Alcohol, tobacco & other drugs in Australia

People who inject drugs (PWID) are among the most marginalised and disadvantaged drug users. They experience poorer health outcomes with a higher chance of premature death, high rates of potentially life threatening infectious diseases, and increased risk of both fatal and non-fatal overdoses [1]. In 2015 it was estimated that there were over 12 million people worldwide who injected drugs [1, 2].

Prevalence of drug injection

In Australia, a low proportion of the general population report injecting drugs. Information on data sources referred to in this section are in Box PWID1. The National Drug Strategy Household Survey (NDSHS) found that in 2016, 1.6% of the population aged 14 and over had injected a drug in their lifetime (Table S2.31), with 0.3% having injected a drug in the past year (both stable from 2013) (Table S2.32, Figure PWID1). Males who were aged 14 and over were more likely to have recently injected drugs (in the past year) than their female counterparts (0.4% compared to 0.2%) [3].

Drug type

Heroin and meth/amphetamine are the most commonly injected drugs in Australia, however there are changing patterns of use [3,5,6]. Other common drugs injected include pharmaceutical opioids and performance and image enhancing drugs (such as steroids, peptides or hormones) (Table S3.63). 

Methamphetamine

Data from the 2013–2017 Australian and Needle Syringe Program Survey (Figure PWID2) showed that:

• Methamphetamine is now the most commonly injected drug in Australia and its use by PWID has increased significantly from 29% in 2013 to 41% in 2017 [5] (Table S3.63). This increase is consistent with findings from the 2016 NDSHS [2] and the 2018 IDRS [6].
• In 2017, methamphetamine was the most commonly injected drug in the majority of jurisdictions, including New South Wales (36%), Northern Territory (47%), Queensland (43%), South Australia (49%), Tasmania (31%) and Western Australia (54%) [5].

Heroin

• Nationally, heroin was the second most commonly reported last injected drug in 2017, with the proportion of respondents who reported last injecting heroin remaining relatively steady between 2013 (29%, when it was equal with methamphetamine as the most commonly reported last injected drug) and 2017 (30%) [5] (Table S3.63).
• Heroin remained the most common ‘drug last injected’ (most recent drug injected) in the ACT (49%) and Victoria (62%) [6].
• The 2017 IDRS found that heroin as the ‘drug first injected’ (first drug ever injected in their lifetime) significantly decreased between 2016 and 2017 (38% compared to 33%) [4] (Table S3.64).

Pharmaceutical opioids

• Pharmaceutical opioids (including morphine and oxycodone) were the third most commonly reported class of drugs that were injected, although prevalence declined significantly from 14% in 2013 to 9% in 2017 [5] (Table S3.63).
• Specifically:
  • 5% reported injecting methadone
  • 2% reported injecting buprenorphine
  • 1% reported injecting buprenorphine/naloxone [5] (Table S3.63).

Health and harms

Injecting drug use is a major risk factor for transmitting blood-borne viruses, including HIV, hepatitis B and hepatitis C. Needle and syringe sharing among people who inject drugs is partly responsible for transmitting infection, although unsafe sexual behaviours also play a role [7].

Burden of disease and injury

Injecting drug use was responsible for 0.4% of the total burden of disease and injuries in 2011 [8].

Unsafe injecting practices are linked to Hepatitis B, Hepatitis C, HIV/AIDS, Liver cancer and chronic liver disease. Liver cancer and chronic liver disease are the long term consequences of contracting hepatitis B and hepatitis C infection. Chronic liver disease was responsible for 65%, and Liver cancer 32%, of the burden due to unsafe injecting practices [8].

Injecting risk behaviours

Data from the Australian NSP survey provides some evidence of the harms related to injecting drug use in persons who regularly inject drugs in Australia:

• the proportion of respondents reporting reuse of needles and syringes (including the reuse of one’s own syringes) was stable, between 23% in 2013 to 24% in 2017
• the proportion of respondents reporting receptive sharing of needles and syringes increased, from 15% in 2013 to 17% in 2017 [5].

Data from the Illicit Drug Reporting System (IDRS) provides addition evidence of harms, including:

• 11% of participants of the 2018 IDRS reporting lending a needle to someone after they had used it, and 9% reported borrowing a needle after someone else had used it. Re-use of their own needle was reported by 37% of IDRS participants.
• Past month sharing of injecting equipment such as filters, water and mixing containers (e.g. spoons) was reported by 20% of participants, stable from 2017 but a significant decrease from 2016 (26%)  and has declined from a high of 51% in 2000 [6] (Table S3.65).

Injection-related health problems

The 2018, the IDRS found that 73% of participants in the national sample had experienced an injection-related health problem in the month preceding interview. This was a significant increase from the 65% of participants in the 2017 national sample, driven by an increase in rates of scarring/bruising and dirty hits. Of those who commented (n=828):

• 52% experienced scarring/bruising
• 43% experienced difficulty injecting, most likely indicating poor vascular health among a percentage of this group
• 14% reported that they had experienced a ‘dirty hit’ (i.e. a hit that made them feel sick), in the month preceding interview [6] (Table S3.66).

The ANSPS found that HIV antibody prevalence is low and stable nationally (2.1% in 2017) (Table S3.67). Some populations of PWID are at greater risk of HIV than others.

• Nationally, across all survey years except 2012, HIV antibody prevalence was consistently higher among male respondents than among female respondents (Figure PWID4). HIV antibody prevalence has also been consistently higher among homosexual male respondents than among bisexual and heterosexual male respondents or female respondents.
• Between 2013 and 2017, HIV prevalence was also higher among men who reported methamphetamine as the last drug injected compared to men who reported last injecting other drugs, and among men who reported sex work in the month preceding the survey compared to men who did not report sex work.
• Prevalence of HIV infection among Aboriginal and Torres Strait Islander respondents increased from 1.3% in 2013 to 3.6% in 2017 [5]. 

