Amanda Roxburgh

Prescription of opioid analgesics and related harms in Australia.

Objective: To document trends in: (i) prescribing of morphine and oxycodone; (ii) hospital separations for overdose; (iii) presentations for treatment of problems associated with these drugs; and (iv) oxycodone‐related mortality data in Australia.

The epidemiology of methamphetamine use and harm in Australia

INTRODUCTION AND AIMS There has been considerable media attention recently upon possible increases in methamphetamine use in Australia. Much of this debate has focused upon extreme cases of problematic crystal methamphetamine use, without reference to the broader population context. This paper provides data on methamphetamine use in Australia, and documents trends in methamphetamine-related harms. DESIGN AND METHODS Data used were from: (1) Australian Customs Service drug detections; (2) Australian Crime Commission drug seizure, arrest and clandestine laboratory detections data; (3) National Drug Strategy Household Survey (NDSHS) and Australian Secondary Student Alcohol and Drug Survey (ASSADS); (4) data from the Illicit Drug Reporting System (IDRS) and Ecstasy and related Drug Reporting System (EDRS); and (5) data from NSW Emergency Department Information System, National Hospital Morbidity Database and Australian Bureau of Statistics causes of death databases. RESULTS There appears to have been an increase in both importation and local manufacture of meth/amphetamine. Population data show that meth/amphetamine use remains low and stable. However, clear increases in crystal methamphetamine use have occurred among sentinel groups of regular drug users. Frequent crystal use among regular injecting drug users is associated with earlier initiation to injecting, greater injection risk behaviours and more extensive criminal activity. In recent years, indicators of meth/amphetamine-related harm have stabilised, following steady increases in earlier years. DISCUSSION AND CONCLUSIONS Some methamphetamine users experience significant problems related to their use; harms are particularly prevalent among regular IDU. Methamphetamine users, however, are a diverse group, and strategies need to be appropriately targeted towards different kinds of users.

Trends in morphine prescriptions, illicit morphine use and associated harms among regular injecting drug users in Australia

This paper examines population trends in morphine prescriptions in Australia, and contrasts them with findings from annual surveys with regular injecting drug users (IDU). Data on morphine prescriptions from 1995 to 2003 were obtained from the Drug Monitoring System (DRUMS) run by the Australian Government Department of Health and Ageing. Data collected from regular IDU as part of the Australian Illicit Drug Reporting System (IDRS) were analysed (2001 - 2004). The rate of morphine prescription per person aged 15 - 54 years increased by 89% across Australia between 1995 and 2003 (from 46.3 to 85.9 mg per person). Almost half (46%) of IDU surveyed in 2004 reported illicit morphine use, with the highest rates in jurisdictions where heroin was less available. Recent morphine injectors were significantly more likely to be male, unemployed, out of treatment and homeless in comparison to IDU who had not injected morphine. They were also more likely to have injected other pharmaceutical drugs and to report injection related problems. Among those who had injected morphine recently, the most commonly reported injecting harms were morphine dependence (38%), difficulty finding veins into which to inject (36%) and scarring or bruising (27%). Morphine use and injection is a common practice among regular IDU in Australia. In some cases, morphine may be a substitute for illicit heroin; in others, it may be being used to treat heroin dependence where other pharmacotherapies, such as methadone and buprenorphine, are perceived as being unavailable or undesirable by IDU. Morphine injection appears to be associated with polydrug use, and with it, a range of problems related to drug injection. Further research is required to monitor and reduce morphine diversion and related harms by such polydrug injectors.

The epidemiology of cannabis use and cannabis-related harm in Australia 1993-2007.

