Interpreting changes in heroin supply in Melbourne: droughts, gluts or cycles?

The impacts of COVID-19 measures on drug markets and drug use among a cohort of people who use methamphetamine in Victoria, Australia

BACKGROUND AND AIMS

Few studies of the impacts of the coronavirus disease 2019 (COVID-19) public health measures on drug markets and drug use patterns have used longitudinal data. We aimed to examine whether COVID-19 measures were associated with increases in methamphetamine price, decreases in methamphetamine use frequency and subsequent changes in secondary outcomes of other drug use frequency in metropolitan Melbourne and regional Victoria.

DESIGN

Longitudinal analysis framework was used from a longitudinal cohort of people who use methamphetamine.

SETTING

Victoria state, Australia.

PARTICIPANTS

One hundred eighty-five VMAX study participants who reported a methamphetamine purchase after the onset of the pandemic were used for the price paid analysis. Methamphetamine or other drug use frequency analysis was performed using 277 participants who used methamphetamine during the pandemic or in the year before the pandemic.

MEASUREMENTS

Price paid per gram of methamphetamine derived from the most recent purchase price and most recent purchase quantity. Frequency of methamphetamine and other drug use measured as the average number of days per week used in the last month.

FINDINGS

Compared with pre-COVID-19 period, methamphetamine prices increased by AUD351.63 (P value <0.001) and by AUD456.51 (P value <0.001) in Melbourne and regional Victoria, respectively, during the period in which the most intense public health measures were implemented in Victoria. Although prices decreased after harder restrictions were lifted (by AUD232.84, P value <0.001 and AUD263.68, P value <0.001, in Melbourne and regional Victoria, respectively), they remained higher than pre-COVID-19 levels. A complementary 76% decrease was observed in relation to methamphetamine use frequency in regional Victoria (P value = 0.006) that was not offset by any changes in the frequency of use of other drugs such as alcohol, tobacco or other illicit drugs.

CONCLUSION

COVID-19 public health measures in Victoria state, Australia, appear to have been associated with major price changes in the methamphetamine market and decreased frequency of use of the drug.

COVID-19 and the health of people who use drugs: What is and what could be?

SARS-CoV-2, the virus that causes COVID-19, has changed the world as we know it, and continues to do so. How COVID-19 affects people who use drugs, the environments in which they live, and capacities of response, warrants immediate attention. This special issue begins to map how COVID-19 is altering the health of people who use drugs, including in relation to patterns of drug use, service responses, harms that may relate to drug use, interventions to reduce risk of harms, COVID-19 health, and drug policies. We emphasise the need to envisage COVID-19 and its effects as a matter of intersecting ‘complex adaptive systems’: that is, the impacts of COVID-19 extend beyond the virus and related illness conditions to encompass multiple social, cultural, economic, policy and political effects; and these affect the health of people who use drugs directly as well as indirectly by altering the risk and enabling environments in which they live. We synthesize emergent evidence on the impact of COVID-19 on the health of people who use drugs. A key concern we identify is how to sustain policy and service delivery improvements prompted by COVID-19. We need to maintain an ethos of emergent adaptation and experimentation towards the creation of safer environments in relation to the health of people who use drugs.

Harm reduction programs and policy in Australia: barriers and enablers to effective implementation

Abstract. Background: Harm reduction is an integral component of Australia’s overall national drug policy. Harm reduction policy and interventions can be applied to any legal or illegal drug to mitigate harm without necessarily reducing use, but harm reduction is traditionally conceptualised in relation to injecting drug use. Early and comprehensive adoption of many innovative harm reduction interventions has meant that Australia has had significant success in reducing a number of drug related harms, avoided disease epidemics experienced in other countries, and established programs and practices that are of international renown. However, these gains were not easily established, nor necessarily permanent. Aim: In this paper we explore the past and present harm reduction policy and practice contexts that normalised and facilitated harm reduction as a public health response, as well as those converse contexts currently creating opposition to additional or expanded interventions. Importantly, this paper discusses the intersection between various interventions, such as needle and syringe distribution and drug treatment programs. Finally, we detail some of the practical lessons that have been learned via the Australian experience, with the hope that these lessons will assist to inform and improve international harm reduction implementation.

