Emerging trends in drug use, harms, and markets: Findings from Drug Trends 2018 National Drug and Alcohol Research Centre Symposium, Monday 8th October, Sydney Dr Amy Peacock, National Drug and Alcohol Research Centre, UNSW, Sydney

Acknowledgements Funding: Australian Government Department of Health: for funding provided under the Drug and Alcohol Program Drug Trends Team: National Drug and Alcohol Research Centre: Daisy Gibbs, Antonia Karlsson, Anant Mathur, Rachel Sutherland, Julia Uporova, Amanda Roxburgh, Timothy Dobbins, Louisa Degenhardt, and Michael Farrell Burnet Institute: Amy Kirwan, Arthur Truong, Campbell Aitken and Paul Dietze School of Medicine, University of Tasmania: Ellie Bucher and Raimondo Bruno National Drug Research Institute (WA): James Fetherston, Jodie Griggs and Simon Lenton School of Public Health, The University of Queensland (QLD): Caroline Salom and Rosa Alati Northern Territory Department of Health (NT): Chris Moon Other Acknowledgements: IDRS and EDRS participants: for the time they give to complete the interview Data custodians: for the timely provision of data and input on analysis and interpretation Stakeholders: for engagement with and input on Drug Trends

National Monitoring with Secondary Data Sentinel Sample Monitoring AIM To establish, maintain, and continuously improve monitoring of drug trends across Australia DATA SOURCES National Monitoring with Secondary Data Jurisdictional Monitoring with Secondary Data Sentinel Sample Monitoring Online Monitoring Mortality Data Drug-induced deaths from NCIS and ABS Hospitalisation Data Drug-induced hospitalisations from NHMD Other Sources NDSHS, AODTS-NMDS etc Various data sources assessing drug use and harms at the population-level (e.g., hospital separations, emergency department presentations) and subpopulation level (e.g., NSP visits) Illicit Drug Reporting System (IDRS) Ecstasy and Related Drug Reporting System (EDRS) Annual interviews with people who inject drugs (IDRS) and who use stimulants (EDRS) Darknet Market Data Scraping listings on darknet drug markets ENGAGEMENT/ DISSEMINATION Single source regular reports Single source regular reports Single source regular reports Single source regular reports Input from CIs, national stakeholders, and jurisdiction stakeholders to inform priority research questions and interrogation of data Analytical reports using triangulated data

IDRS and EDRS interview samples, 2018 Key Caveats Findings do not represent drug use in the general population, nor trends in regional/remote areas People report what they think the substance was (no objective data on actual contents) Need to be interpreted in context of other data sources IDRS (910 people in 2018) EDRS (799 people in 2018) People who regularly inject illicit drugs residing in capital cities (approx. 100-150 per city) People who regularly use ecstasy or other stimulants residing in capital cities (approx. 100 per city) Interviewed May-July each year Interviewed March-June each year Mostly male (66%) middle-aged (mean 43 yrs) Mostly male (59%) and young (median 21 yrs) Majority unemployed (87%) Majority studying (18%) or employed (71%) Homelessness/unstable housing high (14%) Few homeless or in unstable housing (2%) History of incarceration high (56%) History of incarceration lower (4%) Two in five (41%) in drug treatment Few in drug treatment (1%) Focused on illicit drugs

Perceived purity as ‘high’ Sample who use ecstasy and other stimulants (EDRS): Ecstasy use past six months Main form: Capsules – NSW, VIC Pills – ACT, TAS, WA, NT, QLD Crystal – SA (all jurisdictions ≥53% reported recent use of crystal) 27% of the total sample report weekly or more frequent ecstasy use Perceived purity as ‘high’ Note. Participants were recruited on the basis of ecstasy use until 2013, when the eligibility criterion was expanded across all jurisdictions to include any regular illicit stimulant use.

Other indicators of trends in ecstasy use and markets Drug seizure data: Wastewater data: Consistently lowest detected substance (excepting new psychoactive substances) Household survey data: 2.2% of people aged 14+ reported past year use in 2016 (declining relative to previous years). ACIC. (2018). Illicit Drug Data Report; ACIC (2018). National Wastewater Monitoring Program; AIHW (2017). National Drug Strategy Household Survey

Dutch Drug Information Monitoring System (DIMS) In 2017, 12,161 visitors handed in 11,963 samples for analysis (59% ecstasy/MDMA) https://www.drugs-test.nl/dims

Sample who use stimulants (EDRS) and who inject drugs (IDRS): Cocaine use last six months 7% of cocaine consumers in EDRS reported weekly or more frequent use 96% of cocaine consumers in EDRS reported snorting cocaine 62% of cocaine consumers in EDRS said cocaine was ‘easy’ or ‘very easy’ to obtain

Sample who use stimulants (EDRS): Cocaine use last six months Highest % recorded for VIC (84%), ACT (75%), NSW (71%), WA (47%), and QLD (60%) NT declined from 57% to 40% but has fluctuated over years. NSW upwards (62% to 71% and highest recorded since monitoring began), QLD showed upwards, SA stayed the same

Other indicators of trends in cocaine use and markets Wastewater data: Population-weighted average consumption of cocaine in regional sites almost doubled between August 2016 and August 2017, with population-weighted average consumption in capital sites increasing by around 30 per cent. Household survey data: 2.5% of people aged 14+ reported past year use in 2016 (vs 2.1% in 2013 and 2010 and 1.6% in 2007). National drug seizures detections: Main source country Colombia Number and weight of seizures at the borders and nationally were at highest levels identified, increase in cocaine-related arrests. International mail stream accounts for greatest number and air cargo greatest weight Our data and that provided the IDDR don’t suggest significant change in price Cavveats to wastewater given prior to that period had seen a decrease ACIC. (2018). Illicit Drug Data Report; ACIC (2018). National Wastewater Monitoring Program; AIHW (2017). National Drug Strategy Household Survey

