Australian Heroin Shortage Research Articles

“It's Russian roulette”: Adulteration, adverse effects and drug use transitions during the 2010/2011 United Kingdom heroin shortage

BackgroundBetween late 2010 and mid 2011 there was a significant heroin shortage in the United Kingdom (UK), resulting in a rapid drop in street heroin purity and increase in price. The most well documented event of this kind is the 2000–2001 Australian heroin shortage, with little published research addressing the UK context. In this paper we draw on qualitative data to explore the impact of, and responses to, the 2010/2011 shortage among London-based heroin users. MethodsData collection comprised longitudinal life history and narrative interviews with 37 PWID in 2010–2011. The average age of participants was 40, with a 20-year average duration of injecting. Heroin was the drug of choice for the majority of participants (25), with 12 preferring to inject a crack-cocaine and heroin mix. Recruitment took place through London drug and alcohol services and peer networks. ResultsThe majority of participants continued to source and inject heroin despite reported decline in purity and increased adulteration. Transitions to poly-drug use during the heroin shortage were also common, increasing vulnerability to overdose and other drug related harms. Participants enacted indigenous harm reduction strategies in attempting to manage changes in drug purity and availability, with variable success. ConclusionEpidemiological data gathered during periods of heroin shortage is often drawn on to emphasise the health benefits of reductions in supply. Our findings highlight the importance of understanding the ways in which heroin shortages may increase, as well as reduce, harm. There is a need for enhanced service provision during periods of drug shortage as well as caution in regard to the posited benefits of supply-side drug law enforcement.

How do drug market changes affect characteristics of injecting initiation and subsequent patterns of drug use? Findings from a cohort of regular heroin and methamphetamine injectors in Melbourne, Australia

BackgroundChanges in drug market characteristics have been shown to affect drug use patterns but few studies have examined their impacts on injecting initiation experiences and subsequent patterns of injecting drug use (IDU). MethodsWe collected data on self-reported injecting initiation experiences and past-month patterns of IDU from 688 regular heroin and methamphetamine injectors in Melbourne, Australia, who initiated injecting across three different drug market periods (prior to the Australian heroin shortage (‘high heroin’)/immediately following the shortage (‘low heroin’)/‘contemporary’ markets (fluctuating heroin and methamphetamine availability)). We used univariable and multivariable logistic regression to examine the relationship between period of injecting initiation and first drug injected, and multinomial logistic regression for the relationship between period of injecting initiation and current injecting patterns. Results425 participants (62%) reported initiating injecting in the high heroin period, 146 (21%) in the low heroin period, and 117 (17%) in the contemporary period. Participants who initiated injecting during the low heroin period were twice as likely to initiate injecting using a drug other than heroin (AOR: 1.94, 95% CI: 1.27–2.95). The most common patterns of drug use among study participants in the month preceding interview were polydrug use (44%) and primary heroin use (41%). Injecting initiation period was either non-significantly or weakly associated with current drug use pattern, which was more strongly associated with other socio-demographic and drug use characteristics, particularly self-reported drug of choice. ConclusionThe drug market period in which injecting initiation occurred influenced the first drug injected and influenced some aspects of subsequent drug use. In the context of highly dynamic drug markets in which polydrug use is common there is a need for broad harm reduction and drug treatment services which are flexible and responsive to changing patterns of drug use.

Decline in needle exchange use in Vancouver, Canada coincides with the Australian heroin shortage