Recent trends in heroin and pharmaceutical opioid-related harms in Victoria, Australia up to 2018

AIMS

To characterize the trajectory in the years leading up to 2018 in pharmaceutical opioid and heroin morbidity in Victoria, Australia, and to assess the effect on that trajectory of reformulation of oxycodone to a form that could not be easily snorted or injected.

DESIGN

Interrupted time-series analyses of population-level data before versus after reformulation of oxycodone, stratified by sex.

SETTING

Victoria, Australia.

PARTICIPANTS

The population of Victoria aged 12+ years.

MEASUREMENTS

Ambulance patient care and emergency department (ED) records were examined using both fixed-code and free-text fields, with each record manually cleaned and checked by trained coders. These were used to derive the output variables providing an index of harm: rates of opioid-related ambulance attendances and ED attendances for pharmaceutical opioids and heroin. The input variable was pre- versus post-oxycodone reformulation.

FINDINGS

There were 30 045 opioid-related ambulance attendances from January 2012 to October 2018 (54% heroin-related), and 10 113 ED attendances from July 2008 to June 2018 (39% heroin-related). There was an increase in the rate (events per 100 000 people per year) of all opioid ED attendances from 2008 to 2018 [increase = 0.063; 95% confidence interval (CI) = 0.049, 0.078]. Pharmaceutical opioid ED attendances decreased from 2014 onwards (slope change = -0.083; 95% CI = -0.108, -0.059). Heroin-related ED attendances increased from 2014 to 2018; 11 324 heroin-related ambulance attendances and 1980 ED attendances were observed from April 2014 to June 2018, compared with the respective estimates of 8176, and 1661 had the pre-April 2014 trend continued (ambulance slope change = 0.296, 95% CI = 0.104, 0.489; ED slope change = 0.026, 95% CI = 0.005, 0.046). The inflection point of 2014 coincided with the re-formulation of oxycodone.

CONCLUSION

In Victoria, Australia, there appears to have been a trend starting around mid-2014 of increasing heroin-related harm, and a flattening of the increase or a decrease of harms relating to pharmaceutical opioids. These changes may, in part, reflect reformulation of oxycodone to reduce the extent to which it can be injected or snorted.

The effects of needle-sharing and opioid substitution therapy on incidence of hepatitis C virus infection and reinfection in people who inject drugs

Although high hepatitis C virus (HCV) prevalence has been observed in people who inject drugs (PWID) for decades, research suggests incidence is falling. We examined whether PWIDs' use of opioid substitution therapy (OST) and their needle-and-syringe sharing behaviour explained HCV incidence. We assessed HCV incidence in 235 PWID in Melbourne, Australia, and performed discrete-time survival with needle-sharing and OST status as independent variables. HCV infection, reinfection and combined infection/reinfection incidences were 7·6 [95% confidence interval (CI) 4·8-11·9], 12·4 (95% CI 9·1-17·0) and 9·7 (95% CI 7·4-12·6) per 100 person-years, respectively. Needle-sharing was significantly associated with higher incidence of naive HCV infection [hazard ratio (HR) 4·9, 95% CI 1·3-17·7] but not reinfection (HR 1·85, 95% CI 0·79-4·32); however, a cross-model test suggested this difference was sample specific. Past month use of OST had non-significant protective effects against naive HCV infection and reinfection. Our data confirm previous evidence of greatly reduced HCV incidence in PWID, but not the significant protective effect of OST on HCV incidence detected in recent studies. Our findings reinforce the need for greater access to HCV testing and prevention services to accelerate the decline in incidence, and HCV treatment, management and support to limit reinfection.

Policing, crime and public health

This article examines the influence on policing in Sydney, Australia of the crime control strategies developed in New York City in the 1990s, which are popularly credited with having significantly reduced crime rates. The ‘New York miracle’ is considered as an ‘enthusiasm’, a positive relation of the moral panic. Claims that the NYPD reduced crime with a strategy based on ‘zero tolerance’ or ‘broken windows’ are critically examined. The second half of the article presents a case study of how international developments in policing impacted on a heroin market in Cabramatta, a suburb of Sydney which, in the 1990s, became known as Australia’s ‘heroin capital’. The study shows how transferred policies are implemented, how elements of them may conflict, and how the crucial transfer may be not so much of particular policies, but rather of less specific perceptions and attitudes, in this case a confidence in the ability of police to reduce crime. It concludes by focusing on the collateral damage (particularly to public health) caused by police crackdowns on drug markets. Research is reported which found an alarming increase in the incidence of hepatitis C among intravenous drug users as a result of policing activity in Cabramatta.