Sample who use stimulants (EDRS): Other drug use last six months ≤5 days typical frequency of consumption for all substances https://www.tga.gov.au/book-page/13-alkyl-nitrites Amyl nitrite – currently schedule 4 and often sold as cleaner, and found in sex shops Plan to change to schedule 9 (prohibited substance – same as ecstasy, LSD) – little to no therapeutic benefit Note. Axis has been modified to 0-70 to better show trends

Sample who use stimulants (EDRS) and who inject drugs (IDRS): Methamphetamine use last six months 18% of consumers in EDRS reported weekly or more frequent use 65% of consumers in IDRS reported weekly or more frequent use 8% of methamphetamine consumers who reported weekly or more frequent use had received drug treatment for methamphetamine in the past year

Sample who use stimulants (EDRS) and who inject drugs (IDRS): Methamphetamine use last six months 96% of consumers in IDRS reported injecting crystal EDRS: Four states (NT, QLD, WA, and SA) where crystal ↑ speed. IDRS: All states crystal ↑ speed 35% of consumers in IDRS reported smoking crystal Consistent trend over the last few years for SA and NT, QLD fluctuates but small %, WA also small %

Amphetamine-induced deaths in Australia 2016 N=108 2011 N=22 Note. Deaths are for all-ages and 2015 and 2016 estimates are preliminary. Small cell sizes may have been randomised to protect confidentiality. ICD codes: X41 with F15 or X41 with T43.6  For online interactive visualisations, visit: https://ndarc.med.unsw.edu.au/resource/opioid-amphetamine-and-cocaine-induced-deaths-australia-august-2018

Amphetamine-induced deaths in Australia Note. Deaths are for all-ages and 2015 and 2016 estimates are preliminary. Small cell sizes may have been randomised to protect confidentiality. For online interactive visualisations, visit: https://ndarc.med.unsw.edu.au/resource/opioid-amphetamine-and-cocaine-induced-deaths-australia-august-2018

of jurisdiction samples report recent use of heroin Sample who inject drugs (IDRS): Heroin and pharmaceutical opioid injection last six months 8% (TAS)-83% (VIC/NSW) of jurisdiction samples report recent use of heroin No jump in frequency of heroin or other pharmaceutical opioid use following reformulation See ‘Larance et al. (2018). The effects of a potentially tamper-resistant oxycodone formulation…Lancet Psychiatry’ for further information

Sample who inject drugs (IDRS): Pregabalin last six months Pregabalin: gabapentinoid used to treat neuropathic pain and epilepsy Prescribed use: 16.4% lifetime use 10.4% recent use Non-prescribed use: 26.2% lifetime use 15.3% recent use Gabapentinoid Lyrica Subsidised in 2013 New work showing huge increases in dispensing, as well as poison information centre calls and deaths where pregabalin is cited Animal studies showing that gabapentoids potentiate the effects of opioids, and can be additive with opioids in depressing respiration and could reverse tolerance to respiratory depressant effects Evidence increased risk of opioid-related death

Sample who use stimulants (EDRS) and who inject drugs (IDRS): Codeine use and change in scheduling

Sample who inject drugs (IDRS): Non-fatal overdose Past year non-fatal overdose: NSW: 25% ACT: 19% VIC: 38% (↑ 24%) TAS: 9% SA: 13% WA: 15% NT: 12% QLD: 21%

Sample who inject drugs (IDRS): “Glass half-full outcomes” Naloxone Hepatitis C Injecting risk behaviours 58% heard of naloxone training programs 18% completed training 8% of the total sample had been resuscitated by someone who had completed training 34% of those who had completed training had used naloxone to resuscitate someone 55% Had been told they were HCV positive (54% in 2017) 48% of these participants had received antiviral treatment (32% in 2017) 30% had received antiviral treatment in the past year

IDRS: What did you use yesterday? 98% of the sample reported using drugs yesterday – this represents around 80% who had used one of these drugs yesterday, - around 25% reported using combination 93% of the sample reporting using other drugs last time they used illicit stimulant 38% had used stimulant drugs for 48 hours or more in the last six months EDRS: What did you use last time you had an illicit stimulant?

Sample who use stimulants (EDRS) and who inject drugs (IDRS): High frequency drug use last six months Note. Axis has been modified to 0-70 to better show trends

Sample who use stimulants (EDRS): Other patterns of use last six months

https://drugsand.me/en/ https://www.talkingdrugs.org/

Key points Increasing use of ecstasy and methamphetamine forms known to be of higher purity Possible gap in treatment engagement for those using methamphetamine at high frequency or do not see it as primary drug of concern? Increasing use of cocaine, although frequency of use remains low Aligns with other data sources and with trends in some other countries Important to monitor experience of harms going forward Declining use of pharmaceutical opioids with no obvious increase in use (or frequency of use) of heroin Increased non-prescribed use of other drugs (e.g., pregabalin) of concern Reports of non-fatal overdose stable in most jurisdictions Positive steps in terms of naloxone awareness and use, HCV treatment uptake, and reduced engagement in injecting risk behaviours Continuing trends of engagement in behaviours indicative of problematic use More comprehensive monitoring of harm reduction/protective behaviour strategies in future interviews

For further information Contact: drugtrends@unsw.edu.au Visit: https://ndarc.med.unsw.edu.au/program/drug-trends Subscribe: https://tinyurl.com/y8g5y7t9 Download: Follow: National Drug and Alcohol Research Centre (NDARC) @NDARCNEWS #DrugTrends