t e i t i a s C It has recently been demonstrated that a number of indiators of heroin use have declined in Vancouver, Canada oinciding with the Australian heroin shortage (Wood, Stoltz, ontaner, & Kerr, 2006b; Wood, Stoltz, Li, Montaner, & err, 2006a). These findings have important implications for he debate regarding the causes of the Australian heroin shortge. Identification of a contemporaneous decline in the heroin arket of a separate country, which traditionally receives its upply from the same source country (Burma), challenges he perspective that the shortage was precipitated by unique ocal factors, such as law enforcement initiatives. However, uestions have been raised regarding whether Vancouver has ctually experienced a heroin shortage, and there have been alls for further evidence to support this claim (Caulkins & euter, 2006; Smithson, 2006). A reduction in syringe exchange activity in Australia has een documented to coincide with the onset of the Australian eroin shortage (Day, Degenhardt, Gilmour, & Hall, 2004), hich is believed to have begun in approximately January 001. Since measures of syringe exchange were noted to ecline in Australia coinciding with the Australian shortge, we sought to examine if syringe exchange activity data eclined in Vancouver coinciding with the Australian heroin hortage. Consideration of longitudinal measures of Vancouver neele exchange data requires consideration of local policy hanges. Subsequent to the emergence of an explosive HIV pidemic among IDU in Vancouver in 1997 (Strathdee et al., 997), significant efforts were made to expand existing neele exchange programmes as difficulty accessing needles was ound to be a primary factor driving needle sharing locally Wood, Tyndall, Spittal, Li, Hogg, O’Shaughnessy, et al.,

Australian heroin seizures and the causes of the 2001 heroin shortage

This paper uses Australian heroin seizure data, along with estimates of the size of the Australian heroin market to evaluate the impact of drug law enforcement on the 2001 Australian heroin shortage from the percentage of the market seized. It also critically examines international heroin production trends and published reports on the causes of the Australian heroin shortage. Its conclusion is that previous studies may have overstated the success of drug law enforcement and that the most likely explanation for Australia's 2001 heroin shortage was a significant decline in heroin production world-wide, due to a general move away from heroin production in the countries of Southeast Asia and the prohibition on opium growing by the Taliban regime in Afghanistan.

CANADIAN HEROIN SUPPLY AND THE AUSTRALIAN ‘HEROIN SHORTAGE’

We wish to comment on the recent article by Wood et al. [1], which questioned whether law enforcement contributed to the Australian heroin shortage in 2001. We agree with Wood et al. that reductions in international heroin supply may have played a larger role than we supposed in the Australian heroin shortage. We stress, however, that we acknowledged in our paper that changes in source countries probably did play a role (p. 466) [2]. We have never claimed, as some of our critics have assumed, that law enforcement activity was the sole, or even the major explanation of the Australian heroin shortage. None the less, for the following reasons we doubt that Australian heroin shortage can be wholly or largely explained by a reduction in heroin production in source countries. First, the timing of the onset of the Australian shortage can be specified to within a month. There was a simultaneous reduction in heroin availability reported by heroin users throughout the whole of Australia that began in late December and early January 2001. Time-series analysis of a wealth of monthly data reflecting the size of the heroin market pointed strongly to the occurrence of an external ‘shock’ to the heroin supply system on that date (e.g. [3–8]). This was clearest in the most direct indicators of heroin use, namely, fatal and non-fatal drug overdoses [9,10]. It was echoed in data on heroin price, purity and availability [11,12]. All analyses pointed to January 2001 as the time when there was a substantial change in the heroin market. This was consistent with the reports of heroin users, treatment providers, police [13,14] and the researchers who conducted research on the ground to investigate this unique event [15,16]. There was no comparable event in Vancouver that was reported at the time by key informants whom we contacted when undertaking our analyses of the reasons for Australian heroin shortage [14]. Secondly, the size of the decrease in fatal and non-fatal overdose in Australia was much larger (as well as more immediate) than the smaller (and more gradual) decline in overdoses observed in Vancouver. This reduction also occurred in the much larger heroin market of Sydney and Melbourne (the capital cities of States where it has been estimated there were possibly 70 000 regular heroin users in 2000 [17]) than the much smaller Vancouver market (where it might be estimated that there were 2000 such users, estimated from the number of overdose deaths) where fewer than half of the injectors surveyed reported daily heroin use. Thirdly, if the decline in overdose mortality in Vancouver data can be used to estimate the contribution that declining supply may have made in Australia, then it would explain about half the observed decline in Australian overdose deaths. This still leaves open the possibility that high-level law enforcement contributed to the Australian shortage. Fourthly, we did not argue that heroin seizures directly affected heroin supply in Australia. Rather, we argued that large seizures deterred large-scale centralized heroin importation syndicates from importing heroin in large quantities into Australia. This is supported by the fact that the amount of heroin seized in Australia was much larger than that in Vancouver in terms of both the absolute size (total kg) and in terms of probable market share [18]. Such large seizures might be expected to have a larger deterrent effect on heroin importers when supply in source countries was declining. Fifthly, the hypothesis that source country supply wholly explains the Australian shortage does not explain why there was a much larger reduction in heroin supply in Australia than in Vancouver, when Australian cities have a much larger heroin market, and are geographically much closer to source countries in the Golden Triangle than Vancouver. We agree with Wood et al. that we should avoid premature acceptance of the hypothesis that law enforcement activities played a major role in the Australian heroin shortage, given the paucity of data in the literature indicating that law enforcement activities have large effects on the size of heroin or other drug markets. We also believe that scepticism should be responsive to evidence when something unusual happened, as our data indicate that it clearly did in Australia in January 2001. It would be unwise to rule out on a priori grounds the possibility that the Australian heroin shortage may have been one of those rare occasions in which law enforcement activities contributed to reduced drug supply.