Street-Level Drug Market Activity in Sydney's Primary Heroin Markets: Organization, Adulteration Practices, Pricing, Marketing and Violence

This study is a qualitative exploration of two distinctive high-profile street drug markets in Sydney, Australia. Semi-structured interviews were conducted with 32 street-level heroin dealers about their experiences of selling drugs in these areas, market organization, drug adulteration and quality assessment practices, and the extent and impact of violence associated with these markets. Most dealers operated independently, working for themselves or in loosely defined groups of two or three with little or no hierarchy while others acted as “runners,” selling for others for a percentage of sales. A range of “folk” or nonscientific methods were employed for testing the quality of drugs, and adulteration or “cutting” of drugs was rare. Moreover, this research suggests that even during periods of heroin scarcity, increased adulteration is not an inevitable outcome. In contrast to popular perceptions, dealers in both areas cooperated with each other, and little intimidatory rivalry was reported or observed. Indeed, most participants considered violence to be fairly rare, largely avoidable, and not an inevitable consequence of their involvement in the market. Numerous popular drug market and drug dealer stereotypes about the two locations were not supported by the findings.

Working together: Expanding the availability of naloxone for peer administration to prevent opioid overdose deaths in the Australian Capital Territory and beyond

ISSUE

Since the mid-1990s, there have been calls to make naloxone, a prescription-only medicine in many countries, available to heroin and other opioid users and their peers and family members to prevent overdose deaths.

CONTEXT

In Australia there were calls for a trial of peer naloxone in 2000, yet at the end of that year, heroin availability and harm rapidly declined, and a trial did not proceed. In other countries, a number of peer naloxone programs have been successfully implemented. Although a controlled trial had not been conducted, evidence of program implementation demonstrated that trained injecting drug-using peers and others could successfully administer naloxone to reverse heroin overdose, with few, if any, adverse effects.

APPROACH

In 2009 Australian drug researchers advocated the broader availability of naloxone for peer administration in cases of opioid overdose. Industrious local advocacy and program development work by a number of stakeholders, notably by the Canberra Alliance for Harm Minimisation and Advocacy, a drug user organisation, contributed to the rollout of Australia's first prescription naloxone program in the Australian Capital Territory (ACT). Over the subsequent 18 months, prescription naloxone programs were commenced in four other Australian states.

IMPLICATIONS

The development of Australia's first take-home naloxone program in the ACT has been an 'ice-breaker' for development of other Australian programs. Issues to be addressed to facilitate future scale-up of naloxone programs concern scheduling and cost, legal protections for lay administration, prescribing as a barrier to scale-up; intranasal administration, administration by service providers and collaboration between stakeholders.

How do drug market changes affect characteristics of injecting initiation and subsequent patterns of drug use? Findings from a cohort of regular heroin and methamphetamine injectors in Melbourne, Australia

BACKGROUND

Changes in drug market characteristics have been shown to affect drug use patterns but few studies have examined their impacts on injecting initiation experiences and subsequent patterns of injecting drug use (IDU).

METHODS

We collected data on self-reported injecting initiation experiences and past-month patterns of IDU from 688 regular heroin and methamphetamine injectors in Melbourne, Australia, who initiated injecting across three different drug market periods (prior to the Australian heroin shortage ('high heroin')/immediately following the shortage ('low heroin')/'contemporary' markets (fluctuating heroin and methamphetamine availability)). We used univariable and multivariable logistic regression to examine the relationship between period of injecting initiation and first drug injected, and multinomial logistic regression for the relationship between period of injecting initiation and current injecting patterns.

RESULTS

425 participants (62%) reported initiating injecting in the high heroin period, 146 (21%) in the low heroin period, and 117 (17%) in the contemporary period. Participants who initiated injecting during the low heroin period were twice as likely to initiate injecting using a drug other than heroin (AOR: 1.94, 95% CI: 1.27-2.95). The most common patterns of drug use among study participants in the month preceding interview were polydrug use (44%) and primary heroin use (41%). Injecting initiation period was either non-significantly or weakly associated with current drug use pattern, which was more strongly associated with other socio-demographic and drug use characteristics, particularly self-reported drug of choice.

