Monitoring Trends in Monitoring Trends in Illicit Drug Use in Illicit Drug Use in AustraliaAustralia

Wayne HallWayne HallSchool of Population Health, School of Population Health, University of Queensland University of Queensland and and

Louisa Degenhardt and Natasha Louisa Degenhardt and Natasha SindicichSindicichNational Drug and Alcohol Research Centre, National Drug and Alcohol Research Centre, University of New South WalesUniversity of New South Wales

Australian Monitoring of Australian Monitoring of Illicit Drug Use 1: General Illicit Drug Use 1: General PopulationPopulation National School Surveys: National School Surveys:

Content Content FrequencyFrequency Limitations Limitations

Household surveys (2-3 yearly since Household surveys (2-3 yearly since 1985) 1985)

trends in lifetime and past year usetrends in lifetime and past year use– best for cannabisbest for cannabis– less useful for cocaine, heroin and IDUless useful for cocaine, heroin and IDU

Declining response rate: now under 50%Declining response rate: now under 50%

Patterns of illicit drug use in Patterns of illicit drug use in Australia, 2007 persons aged Australia, 2007 persons aged 20-2920-29

Trends in recent use among Trends in recent use among Australian males 20-29 Australian males 20-29 yearsyears

Trends in recent use among Trends in recent use among Australian males 20-29 Australian males 20-29 yearsyears

Trends in recent use among Trends in recent use among Australian males 20-29 Australian males 20-29 yearsyears

Monitoring of Illicit Drug Monitoring of Illicit Drug Use 2: Mortality & Morbidity Use 2: Mortality & Morbidity DataData

Mortality data: drug related deathsMortality data: drug related deaths– Good toxicology data on suspicious deathsGood toxicology data on suspicious deaths– Available on line: best for opioidsAvailable on line: best for opioids

Morbidity dataMorbidity data– Hospital separations that are drug-relatedHospital separations that are drug-related

dependence, OD, intoxication, psychosesdependence, OD, intoxication, psychoses Treatment seeking populationsTreatment seeking populations

– National Minimum Data SetNational Minimum Data Set– National Opioid Substitution Treatment dataNational Opioid Substitution Treatment data

Opioid Overdose Mortality per Opioid Overdose Mortality per million Australian adults, 15-44 million Australian adults, 15-44 years, 1964-1997years, 1964-1997

0

10

20

30

40

50

60

70

80

1964 1968 1972 1976 1980 1984 1988 1992 1996

years

deat

hs p

er 1

000

000

pop

Trends in proportion of Trends in proportion of male overdose deaths 1964-male overdose deaths 1964-19971997

Trends in opioid overdose Trends in opioid overdose age at death 1964-1997age at death 1964-1997

Cohort trends in opioid Cohort trends in opioid overdose death in males, overdose death in males, 1964-19971964-1997

Age at which overdose Age at which overdose deaths exceeded 5% of all deaths exceeded 5% of all deathsdeaths

Monitoring of Illicit Drug Monitoring of Illicit Drug Use 3: Trends in Special Use 3: Trends in Special PopulationsPopulations

Drug Use Monitoring in Australia (DUMA)Drug Use Monitoring in Australia (DUMA) Established 1999 based on US ADAM Established 1999 based on US ADAM Quarterly urinalyses & surveys of arrestees in 5 Quarterly urinalyses & surveys of arrestees in 5

statesstates Illicit Drug Reporting System (IDRS) Illicit Drug Reporting System (IDRS)

Developed 1994-5Developed 1994-5 In operation in NSW since 1996 In operation in NSW since 1996 National study since 2000National study since 2000

Ecstasy-related Drug Reporting System (EDRS) Ecstasy-related Drug Reporting System (EDRS) Developed 2000; in operation since 2001 Developed 2000; in operation since 2001 National study since 2003National study since 2003

AimsAims of IDRS & EDRS of IDRS & EDRS

Act as Act as early warning systemearly warning systems to detect changing s to detect changing patterns of use and harmpatterns of use and harm

Data on price, purity, and availability of illicit Data on price, purity, and availability of illicit drugsdrugs

Monitor patterns of use, trends & harms over timeMonitor patterns of use, trends & harms over time

Priorities for specialised/detailed research Priorities for specialised/detailed research

