Substances injected at the Sydney supervised injecting facility: A chemical analysis of used injecting equipment and comparison with self-reported drug type

Providing information about substances injected can reduce the negative impact of illicit drug consumption and support people who inject drugs to make informed decisions. In Australia, information about drugs injected relies largely on periodic self-report surveys. For the first time, the analysis of the residual content of used injecting equipment was conducted in a supervised injecting facility (SIF) located in Sydney, Australia. The aim was to gain a better understanding of the substances injected by clients through: (1) chemical analyses of the content of used syringes; (2) comparison of these results with clients' self-reported drug use; and (3) assessing the usefulness of analysing other injecting equipment to detect substances used. During one week in February 2019, syringes and other injecting equipment were collected at the Sydney SIF. Their residual content was analysed by gas-chromatography/mass-spectrometry. Heroin was the most commonly detected substance (present in 51% of syringes), followed by methamphetamine (22%) and oxycodone (10%). In addition to the main psychoactive substance, cutting agents reported in the literature were also detected in used syringes. The main psychoactive substance identified by laboratory analysis reliably corresponded with users' self-reported drug type. Analytical confirmation of substances injected allows for the provision of better targeted harm reduction messaging based on timely and objective data. The approach used is amenable to clients and feasible in the Australian SIF context. Upscaling and wider implementation could be done through Needle and Syringe Programs, and would support the early detection of harmful substances entering drug markets and better inform harm reduction strategies.

Does adolescent heavier alcohol use predict young adult aggression and delinquency? Parallel analyses from four Australasian cohort studies

While the association between heavy alcohol consumption and aggression has been well documented, the causal direction of this association, particularly at a population level, is disputed. A number of causal sequences have been proposed. First, that aggression leads to heavy alcohol use. Second, that heavy alcohol use leads to aggression. Third, that the association between alcohol use and aggression is due to confounding by (a) sociodemographic variables or (b) delinquency. We report here data from four Australasian prospective longitudinal studies of adolescents, to assess the temporal sequence of heavy drinking and aggression over the period from adolescence to young adulthood. The four cohort studies provide a total sample of 6,706 persons (Australian Temperament Project, n = 1701; Christchurch Health and Development Study, n = 931; Mater-University of Queensland Study of Pregnancy, n = 2437; Victorian Adolescent Health Cohort Study, n = 1637). We use multinomial logistic regression to determine whether early adolescent aggression predicts subsequent age of onset of heavy episodic drinking (HED), after adjustment for concurrent sociodemographic factors and delinquency. We then consider whether HED predicts subsequent aggression, after adjusting for past aggression, concurrent delinquency, and a range of confounders. There are broadly consistent findings across the four cohort studies. Early aggression strongly predicts subsequent HED. HED predicts later aggression after adjustment for prior aggression and other confounders. Policies that alter population levels of alcohol consumption are likely to impact on levels of aggression in societies where HED linked to aggression is more common.

Adverse adult consequences of different alcohol use patterns in adolescence: an integrative analysis of data to age 30 years from four Australasian cohorts

BACKGROUND AND AIMS

Studies have linked adolescent alcohol use with adverse consequences in adulthood, yet it is unclear how strong the associations are and to what extent they may be due to confounding. Our aim was to estimate the strength of association between different patterns of adolescent drinking and longer-term psychosocial harms taking into account individual, family and peer factors.

DESIGN

Participant-level data were integrated from four long-running longitudinal studies: Australian Temperament Project, Christchurch Health and Development Study, Mater Hospital and University of Queensland Study of Pregnancy and Victorian Adolescent Health Cohort Study.

SETTING

Australia and New Zealand.

PARTICIPANTS

Participants were assessed on multiple occasions between ages 13 and 30 years (from 1991 to 2012). Number of participants varied (up to n = 9453) by analysis.