CONCLUSION

The drug market period in which injecting initiation occurred influenced the first drug injected and influenced some aspects of subsequent drug use. In the context of highly dynamic drug markets in which polydrug use is common there is a need for broad harm reduction and drug treatment services which are flexible and responsive to changing patterns of drug use.

'Miracle cure' or 'liquid handcuffs': reporting on naltrexone and methadone in the Australian print media

INTRODUCTION AND AIMS

The news media is an important source of information regarding new developments in medicine and public health interventions. Previous research has indicated that in many cases, reporting on new treatments can be inaccurate or sensationalist. This paper presents analysis of Australian print media reporting on two treatment options for heroin dependence (naltrexone and methadone). The aim of this study was to quantitatively compare the volume and content of Australian print media reporting on these two treatments, one of which had a long history of use in Australia, and the other which was comparatively newer.

DESIGN AND METHODS

The study constituted a quantitative content analysis of a sample of 859 Australian newspaper articles, published over a 10-year period (1997-2007). Each article paragraph was coded for positive outcomes/benefits of treatment, as well as negative outcomes associated with treatment.

RESULTS

The analysis revealed that during this period, the Australian print media was significantly more likely to report the potential positive outcomes of naltrexone treatment, compared with the negative outcomes. In contrast, reporting on methadone focused more on the negative outcomes and side effects.

DISCUSSION AND CONCLUSIONS

The relative frequency by which the benefits of naltrexone were mentioned in this sample of news content is somewhat at odds with the extant efficacy and effectiveness research evidence. The findings suggest that reporting on these treatments in the Australian print media has not been balanced. This type of reporting has potential implications for public attitudes, as well as policy decisions.

'It's more about the heroin': injection drug users' response to an overdose warning campaign in a Canadian setting

AIMS

To assess heroin injectors' perceptions of and responses to a warning issued by public health officials regarding high-potency heroin and increases in fatal overdoses.

DESIGN

Semi-structured qualitative interviews.

SETTING

Vancouver, Canada.

PARTICIPANTS

Eighteen active heroin injectors.

MEASUREMENTS

Semi-structured interview guide focussing on heroin injectors' perceptions of and responses to the overdose warning, including reasons for failing to adhere to risk reduction recommendations.

FINDINGS

Although nearly all participants were aware of the warning, their recollections of the message and the timing of its release were obscured by on-going social interactions within the drug scene focussed on heroin quality. Many injection drug users reported seeking the high potency heroin and nearly all reported no change in overdose risk behaviours. Responses to the warning were shaped by various social, economic and structural forces that interacted with individual behaviour and undermined efforts to promote behavioural change, including sales tactics employed by dealers, poverty, the high cost and shifting quality of available heroin, and risks associated with income-generating activities. Individual-level factors, including emotional suffering, withdrawal, entrenched injecting routines, perceived invincibility and the desire for intense intoxication also undermined risk reduction messages.

CONCLUSIONS

Among heroin injectors in British Columbia, a 2011 overdose warning campaign appeared to be of limited effectiveness and also produced unintended negative consequences that exacerbated overdose risk.

Establishing the Melbourne Injecting Drug User Cohort Study (MIX): rationale, methods, and baseline and twelve-month follow-up results

BACKGROUND

Cohort studies provide an excellent opportunity to monitor changes in behaviour and disease transmission over time. In Australia, cohort studies of people who inject drugs (PWID) have generally focused on older, in-treatment injectors, with only limited outcome measure data collected. In this study we specifically sought to recruit a sample of younger, largely out-of-treatment PWID, in order to study the trajectories of their drug use over time.

METHODS

Respondent driven sampling, traditional snowball sampling and street outreach methods were used to recruit heroin and amphetamine injectors from one outer-urban and two inner-urban regions of Melbourne, Australia. Information was collected on participants' demographic and social characteristics, drug use characteristics, drug market access patterns, health and social functioning, and health service utilisation. Participants are followed-up on an annual basis.