Changes in the initiation of heroin use after a reduction in heroin supply

Increasing heroin use in Australia over the past 30 years has been associated with a decline in the age of initiation to heroin use. The 2001 Australian heroin shortage was used to assess the effects of a reduction in heroin supply on age of initiation into heroin injecting. Data collected from regular injecting drug users (IDU) over the period 1996 - 2004 as part of the Australian Illicit Drug Reporting System were examined for changes in self-reported age of first heroin use after the onset of the heroin shortage. Estimates were also made of the number of young people who may not have commenced injecting heroin during the heroin shortage. The proportion of IDU interviewed in the IDRS who were aged <or=24 years decreased from 46% in 1996 to 12% in 2004, with the most marked drop in 2001, the year in which there was an abrupt and marked reduction in heroin availability. Of those who reported first injecting between 1993 and 2000, similar proportions reported heroin and amphetamine as the first drug injected. After 2000, methamphetamine was the drug most often reported as being the first injected. Estimates suggested that between 2745 and 10,560 young people may not have begun to inject heroin in 2001 as a result of reduced heroin supply. If around one in four of these young users had progressed to regular or dependent heroin use, then there may have been a reduction of between 700 and 2500 dependent heroin users. There was an increase in amphetamine injecting but it is unclear to what extent any reduction in heroin injecting has been offset by increased amphetamine injecting. Reduced heroin availability probably resulted in a reduction in the number of new heroin injectors in Australia. Efforts need to be made to reduce the chances that young people who have initiated methamphetamine injecting do not move to heroin injecting when the heroin supply returns.

The "lessons" of the Australian "heroin shortage".

Heroin use causes considerable harm to individual users including dependence, fatal and nonfatal overdose, mental health problems, and blood borne virus transmission. It also adversely affects the community through drug dealing, property crime and reduced public amenity. During the mid to late 1990s in Australia the prevalence of heroin use increased as reflected in steeply rising overdose deaths. In January 2001, there were reports of an unpredicted and unprecedented reduction in heroin supply with an abrupt onset in all Australian jurisdictions. The shortage was most marked in New South Wales, the State with the largest heroin market, which saw increases in price, dramatic decreases in purity at the street level, and reductions in the ease with which injecting drug users reported being able to obtain the drug. The abrupt onset of the shortage and a subsequent dramatic reduction in overdose deaths prompted national debate about the causes of the shortage and later international debate about the policy significance of what has come to be called the "Australian heroin shortage". In this paper we summarise insights from four years' research into the causes, consequences and policy implications of the "heroin shortage".

THE CAUSE OF THE AUSTRALIAN HEROIN SHORTAGE: TIME TO RECONSIDER?