AIMS To examine trends in patterns of cannabis use and related harm in the Australian population between 1993 and 2007. DESIGN Analysis of prospectively collected data from: (1) the National Drug Strategy Household Survey (NDSHS) and Australian Secondary Student Alcohol and Drug Survey (ASSADS); (2) the National Hospital Morbidity Database (NHMD); and (3) the Alcohol and Other Drug Treatment Services National Minimum Dataset (AODTS-NMDS). PARTICIPANTS Australians aged 14 years and over from the general population; students aged 12-17 years; public and private hospital in-patients; public and private in-patients and out-patients attending for drug treatment. MEASUREMENT Prevalence of 12-month cannabis use among the general population and secondary students. Proportions in the general population by age group reporting: daily cannabis use; difficulties in controlling cannabis use; and heavy cannabis use on each occasion. Number of hospital and treatment presentations for cannabis-related problems. FINDINGS Prevalence of past-year cannabis use has declined in the Australian population since the late 1990s. Among those reporting past-year use, daily use is prevalent among 40-49-year-olds, while heavy patterns of use are prevalent among 14-19-year-olds. Hospital presentations for cannabis-related problems reflect similar trends. Past-year cannabis use has decreased among the 10-19-year age group, but those who are daily users in this age group report using large quantities of cannabis. CONCLUSIONS Despite declines in the prevalence of cannabis use, continued public health campaigns warning of the harms associated with cannabis use are essential, aimed particularly at users who are already experiencing problems. The increasing demand for treatment for cannabis problems in Australia suggests the need for more accessible and more effective interventions for cannabis use disorders.

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

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

Estimating the number of regular and dependent methamphetamine users in Australia, 2002-2014

Objective: To estimate the number of regular and dependent methamphetamine users in Australia.

Trends in fentanyl prescriptions and fentanyl‐related mortality in Australia

INTRODUCTION AND AIMS The study aims to quantify trends in fentanyl prescribing and fentanyl mortality in Australia within the context of concern among health professionals concerning increasing accessibility of fentanyl, and the harms that may arise as a result. DESIGN AND METHODS This paper presents data on prescribing patterns of fentanyl by 10 year age group adjusted by population rate, detailed analyses of fentanyl-related deaths from the National Coronial Information System and deaths adjusted for prescribing levels within Australia. RESULTS Fentany prescriptions have increased and are most prevalent among Australians aged over 80 years. One hundred and thirty-six fentanyl-related deaths were recorded during 2000-2011; 54% of decedents had a history of injecting drug use and, among this group, 95% had injected fentanyl at the time of death; 62% of deaths recorded misuse (most notably injection) of fentanyl; 50% recorded a history of drug dependence and 40% a mental health problem; 37% recorded a history of chronic pain; and 36% recorded fentanyl as being prescribed at the time of death. Deaths were primarily among Australians under 47 years of age. DISCUSSION AND CONCLUSIONS There have been significant increases in fentanyl prescribing in Australia. It is unclear what proportion of this increase represents legitimate treatment of pain. Fentanyl deaths have also increased, although mortality is currently low in Australia. A large proportion of the deaths involved the injection of diverted fentanyl, highlighting the need for messages regarding safer injecting practices targeting people who inject drugs, and strategies to minimise the risks of diversion.

Sexual identity and prevalence of alcohol and other drug use among Australians in the general population

BACKGROUND International research assessing differences in the prevalence of alcohol and other drug (AOD) use among Lesbian Gay Bisexual and Transgender (LGBTI) and heterosexual populations shows elevated prevalence rates of substance use among LGBTI people. To date no research has been published investigating these differences at a population level among both men and women in Australia. METHODS The 2013 National Drug Strategy Household Survey, a multistage stratified population sample collecting data on AOD use in the Australian population over 14 years of age, was analysed for differences between gay and bisexual (GB) men and lesbian/gay and bisexual (LGB) women and their heterosexual counterparts in: (1) the prevalence of lifetime and past year tobacco and AOD use; (2) age of initiation of tobacco and AOD use; and (3) frequency of alcohol and cannabis use, and history of AOD treatment. RESULTS There were elevated rates of past year cannabis (22.4%), ecstasy (11.8%) and methamphetamine (9.7%) use among GB men compared to heterosexual men (12.4%, 2.9% and 2.5%). LGB women also reported elevated rates of past year use (tobacco - 23.7%; cannabis - 24.6%) compared to heterosexual women (10.6% and 7.1%). LGB women initiated tobacco (15.2 years) and alcohol (15.5 years) at an earlier age than heterosexual women (16.6 and 17.7 years), and were significantly more likely to report daily alcohol consumption (OR 3.2, 95% CI: 2.1, 5.1), and weekly or more frequent cannabis use (OR 1.7, 95%CI: 1.1, 3.1). CONCLUSIONS These findings are indicative of the need for more responsive and targeted AOD harm reduction and treatment services for LGBTI communities in Australia. Of concern is the elevated risk among LGB women for earlier initiation of substance use, and the development of problematic consumption patterns. Further research, investigating the risk and protective factors for AOD use among LGB women is warranted.