RESULTS

688 PWID were recruited into the study. At baseline, the median age of participants was 27.6 years (IQR: 24.4 years - 29.6 years) and two-thirds (67%) were male. Participants reported injecting for a median of 10.2 years (range: 1.5 months - 21.2 years), with 11% having injected for three years or less. Limited education, unemployment and previous incarceration were common. The majority of participants (82%) reported recent heroin injection, and one third reported being enrolled in Opioid Substitution Therapy (OST) at recruitment. At 12 months follow-up 458 participants (71% of eligible participants) were retained in the study. There were few differences in demographic and drug-use characteristics of those lost to follow-up compared with those retained in the study, with attrition significantly associated with recruitment at an inner-urban location, male gender, and providing incomplete contact information at baseline.

CONCLUSIONS

Our efforts to recruit a sample of largely out-of-treatment PWID were limited by drug market characteristics at the time, where fluctuating heroin availability has led to large numbers of PWID accessing low-threshold OST. Nevertheless, this study of Australian injectors will provide valuable data on the natural history of drug use, along with risk and protective factors for adverse health outcomes associated with injecting drug use. Comprehensive follow-up procedures have led to good participant retention and limited attrition bias.

Reduction in HCV incidence among injection drug users attending needle and syringe programs in Australia: a linkage study

OBJECTIVES

We examined trends in HCV incident infection among injection drug users (IDUs) attending needle and syringe programs (NSPs) in Australia in 1995 to 2010.

METHODS

We created a passive retrospective cohort of 724 IDUs who tested negative for HCV antibodies by a simple deterministic method linking partial identifiers to find repeat respondents in annual cross-sectional serosurveillance.

RESULTS

We identified 180 HCV seroconversions over the study period, for a pooled incidence density of 17.0 per 100 person-years (95% confidence interval [CI] = 14.68, 19.66). Incidence density declined, from a high of 30.8 per 100 person-years (95% CI = 21.3, 44.6) in 2003 to a low of 4.0 (95% CI = 1.3, 12.3) in 2009.

CONCLUSIONS

A decline in HCV incidence among Australian IDUs attending NSPs coincided with considerable expansion of harm reduction programs and a likely reduction in the number of IDUs, associated with significant changes in drug markets. Our results demonstrate the capacity of repeat cross-sectional serosurveillance to monitor trends in HCV incidence and provide a platform from which to assess the impact of prevention and treatment interventions.

Morbidity associated with heroin overdose presentations to an emergency department: a 10-year record linkage study

INTRODUCTION

To examine hospitalizations in a cohort of 224 patients who presented with non-fatal heroin overdose to an ED.

METHODS

A record linkage study, using the morbidity, mental health and mortality databases in the Data Linkage Unit of the Department of Health, Western Australia. The main outcome measures were hospital separations 5 years before and after entry into the cohort.

RESULTS

Before entry into the cohort, 199 (89%) patients had an admission to mental health services. These 199 had a combined total of 1367 separations, most commonly for a mental health condition, injury or poisoning. Women had more than twice the relative risk (RR) of men for all separations (RR 2.35, 95% confidence interval [CI] 1.96-2.82, P < 0.001) and for injury and poisoning separations (RR 2.04, 95% CI 1.56-2.66, P < 0.001). The highest concentrations of separations occurred within 1 year before and 1 year after entry into the cohort. There were 12 (5.4%, 95% CI 2.9-9.4%) deaths, most commonly from overdose.

CONCLUSION

Non-fatal heroin overdose ED presentations are associated with a cluster of hospitalizations around that episode, likely to be related to heroin availability. Presentation to hospital by heroin users represents an opportunity to counsel less risky behaviour.

The prevalence and correlates of buprenorphine inhalation amongst opioid substitution treatment (OST) clients in Australia

BACKGROUND

Diversion and injection of buprenorphine (Subutex(®)) and buprenorphine-naloxone (Suboxone(®)) have been well documented. Recent international research and local anecdotal evidence suggest that these medications are also used by other routes of administration, including smoking and snorting.

METHODS

A cross-sectional sample of 440 opioid substitution treatment (OST) clients was recruited through pharmacies and clinics in three Australian jurisdictions, and interviewed face-to-face using a structured questionnaire. Eligible participants were those aged 18 or over, who had resided in their home state for at least six months, and had been in their current treatment episode for at least 4 weeks. We compared differences in characteristics between clients who had ever inhaled (smoked or snorted) buprenorphine (including buprenorphine-naloxone) and other OST clients. Logistic regression was used to identify correlates of buprenorphine inhalation. Sixty-eight clients who had never used buprenorphine were excluded from analysis.