Provide an evidence base forProvide an evidence base for policy policy

Drugs focused on IDRSDrugs focused on IDRS

Injecting Drug Users

(IDRS)•Heroin•Cocaine•Methamphetamine

–Speed powder

–Base

–Ice/Crystal

•Cannabis•Other opioids•Diverted pharmaceuticals

Drugs focused on EDRSDrugs focused on EDRS

Regular Ecstasy Users

(EDRS)•Ecstasy •Cocaine •Methamphetamine

–Speed powder

–Base

–Ice/Crystal

•MDA•Ketamine•GHB•LSD

MethodologyMethodology

Three parts:Three parts:

Drug user interviews Drug user interviews

Key expert interviewsKey expert interviews

Indicator dataIndicator data

Data collected Australia wide on an annual Data collected Australia wide on an annual basisbasis

IDRS in NSW since 1996 and national since 2000IDRS in NSW since 1996 and national since 2000

EDRS national data since 2003EDRS national data since 2003

Sample criteria user Sample criteria user surveysurvey

Injecting Drug Users

(IDRS)

Regular Ecstasy Users

(EDRS)

Injected in the last 6 months Ecstasy use in the last 6 months

In the “market” for the past year In the “market” for the past year

Sampled from needle and syringe programs, outreach, clinics, snowballing

Advertised in street press, music and clothing shops, universities and snowballing

Around 100 participants from each jurisdiction

Around 100 participants from each jurisdiction

Surveys of IDU/REUSurveys of IDU/REU

Sentinel populations of polydrug usersSentinel populations of polydrug users Knowledgeable about: Knowledgeable about:

drug prices & availability ofdrug prices & availability of opiates, amphetamine, cannabis, cocaineopiates, amphetamine, cannabis, cocaine ecstasy and related drug marketsecstasy and related drug markets emerging drugs: illicit or pharmaceuticalemerging drugs: illicit or pharmaceutical

Polydrug users whose drug use Polydrug users whose drug use reflects: reflects:

availability & price of different drugsavailability & price of different drugs changes in route of administrationchanges in route of administration new drug use, e.g. pharmaceuticals, OTCnew drug use, e.g. pharmaceuticals, OTC

Key ExpertsKey Experts

Law enforcement officialsLaw enforcement officials Health workers Health workers

NSEP and outreach workersNSEP and outreach workers Treatment staffTreatment staff

Users groupsUsers groups Drug researchers Drug researchers Specialised knowledge complementsSpecialised knowledge complements

user surveys and indicator data user surveys and indicator data

Leading IndicatorsLeading Indicators

Originally Originally law enforcement data on drug price & purity law enforcement data on drug price & purity Other survey data e.g. NSP attendeesOther survey data e.g. NSP attendees Alcohol and Drug Information Service callsAlcohol and Drug Information Service calls

Later addedLater added Ambulance data on suspected overdosesAmbulance data on suspected overdoses On line coronial data on drug-related deathsOn line coronial data on drug-related deaths Drug use among Sydney MSIC clientsDrug use among Sydney MSIC clients

Annual meetings of Annual meetings of researchers and policy researchers and policy makersmakers Rationality is a social processRationality is a social process

Debate about data and its implicationsDebate about data and its implications

Triangulation of IDRS dataTriangulation of IDRS data Against experiences of key informantsAgainst experiences of key informants

Testing against other informationTesting against other information Especially lagging indicatorsEspecially lagging indicators

Exploring alternative explanations Exploring alternative explanations

What has the IDRS What has the IDRS shown: heroin use 1996-shown: heroin use 1996-2008?2008? Heroin epidemic circa 1996-1999 Heroin epidemic circa 1996-1999

Younger users initiating via smokingYounger users initiating via smoking Increased purity & decreased price Increased purity & decreased price Rising fatal & non-fatal overdose rateRising fatal & non-fatal overdose rate Public injectingPublic injecting

Abrupt reduction in heroin supplyAbrupt reduction in heroin supply Start of 2001 in all states and territories Start of 2001 in all states and territories 40% decline in OD deaths in 2001 40% decline in OD deaths in 2001 sustained thereaftersustained thereafter Brown Heroin available since 2006Brown Heroin available since 2006

Frequency of NSW heroin use, 1996-Frequency of NSW heroin use, 1996-20082008

((source: NSW IDRS IDU surveys)source: NSW IDRS IDU surveys)

0

30

60

90

120

150

180

Med

ian

days

' us

ed

Note: Maximum days = 180

Number of ambulance callouts Number of ambulance callouts to NSW heroin overdoses 1995-to NSW heroin overdoses 1995-