MEASUREMENTS

Three patterns of alcohol use (frequent, heavy episodic and problem drinking) were assessed prior to age 17. Thirty outcomes were assessed to age 30 spanning substance use and related problems, antisocial behaviour, sexual risk-taking, accidents, socio-economic functioning, mental health and partner relationships.

FINDINGS

After covariate adjustment, weekly drinking prior to age 17 was associated with a two- to threefold increase in the odds of binge drinking [odds ratio (OR) = 2.14; 95% confidence interval (CI) = 1.57-2.90], drink driving (OR = 2.78; 95% CI = 1.84-4.19), alcohol-related problems (OR = 3.04; 95% CI = 1.90-4.84) and alcohol dependence (OR = 3.30; 95% CI = 1.69-6.47) in adulthood. Frequency of drinking accounted for a greater proportion of the rate of most adverse outcomes than the other measures of alcohol use. Associations between frequent, heavy episodic and problem drinking in adolescence and most non-alcohol outcomes were largely explained by shared risk factors for adolescent alcohol use and poor psychosocial functioning.

CONCLUSIONS

Frequency of adolescent drinking predicts substance use problems in adulthood as much as, and possibly more than, heavy episodic and problem drinking independent of individual, family and peer predictors of those outcomes.

Uptake of wheel-filtration among clients of a supervised injecting facility: Can structured education work?

INTRODUCTION AND AIMS

Wheel-filtration of pharmaceutical opioid tablets is a recognised harm reduction strategy, but uptake of the practice among people who inject drugs is low. The study aimed to: (i) examine perceptions of filtration practices; (ii) provide structured education on wheel-filtration; and (iii) assess uptake of the practice.

DESIGN AND METHODS

Frequent opioid tablet injectors (n = 30) attending a supervised injecting facility in Sydney, Australia, received hands-on instruction on wheel-filtration based on recommended practice. Pre-education, post-education and follow-up questionnaires were administered.

RESULTS

Wheel-filtration was generally regarded as better than cotton-filtration (the typical method) in terms of perceived effects on health, ease of use and overall drug effect. Sixty-eight percent of those who said they would try wheel-filtration after the education had actually done so. Of those who usually used cotton-filtration, over half (60%) had used wheel-filtration two weeks later.

DISCUSSION AND CONCLUSIONS

Uptake of safer preparation methods for pharmaceutical opioid tablets increases after structured education in wheel-filtration. Findings suggest that SIFs are an effective site for this kind of education. Supervised injecting facility workers are uniquely positioned to provide harm reduction education at the time of injection. [Steele M, Silins E, Flaherty I, Hiley S, van Breda N, Jauncey M. Uptake of wheel-filtration among clients of a supervised injecting facility: Can structured education work? Drug Alcohol Rev 2018;37:116-120].

Young adult sequelae of adolescent cannabis use: an integrative analysis

BACKGROUND

Debate continues about the consequences of adolescent cannabis use. Existing data are limited in statistical power to examine rarer outcomes and less common, heavier patterns of cannabis use than those already investigated; furthermore, evidence has a piecemeal approach to reporting of young adult sequelae. We aimed to provide a broad picture of the psychosocial sequelae of adolescent cannabis use.

METHODS

We integrated participant-level data from three large, long-running longitudinal studies from Australia and New Zealand: the Australian Temperament Project, the Christchurch Health and Development Study, and the Victorian Adolescent Health Cohort Study. We investigated the association between the maximum frequency of cannabis use before age 17 years (never, less than monthly, monthly or more, weekly or more, or daily) and seven developmental outcomes assessed up to age 30 years (high-school completion, attainment of university degree, cannabis dependence, use of other illicit drugs, suicide attempt, depression, and welfare dependence). The number of participants varied by outcome (N=2537 to N=3765).