RESULTS

Sixty-five clients (18%) reported having ever inhaled buprenorphine, with Subutex(®) smoking being most common, reported by 50 clients (77%). In multivariable logistic regression, those who reported ever inhaling buprenorphine were significantly more likely to: be aged 35 or younger, have ever been in prison and have ever injected buprenorphine. Clients from New South Wales and Victoria were significantly less likely to have ever inhaled buprenorphine than those from South Australia.

CONCLUSIONS

Our data indicates that the inhalation of buprenorphine has occurred in a significant minority of Australian OST clients. The motivations, contexts and potential health consequences of buprenorphine use by these atypical routes of administration, particularly in a correctional setting, warrant further exploration.

An evaluation of a heroin overdose prevention and education campaign

INTRODUCTION AND AIMS

Following detection of an upward trend in the frequency of fatal heroin overdoses in Victoria between 2001 and 2003, Victoria's Department of Human Services planned a campaign aimed at increasing injecting drug users' (IDU) awareness of overdose risks and prevention strategies. Stickers, wallet cards and posters featuring five key messages were distributed via needle and syringe programs (NSP) and other drug and alcohol services between November 2005 and April 2006. An evaluation of the campaign was commissioned to be conducted in late 2006.

DESIGN AND METHODS

The evaluation consisted of analysis of three independent data sets--quantitative data collected from IDU during the campaign period (n = 855 at baseline; and a range of 146-656 at follow up); qualitative interviews with IDU who were NSP clients during the campaign period (n = 16) and qualitative interviews with NSP staff and other key stakeholders (n = 9).

RESULTS

While key experts felt that the campaign messages had engendered lasting impact for at least some IDU, these positive impressions were not borne out by the NSP client data, with less than one quarter of all campaign messages being mentioned by a significantly higher proportion of clients during the post-campaign period compared with baseline. Key experts perceived the greatest weakness of the campaign to be the delay between issue identification and the introduction of campaign materials.

DISCUSSION AND CONCLUSIONS

While IDU are generally responsive to health promotion campaigns, future initiatives in this domain should be designed and implemented rapidly and in ways that are sufficiently flexible to cope with shifts in drug markets which could influence the reception of key messages.

The costs and consequences of three policy options for reducing heroin dependency

INTRODUCTION AND AIMS

This study compares the costs and consequences of three interventions for reducing heroin dependency: pharmacotherapy maintenance, residential rehabilitation and prison.

DESIGN AND METHODS

Using Australian data, the interventions' cost - consequence ratio was estimated, taking into consideration reduction in heroin use during the intervention; the length of intervention; and post-intervention effects (as measured by abstinence rates). Sensitivity analyses were conducted, including varying the magnitude and duration of treatment effects, and ascribing positive outcomes only to treatment completers. A hybrid model that combined pharmacotherapy maintenance with a prison term was also considered.

RESULTS

If the post-programme abstinence rates are sustained for 2 years, then for an average heroin user the cost of averting a year of heroin use is approximately AUD$5000 for pharmacotherapy maintenance, AUD$11,000 for residential rehabilitation and AUD$52 000 for prison. Varying the parameters does not change the ranking of the programmes. If the completion rate in pharmacotherapy maintenance was raised above 95% (by the threat of prison for non-completers), the combined model of treatment plus prison may become the most cost-effective option.

DISCUSSION AND CONCLUSIONS

Relative performance in terms of costs and consequences is an important consideration in the policy decision-making process, and quantitative data such as those reported herein can provide insights pertinent to evidence-based policy.

Emergency management of inadvertent accelerated opiate withdrawal in dependent opiate users

Six opiate-dependent drug users presented to the local emergency department within a 10-day period with symptoms of severe opioid withdrawal immediately following intravenous use of recently acquired street 'heroin'. The withdrawal picture was similar to that described in patients undergoing rapid opioid detoxification, suggesting that the substance injected was contaminated with an opiate antagonist. A number of potential compounds are discussed, including naltrexone and buprenorphine, and recommendations for the medical management of severe opiate withdrawal within an emergency setting are outlined. [Lubman DI, Koutsogiannis Z, Kronborg I. Emergency management of inadvertent accelerated opiate withdrawal in dependent opiate users.