Crystalline methamphetamine use and methamphetamine-related harms in Australia

INTRODUCTION AND AIMS Concerns about crystal methamphetamine use and harm have increased in multiple countries. This paper describes how changes in the availability and use of crystal methamphetamine have impacted on methamphetamine-related harms in Australia. DESIGN AND METHODS Data on methamphetamine use were obtained from population-level surveys, health service data and surveys of drug use among sentinel groups of ecstasy users and people who inject drugs. Data were obtained on seizures, arrests, clandestine laboratory detections, hospital separations, mental health unit admissions, drug telephone helpline calls and drug treatment episodes. Segmented linear regression models were fitted to identify changes in these series using log-transformed data where appropriate. RESULTS The availability of crystal methamphetamine has increased as evidenced by increased laboratory detections, domestic seizures and purity of the seized drug. Population surveys do not report an increase in the number of people who used at least once in the past year. However, more users report using crystal methamphetamine rather than lower-purity powder methamphetamine and more regular use. Indicators of methamphetamine-related harms have increased in parallel with this change. Amphetamine-related helpline calls, drug treatment, arrests and hospital admissions for amphetamine disorders and psychosis all peaked in the mid-2000s, declined for several years and have increased steeply since 2010. DISCUSSION AND CONCLUSIONS The increased availability and use of crystal methamphetamine have been associated with increased regular use and harms. Treatment is required for those experiencing problems and the capacity of health services to provide care needs to be enhanced.[Degenhardt L, Sara G, Connor JP, McKetin R, Roxburgh A, Dobbins T, Farrell M, Burns L, Hall WD. Crystalline methamphetamine use and methamphetamine-related harms in Australia. Drug Alcohol Rev 2017;36:160-170].

Changes in non-opioid substitution treatment episodes for pharmaceutical opioids and heroin from 2002 to 2011

BACKGROUND There has been a well-documented increase in the non-medical use of pharmaceutical opioids (PO) worldwide. However, there has been little detailed examination of treatment demand, or the characteristics of those presenting for treatment, particularly for treatments other than opioid substitution. METHODS Data from closed drug and alcohol treatment episodes from the Alcohol and Other Drug Treatment Services National Minimum Data Set (AODTS-NMDS, representing non-opioid substitution treatment) in Australia for 2002-2003 to 2010-2011 were examined. In the four jurisdictions where detailed data were available, episodes where heroin was the principal drug of concern were compared to episodes for the four most frequently reported pharmaceutical opioids (morphine, codeine, fentanyl and oxycodone). RESULTS In 2002-2003, most (93%) opioid treatment was related to heroin with seven percent of all opioid treatment episodes reporting a PO as the principal drug of concern. In 2010-2011, 20% of all opioid treatment episodes were attributed to POs. Distinct changes over time were observed for different opioids. There was an increase in the average age at the start of treatment for heroin and oxycodone episodes, and a reduction in the proportion of females for codeine episodes, with 67% in 2002-2003 compared with 44% in 2010-2011. Codeine and oxycodone episodes had the lowest current or past injection rates. CONCLUSIONS Clear differences were observed over time and between different opioids. Monitoring these emerging patterns will be important to inform treatment needs, particularly in light of different patterns of poly drug use, different routes of administration and changing demographic characteristics.