FINDINGS

We recorded clear and consistent associations and dose-response relations between the frequency of adolescent cannabis use and all adverse young adult outcomes. After covariate adjustment, compared with individuals who had never used cannabis, those who were daily users before age 17 years had clear reductions in the odds of high-school completion (adjusted odds ratio 0·37, 95% CI 0·20-0·66) and degree attainment (0·38, 0·22-0·66), and substantially increased odds of later cannabis dependence (17·95, 9·44-34·12), use of other illicit drugs (7·80, 4·46-13·63), and suicide attempt (6·83, 2·04-22·90).

INTERPRETATION

Adverse sequelae of adolescent cannabis use are wide ranging and extend into young adulthood. Prevention or delay of cannabis use in adolescence is likely to have broad health and social benefits. Efforts to reform cannabis legislation should be carefully assessed to ensure they reduce adolescent cannabis use and prevent potentially adverse developmental effects.

FUNDING

Australian Government National Health and Medical Research Council.

Factors associated with variability and stability of cannabis use in young adulthood

BACKGROUND

This study investigated the factors associated with initiating cannabis use, reverting to cannabis use and remaining a cannabis user in young adulthood. This is an important area of research as the risk for cannabis initiation is extending beyond adolescence and opportunities to influence cannabis use pathways can emerge throughout the life-course.

METHODS

A large, community-based sample was followed prospectively. Data from two successive waves (mean age 23 years and 27 years respectively) of the Path Through Life Study (PATH) were analysed (n=2045). The longitudinal design enabled change in cannabis use in young adulthood to be predicted based on factors assessed approximately four years prior.

RESULTS

An environment of licit drug use was strongly associated with initiating cannabis use (tobacco: OR=4.98, 95%CI: 2.31-10.76) and reverting to cannabis use in young adulthood (alcohol: OR=2.13, 95%CI: 1.42-3.19). Greater fun seeking was found to orientate people towards initiating cannabis use in young adulthood (OR=1.17, 95%CI: 1.04-1.30). Higher psychoticism increased the odds of remaining a cannabis user (OR=1.19, 95%CI: 1.07-1.33). Religious involvement was protective of cannabis initiation (OR=0.89, 95%CI: 0.83-0.95). Early childhood factors did not influence the pattern of cannabis use in young adulthood.

CONCLUSIONS

The findings make an important contribution to the development of prevention and intervention strategies for young adults by drawing attention to specific areas of risk and protection.

Cannabis use and educational achievement: findings from three Australasian cohort studies

BACKGROUND

The associations between age of onset of cannabis use and educational achievement were examined using data from three Australasian cohort studies involving over 6000 participants. The research aims were to compare findings across studies and obtain pooled estimates of association using meta-analytic methods.

METHODS

Data on age of onset of cannabis use (<15, 15-17, never before age 18) and three educational outcomes (high school completion, university enrolment, degree attainment) were common to all studies. Each study also assessed a broad range of confounding factors.

RESULTS

There were significant (p<.001) associations between age of onset of cannabis use and all outcomes such that rates of attainment were highest for those who had not used cannabis by age 18 and lowest for those who first used cannabis before age 15. These findings were evident for each study and for the pooled data, and persisted after control for confounding. There was no consistent trend for cannabis use to have greater effect on the academic achievement of males but there was a significant gender by age of onset interaction for university enrolment. This interaction suggested that cannabis use by males had a greater detrimental effect on university participation than for females. Pooled estimates suggested that early use of cannabis may contribute up to 17% of the rate of failure to obtain the educational milestones of high school completion, university enrolment and degree attainment.

CONCLUSIONS

Findings suggest the presence of a robust association between age of onset of cannabis use and subsequent educational achievement.

Patterns and harms of pharmaceutical drug use among ecstasy users in Australia

BACKGROUND

There has been a significant incursion of prescription drugs in to the club scene worldwide. The concomitant use of ecstasy and pharmaceutical drugs is associated with potentially serious health-related harms. This has ramifications for people who deliberately combine pharmaceutical drugs with ecstasy to achieve a specific effect and for people legitimately using pharmaceutical drugs for a health condition who may incidentally use ecstasy. This exploratory study had the broad aim to investigate the patterns and harms of concomitant use of pharmaceutical drugs and ecstasy, and to explore participants' experiences when visiting a General Practitioner (GP).