20072007

Effects on Treatment Effects on Treatment ServicesServices

More long term users entered MMT More long term users entered MMT

““New” heroin users less often sought New” heroin users less often sought helphelp

Small increase in treatment seeking Small increase in treatment seeking for amphetamines and cocainefor amphetamines and cocaine

Changes in Crime Changes in Crime

Drug distribution became more covertDrug distribution became more covert Dealers sold other drugs, varying between Dealers sold other drugs, varying between

states states In Adelaide, Brisbane and Melbourne: In Adelaide, Brisbane and Melbourne:

– methamphetaminesmethamphetamines In SydneyIn Sydney

– cocaine injection in street-based sex workerscocaine injection in street-based sex workers

Violent crimeViolent crime short term increase in violent acquisitive crime in Sydney short term increase in violent acquisitive crime in Sydney

Property crimeProperty crime short term increase in Sydney short term increase in Sydney then a long steady decline that has continuedthen a long steady decline that has continued

What has the IDRS What has the IDRS shown about stimulant shown about stimulant use ?use ? Increased cocaine use in NSWIncreased cocaine use in NSW

confined to inner-city Sydney IDUconfined to inner-city Sydney IDU increased purity & decreased priceincreased purity & decreased price

More methamphetamine use since 2003More methamphetamine use since 2003 Especially in ACT & TasmaniaEspecially in ACT & Tasmania Speed and crystal meth the most used Speed and crystal meth the most used

formsforms Small increases in:Small increases in:

Treatment seeking for problem useTreatment seeking for problem use Increased hospitalisations for psychosesIncreased hospitalisations for psychoses

Cocaine use 1996 – 2008Cocaine use 1996 – 2008 (source: NSW IDRS IDU survey)(source: NSW IDRS IDU survey)

0

20

40

60

80

100

% o

f ID

U

recent use

Harms related to opioid and Harms related to opioid and amphetamine use (1)amphetamine use (1)

0

5000

10000

15000

1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07

Heroin/Opioids ATS

Overdose (ED; NSW only) Arrests (National)

Source: Emergency Department Information System, NSW Department of Health

Source:ABCI, 2001, 2002; ACC 2003, 2004 & 2005

Harms related to opioid and Harms related to opioid and amphetamine use (2)amphetamine use (2)

0

3000

6000

9000

12000 Opioids

Amphetamines

Amphetamine-induced psychotic episode

Source: ABS Causes of Death Database; Degenhardt, Roxburgh, (2007a; 2007b)

Source: National Hospital Morbidity Database; Roxburgh & Degenhardt (2006)

Accidental deaths (National) Hospital separations (National)

Drug of choice, 2003-2008Drug of choice, 2003-2008

0

10

20

30

40

50

60

2003 2004 2005 2006 2007 2008

Per

cent

age

(%)

EcstasyCannabisAlcoholSpeed

What has the EDRS shown about ERD markets (1)?

Recent useRecent use

0

5

10

15

20

25

30

35

40

2003 2004 2005 2006 2007 2008

Per

centa

ge

(%)

GHBKetamineLSD

What has the EDRS shown about ERD markets (2)?

What What don’tdon’t they tell us? they tell us?

Trends outside cities Trends outside cities

General population patterns of use General population patterns of use sentinel groups targetedsentinel groups targeted

The size of the drug market The size of the drug market how many users are there?how many users are there?

Other research to address these Other research to address these issuesissues

So what So what dodo they tell us? they tell us? What’s new What’s new

drugsdrugs

harms, extent of harmsharms, extent of harms

price, purity, availabilityprice, purity, availability

What’s the same since last year What’s the same since last year (or the year before…) (or the year before…)

What we need to keep an eye onWhat we need to keep an eye on

Where additional research is required to Where additional research is required to investigate the significance of any trendinvestigate the significance of any trend

AcknowledgementsAcknowledgements

IDRS/EDRS a product of many hands IDRS/EDRS a product of many hands Original work at NDARCOriginal work at NDARC

– Julie Hando; Lisa Maher; Shane DarkeJulie Hando; Lisa Maher; Shane Darke– their many successorstheir many successors

Researchers in each jurisdictionResearchers in each jurisdiction Key Experts in Health & LE Key Experts in Health & LE Injecting Drug Users and Regular Injecting Drug Users and Regular

Ecstasy UsersEcstasy Users

Further information

IDRS and EDRShttp://ndarc.med.unsw.edu.au then click ‘Drug Trends’

2008 reports were released on April 1, 2009.