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.

Heroin in brown, black and white: structural factors and medical consequences in the US heroin market

BACKGROUND

Heroin coming into the United States historically comes from three widely dispersed geographical regions: Southwest Asia, Southeast Asia and Mexico. A fourth source of US-bound heroin, from Colombia, originated in the early 1990s. The fact that the four heroin sources produce differing morphologies and qualities of heroin has not been critically examined. In addition, it is not well established how the contemporary competing dynamics of interdiction, or restriction of heroin flows across international boundaries, and neoliberal, e.g., global expansion of free trade, policies are affecting heroin markets. This paper will highlight changes in the US heroin market, including source trends, the political economy of the now dominant source and the resultant effects on the heroin risk environment by US region.

METHODS

Using a structural and historical framework this paper examines two decades of secondary data sources, including government and drug control agency documents, on heroin flows together with published work on the political and economic dynamics in Latin America.

RESULTS

Co-occurring neoliberal economic reforms may have contributed to paradoxical effects of US/Colombian interdiction efforts. Since entering the US market, heroin from Colombia has been distributed at a much higher quality and lower retail price. An increasingly exclusive market has developed with Mexican and Colombian heroin gaining market share and displacing Asian heroin. These trends have had dramatic effects on the risk environment for heroin consumers. An intriguing factor is that different global sources of heroin produce substantially different products. Plausible associations exist between heroin source/form and drug use behaviours and harms. For example, cold water-soluble powdered heroin (sources: Asia, Colombia) may be associated with higher HIV prevalence in the US, while low-solubility "black tar" heroin (BTH; source: Mexico) is historically used in areas with reduced HIV prevalence. BTH is associated with soft tissue infections caused by Clostridium bacteria.

CONCLUSION

Source and type of heroin are structural factors in the risk environment of heroin users: source dictates distribution and type predicts practice. How specific types of heroin are used and with what risk is therefore distributed geographically. Continued flux in the heroin market and its effects on the risk environment for drug users deserves further attention.

Drug use among homeless young people in Los Angeles and Melbourne

PURPOSE

To examine the effect of time spent homeless on young people's substance use and use of drug and alcohol services in two countries with contrasting policy and service environments.

METHODS

A crossnational survey was conducted of recently homeless and experienced homeless young people in Melbourne (N = 674) and Los Angeles (N = 620). Questions were asked about alcohol and drug use in the past 3 months, frequency of use, injecting drug use, drug dependency, and perceived need for, and use of, drug and alcohol services. Data were analyzed using logistic regression.

RESULTS

Substantial numbers of young people reported use of alcohol and drugs. More Australians than Americans and more experienced than newly homeless reported drug use, although there were no differences in frequency of use in the past 3 months. Polydrug use was common, as were injecting drugs and responses that signified drug dependency. All were more common among Australians and experienced homeless young people. A substantial number of young people had "ever" taken part in a drug or alcohol program, but only a minority believed that they needed help from services. Of these, only a minority had sought help. This was particularly so among those who were classified as drug dependent. Reasons for failure to seek help varied.

CONCLUSION

Substance use is alarmingly high compared to national samples of young people, especially among those who had been homeless for longer periods. Programs to reduce substance use must take account of the prevailing drug cultures, as well as different subgroups of the population.

Australian heroin seizures and the causes of the 2001 heroin shortage

This paper uses Australian heroin seizure data, along with estimates of the size of the Australian heroin market to evaluate the impact of drug law enforcement on the 2001 Australian heroin shortage from the percentage of the market seized. It also critically examines international heroin production trends and published reports on the causes of the Australian heroin shortage. Its conclusion is that previous studies may have overstated the success of drug law enforcement and that the most likely explanation for Australia's 2001 heroin shortage was a significant decline in heroin production world-wide, due to a general move away from heroin production in the countries of Southeast Asia and the prohibition on opium growing by the Taliban regime in Afghanistan.