METHODS

In-depth interviews were conducted with 30 ecstasy/pharmaceutical drug users.

RESULTS

Users reported deliberately combining stimulants (dexamphetamine, methylphenidate (e.g. Ritalin), antidepressants and sildenafil (e.g. Viagra) for non-medical purposes with ecstasy. A wide range of effects were reported. Several clear relationships emerged between the use of pharmaceutical drugs and ecstasy, and the distinctions between these in terms of motivations for use and consequences are discussed. The attitudes of GPs were professional and non-judgemental and there was little reluctance among participants to disclose illicit drug use. Screening for illicit drug use was limited.

IMPLICATIONS

Findings have important implications for clubbers in regard to harm reduction strategies and highlight a number of areas for future research.

Qualitative review of serotonin syndrome, ecstasy (MDMA) and the use of other serotonergic substances: hierarchy of risk

Growth of the antidepressant market and widespread use of the illicit drug ecstasy (methylenedioxymethamphetamine; MDMA) creates a need to delineate the potential harms associated with the concomitant use of ecstasy and serotonergic pharmaceutical drugs. One such harm is serotonin syndrome. The study aimed to synthesize the risk of serotonin syndrome associated with the concomitant use of ecstasy and other serotonergic substances in a clinically relevant hierarchy for psychiatrists and other medical practitioners. An extensive online database search was carried out of the literature on serotonin syndrome, in relation to illicit drugs and simultaneous use of other substances. Numerous licit and illicit substances implicated in serotonin syndrome, when used with ecstasy, have potential for increased toxicity and are presented in a resulting hierarchy of risk. Substances that inhibit serotonin re-uptake are less likely to lead to life-threatening elevations in serotonin when used with ecstasy. High doses or repeated use of stimulants such as methamphetamine and cocaine with ecstasy increase the risk of serotonin syndrome; as does the use of pharmaceutical amphetamine and ecstasy. Serotonin precursors also influence the course of serotonin syndrome when used with ecstasy. Substances that inhibit monoamine oxidase are most likely to lead to serious increases in serotonin when used with ecstasy. Findings highlight the importance of screening for the use of ecstasy and other serotonergic substances when prescribing antidepressant drugs.

The influence of structured education and clinical experience on the attitudes of medical students towards substance misusers

Negative attitudes to patients with substance misuse disorders form a well-recognised barrier to the implementation of best practice. The influence of structured education and clinical experience on the attitudes of medical students towards substance misusers was investigated at an Australian university. First-year students were surveyed before and after 3 weeks of drug and alcohol education and in the same year, fourth-year students were surveyed before and after a 9-week block. Males, older students and those with prior clinical experience tended to have more negative attitudes. Attitudes improved significantly after exposure to interactive learning modules which included contact with patients with substance dependence, including individuals in remission. The level of dislike of problem drinkers significantly decreased after teaching. After fourth-year education, students reported a greater sense of responsibility towards providing intervention and less anticipation of discomfort working with these patients. In particular, confidence and attitudes towards heroin users improved near the end of training after contact with illicit drug users in the small group or individual interview setting. By the end of drug and alcohol education, less than half (42%) of students reported they could not imagine working with substance misusers as a career. Findings support the provision of structured drug and alcohol education and supported clinical experience for every medical student if appropriate evidence-based treatment is to be provided.

Looking back by listening: reflections on an oral history

Oral history values the life experience of others. It provides insight into past events, offering a colourful historical perspective which is alive with emotion and rich in character. This account presents recollections of health care training from a markedly different social, economic, cultural and political environment. Reflecting on the oral history allows exploration of aspects of the interview. Confidentiality, respect, familiarity, bias, language and the generation gap impacted on the process. The potential of older members of the community to contribute to the compilation of historical accounts is recognised and their active role valued.