Consumption. Fifty-five percent of the sample scored five or over on the measure. A score of over five indicates the need for further assessment.

Pharmaceutical opioids
Nearly half of the ACT sample recently used pharmaceutical opioids such as methadone, oxycodone. Of those who recently used pharmaceutical opioids, nearly half reported using them for pain relief and around one-third to seek an opioid effect. Twenty percent of those who commented reported that they were refused pharmaceutical medications due to injecting history. Of those who commented, three-quarters were prescribed pharmaceutical opioids by their general medical practitioner (GP).

OTC codeine
Around two-thirds of the ACT sample reported the use of OTC codeine in their lifetime, with half using OTC codeine in the last six months on a median of six days. Forty-five percent of participants reported using OTC codeine for medical purposes. The main type of medical purpose was short-term pain (81%). Eleven percent of the national sample reported the use of OTC codeine for non-medical purposes.

Injecting equipment use in the last month
Eighty-six percent of the ACT sample who commented reported the use of 1 ml needle and syringes in the last month followed by a winged view infusion set (butterfly) (36%) and wheel filter (32%). The re-use of 1 ml needle and syringe was reported by 43% of the ACT IDRS sample who commented. Of those who commented, 39% reported cleaning 1 ml needle/syringes, with just over half (55%) reporting last cleaning a 1 ml needle/syringe.

Mental and Physical Health problems (SF12)
ACT IDRS participants scored a mean for 34.6 for the mental component score (MCS) and 42.0 for the physical component score (PCS). The ACT IDRS participants had significantly lower MCS and PCS scores compared to the Australian population. Scores indicated that ACT IDRS participants had poorer mental and physical health then the population average.

Health Service Access
The majority of participants (n=55) reported visiting a GP in the last four weeks on a median of one occasion (1-28 occasions). Fifty-six percent reported visiting a GP once in the last four weeks.

Online activities
Of the ACT sample who commented, 37% reported that they had used the internet in the last month, with 12% reporting daily internet use. Of those who had used the internet in the last month, 41% reported going online to get information about drugs. Of those who commented, 33% altered their drug dose and 17% used a new drug combination or route or administration due to information found online. Text messaging was the preferred medium to obtain drugs.

Policy
Ninety-six percent of the ACT IDRS sample, who commented, supported NSPs to reduce problems associated with heroin use. The majority also supported methadone/buprenorphine maintenance programs, treatment with drugs (not including methadone) and regulated injecting rooms. The majority of the ACT IDRS sample also supported the legalisation of cannabis (92%) for personal use and nearly three-quarters (70%) supported the legislation of heroin for person use. Small numbers supported the increased penalties for sale or supply of cannabis (11%). Between 16% and 24% supported the increased penalties for sale or supply of heroin, methamphetamine or cocaine.

Implications

In 2011 there was an increase, compared to 2010, in the proportion of respondents reporting recent use of any methamphetamine (73% in 2011 compared to 59% in 2010). This represents a break in the decline of methamphetamine use since 2006. The trend of decreasing use of crystal also was broken, with an increase from 48% having recently used crystal in 2010 to 57% in 2011. Crystal continues to be reported by many key experts (KE) as one of the most problematic drugs seen in their service. Reasons for this include the complex mental health issues, aggressiveness and psychosis often associated with crystal use. Despite decreased use, there is still clearly a need for targeted prevention and treatment strategies to help minimise the harms associated with crystal use.
The use of cannabis in this group remains high and problematic. The median days of use of cannabis was reported to be 180 (daily use), with over half (55%) of all participants reporting daily use. KE also reported that cannabis use was high, and that it was one of the most problematic drugs seen in their service due to mental health problems, easy access and widespread acceptability of cannabis use. Efforts to target users with information concerning harms associated with its use, including dependence and co morbid mental health problems, remain important.
A number of KE commented on the increasing use of alcohol, also in the context of polydrug use. This can lead to unpredictable and problematic drug interactions.
Use of licit and illicit benzodiazepines decreased in 2011. The percentage of participants who reported recent use of licit benzodiazepines decreased from 47% in 2010 to 29% in 2011 and 34% reported recent use of illicit benzodiazepines in 2011, down from 42% in 2010.
In 2011, 47% of respondents reported lifetime use of illicit oxycodone, an increase from 21% in 2010. There was also an increase in recent use of oxycodone, increasing from 13% in 2010 to 23% in 2011.
The proportion of participants sharing injecting equipment (e.g. spoons, mixing containers, water and swabs), re-using their own needles and lending used needles remains significant. These results show that continuing education is necessary to inform people who inject drugs (PWID) of the dangers of sharing injecting equipment.
Mental health problems continue to be an area of concern amongst the ACT Illicit Drug Reporting System sample. Scores on the K10 showed that PWID have a higher risk of psychological problems than the general population. This continues to be a consideration for health policy. Greater access to appropriately tailored services and addressing mental health problems within drug and alcohol services would be most beneficial to this group of people who are at a greater risk for psychological distress and drug and alcohol related issues.