Dynamic compartmental model of trends in Australian drug use

A five-state compartment model of trends in illicit drug use in Australia is parameterized using data from multiple sources. The model reproduces historical prevalence and supports what-if analyses under the assumption that past trajectories of drug escalation and desistance persist. For fixed initiation, the system has a unique stable equilibrium. The chief qualitative finding is that even though some users escalate rapidly, regular injection drug use still adjusts to changes in incidence with considerable inertia and delay. This has important policy implications, e.g., concerning the timing of reductions in drug-related social cost generated by interventions that reduce the social cost per injection user versus those that cut drug initiation.

Identification and quantification of change in Australian illicit drug markets

Background

In early 2001 Australia experienced a sudden reduction in the availability of heroin which had widespread effects on illicit drug markets across the country. The consequences of this event, commonly referred to as the Australian 'heroin shortage', have been extensively studied and there has been considerable debate as to the causes of the shortage and its implications for drug policy. This paper aims to investigate the presence of these epidemic patterns, to quantify the scale over which they occur and to estimate the relative importance of the 'heroin shortage' and any epidemic patterns in the drug markets.

Method

Key indicator data series from the New South Wales illicit drug market were analysed using the statistical methods Principal Component Analysis and SiZer.

Results

The 'heroin shortage' represents the single most important source of variation in this illicit drug market. Furthermore the size of the effect of the heroin shortage is more than three times that evidenced by long-term 'epidemic' patterns.

Conclusion

The 'heroin shortage' was unlikely to have been a simple correction at the end of a long period of reduced heroin availability, and represents a separate non-random shock which strongly affected the markets.

The "lessons" of the Australian "heroin shortage"

Heroin use causes considerable harm to individual users including dependence, fatal and nonfatal overdose, mental health problems, and blood borne virus transmission. It also adversely affects the community through drug dealing, property crime and reduced public amenity. During the mid to late 1990s in Australia the prevalence of heroin use increased as reflected in steeply rising overdose deaths. In January 2001, there were reports of an unpredicted and unprecedented reduction in heroin supply with an abrupt onset in all Australian jurisdictions. The shortage was most marked in New South Wales, the State with the largest heroin market, which saw increases in price, dramatic decreases in purity at the street level, and reductions in the ease with which injecting drug users reported being able to obtain the drug. The abrupt onset of the shortage and a subsequent dramatic reduction in overdose deaths prompted national debate about the causes of the shortage and later international debate about the policy significance of what has come to be called the "Australian heroin shortage". In this paper we summarise insights from four years' research into the causes, consequences and policy implications of the "heroin shortage".

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.

The relationship between take-away methadone policies and methadone diversion

The development of policies in relation to unsupervised doses of methadone (take-away doses) should be based upon the best available evidence. There are both risks and benefits associated with take-away doses. This study aimed to explore the relationship between take-away policies and one measure of harm: methadone injection rates. Six different states in Australia were compared in relation to their methadone take-away policy and rates of methadone injection within their population of injecting drug users. At a simplistic level, those states with restrictive and less flexible take-away policies tended to have the lowest reported prevalence of methadone injection. However, this does not fully explain variability in methadone injecting. There were also considerable differences between those states with similar take-away policies. Variables which appear to impact upon methadone injecting rates include: take-away policies, drug preference, drug availability, treatment availability and degree of treatment penetration. Consideration of the benefits, rather than merely the harms, of various take-away policy options may provide an evidence-based platform for take-away policy development.

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.

The contribution of research to Australian policy responses to heroin dependence 1990-2001: a personal retrospection

Periodic public concern about heroin use has been a major driver of Australian drug policy in the four decades since heroin use was first reported. The number of heroin-dependent people in Australia has increased from several hundreds in the late 1960s to around 100,000 by the end of the 1990s. In this paper I do the following: (1) describe collaborative research on heroin dependence that was undertaken between 1991 and 2001 by researchers at the National Drug and Alcohol Research Centre; (2) discuss the contribution that this research may have made to the formulation of policies towards the treatment of heroin dependence during a period when the policy debate crystallized around the issue of whether or not Australia should conduct a controlled trial of heroin prescription; and (3) reflect on the relationships between research and policy-making in the addictions field, specifically on the roles of investigator-initiated and commissioned research, the interface between researchers, funders and policy-makers; and the need to be realistic about the likely impact of research on policy and practice.

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.