• According to the ANSPS, hepatitis C is more common than HIV among PWID. The prevalence of hepatitis C was 49% in 2017, this represents a significant decline over the five-year period from 2013 (Table S3.68). Hepatitis C prevalence of less than 50% has only occurred at one other time since the ANSPS commenced in 1995, with a reported prevalence of 49% last observed in 1998. HCV antibody prevalence was significantly higher among older respondents and those with longer injection histories.

• HCV antibody prevalence was significantly higher among older respondents and those with longer injection histories.
• Prevalence of HCV was also higher among respondents reporting heroin or other opioids as the last drug injected compared to respondents who last injected methamphetamine. 
• HCV antibody prevalence was also consistently higher among respondents who reported imprisonment in the year preceding survey completion compared to those who had not been incarcerated and among respondents who reported receptive syringe sharing in the last month compared to respondents who did not report receptive syringe sharing [5].

• Between 2011 and 2015, the proportion of respondents reporting initiating HCV treatment in the last 12 months was low and stable at 1-3%, but increased significantly to 22% in 2016 and 36% in 2017, with substantial increases observed in all jurisdictions [5].

Policy context

Policy support

The 2016 NDSHS showed that most people supported measures to reduce problems associated with injecting drugs. About two-thirds of the population aged 14 and over supported rapid detoxification therapy (69%), methadone/buprenorphine maintenance programs (68%), needle and syringe programs (67%), treatment with drugs other than methadone (67%) and the use of Naltrexone (66%), which is a medication that blocks the effect of opioids such as heroin. In addition:

• a trial of prescribed heroin received the least support (35%)
• apart from a trial of prescribed heroin and availability of take-home naloxone, higher proportions of females than males supported measures aimed at reducing problems associated with heroin
• support for needle and syringe programs (84%) and a trial of prescribed heroin (68%) was particularly high among recent injecting drug users (Table S3.69)
• in 2016, there was a small but significant decline in the support for use of Naltrexone (from 68% in 2013 to 66%) (Table S3.70).

Needle and syringe programs

All Australian states and territories operate needle syringe programs (NSPs), providing a range of services to PWID [9]. NSPs are designed to reduce the sharing of injecting equipment through the provision of sterile needles and syringes to people who inject drugs. NSPs are a cost-effective measure that has successfully prevented the spread of HIV and hepatitis C infection. NSPs also provide counselling services and actively encourage clients into drug treatment programs [10].

According to the IDRS, in 2017, NSPs were by far the most common source of needles and syringes in the preceding six months (94%), followed by NSP vending machines (19%). Chemists were used by 16% of participants nationally [4] (Table S3.71). This differs to the findings of the NDSHS that found chemists were the most commonly reported source (44.2%), followed by NSPs (40.9%) [3] (Table S3.72). This is likely to reflect the different sampling of the two surveys whereby the NDSHS is targeted at the general population, while the IDRS accesses PWID. 

Medically Supervised Injecting Centres

Medically supervised injecting centres (MSIC) are places where people can use and inject drugs under the supervision of registered nurses, counsellors and health education professionals. This service aims to prevent injury and death by being present when someone injects in order to provide immediate medical assistance as required. Kings Cross in Sydney has been home to an MSIC since 2001 [11], and in 2017 it was announced that another would be implemented in Richmond, Victoria.

References

1. United Nations Office on Drug and Crime (UNODC) 2017. World Drug Report 2017. Vienna: UNODC. Viewed 14 December 2017.
2. World Health Organization 2018. People who inject drugs. Viewed 15 March.
3. Australian Institute of Health and Welfare (AIHW) 2017. National drug strategy household survey 2016: detailed findings. Drug statistics series no. 31. Cat. no. PHE 214. Canberra: AIHW. Viewed 14 December 2017.
4. Karlsson A & Burns L 2018. Australian Drug Trends 2017. Findings from the Illicit Drug Reporting System (IDRS). Australian Drug Trend Series. No. 181. Sydney, National Drug and Alcohol Research Centre, UNSW Australia.
5. Heard S, Iversen J, Geddes L & Maher L 2018. Australian Needle Syringe Program Survey National Data Report 2013-2017: Prevalence of HIV, HCV and injecting and sexual behaviour among NSP attendees. Sydney: Kirby Institute, UNSW..
6. Peacock A, Gibbs D, Sutherland R, Uporova J, Karlsson A, Bruno R, Dietze P, Lenton S, Alati R, Degenhardt L & Farrell M 2018. Australian Drug Trends 2018. Key findings from the National Illicit Drug Reporting System Interviews. Sydney, National Drug and Alcohol Research Centre, UNSW Australia.
7. AIHW 2012. Australia’s health 2010. Australia’s health series no. 12. Cat. No. AUS 122. Canberra: AIHW.
8. AIHW 2018. Impact of alcohol and illicit drug use on the burden of disease and injury in Australia: Australian Burden of Disease Study 2011. Australian Burden of Disease Study series no. 17. Cat. no. BOD 19. Canberra: AIHW.
9. Heard S, Iversen J, Kwon JA & Maher L 2017. Needle Syringe Program National Minimum Data Collection: National Data Report 2017. Sydney: Kirby Institute. Viewed 15 March 2018.
10. Dolan K, MacDonald M, Silins E & Topp L 2005. Needle and syringe programs: a review of the evidence. Canberra: Australian Government Department of Health and Ageing. Viewed 25 January 2018.
11. Uniting 2017. Uniting Medically Supervised Injecting Centre: get to know our story. Viewed 25 January 2018.