THE CAUSE OF THE AUSTRALIAN HEROIN SHORTAGE: TIME TO RECONSIDER?

Using intervention time series analyses to assess the effects of imperfectly identifiable natural events: a general method and example

BackgroundIntervention time series analysis (ITSA) is an important method for analysing the effect of sudden events on time series data. ITSA methods are quasi-experimental in nature and the validity of modelling with these methods depends upon assumptions about the timing of the intervention and the response of the process to it.MethodThis paper describes how to apply ITSA to analyse the impact of unplanned events on time series when the timing of the event is not accurately known, and so the problems of ITSA methods are magnified by uncertainty in the point of onset of the unplanned intervention.ResultsThe methods are illustrated using the example of the Australian Heroin Shortage of 2001, which provided an opportunity to study the health and social consequences of an abrupt change in heroin availability in an environment of widespread harm reduction measures.ConclusionApplication of these methods enables valuable insights about the consequences of unplanned and poorly identified interventions while minimising the risk of spurious results.

Changes in Canadian heroin supply coinciding with the Australian heroin shortage

Previous studies have largely attributed the Australian heroin shortage to increases in local law enforcement efforts. Because western Canada receives heroin from similar source nations, but has not measurably increased enforcement practices or funding levels, we sought to examine trends in Canadian heroin-related indices before and after the Australian heroin shortage, which began in approximately January 2001. During periods before and after January 2001, we examined the number of fatal overdoses and ambulance responses to heroin-related overdoses that required the use of naloxone in British Columbia, Canada. As an overall marker of Canadian supply reduction, we also examined the quantity of heroin seized during this period. Lastly, we examined trends in daily heroin use among injection drug users enrolled in the Vancouver Injection Drug Users Study (VIDUS). There was a 35% reduction in overdose deaths, from an annual average of 297 deaths during the years 1998-2000 in comparison to an average of 192 deaths during 2001-03. Similarly, use of naloxone declined 45% in the period coinciding with the Australian heroin shortage. Interestingly, the weight of Canadian heroin seized declined 64% coinciding with the Australian heroin shortage, from an average of 184 kg during 1998-2000 to 67 kg on average during 2001-03. Among 1587 VIDUS participants, the period coinciding with the Australian heroin shortage was associated independently with reduced daily injection of heroin [adjusted odds ratio: 0.55 (95% CI: 0.50-0.61); P < 0.001]. Massive decreases in three independent markers of heroin use have been observed in western Canada coinciding with the Australian heroin shortage, despite no increases in funding to Canadian enforcement efforts. Markedly reduced Canadian seizure activity also coincided with the Australian heroin shortage. These findings suggest that external global heroin supply forces deserve greater investigation and credence as a potential explanation for the Australian heroin shortage.

MAPPING THE CONSEQUENCES OF AN UNANTICIPATED DRUG SUPPLY CHANGE OF UNCERTAIN ORIGINS: RESPONSE TO THE COMMENTARIES

MAPPING THE CONSEQUENCES OF AN UNANTICIPATED DRUG SUPPLY CHANGE OF UNCERTAIN ORIGINS: RESPONSE TO THE COMMENTARIES

LEARNING FROM UNCOMMON EVENTS: COMMENT ON DEGENHARDT Et al. 2005

The literature contains several studies of the fallout from relatively rapid increases in the availability of illicit heroin (Robins 1993; Strang & Gossop 1994; DuPont 2002). Typically, use rates, overdose deaths and acquisitive crime increase; and with some latency, so does treatment seeking where treatment is available. In contrast, there are few studies of what happens to drug users and their communities when opioid availability abruptly decreases. Such a temporary decrease occurred in the United States in 1972/1973, after the United States persuaded Turkey to cease harvesting opium and adopt the poppy straw extraction method for producing the raw material for medicinal opioids. At the time, only a limited number of indicators of the effects of the heroin shortage were in place. Some of those, such as treatment seeking, were of limited value because there was already excess demand for available treatment capacity; needles were not yet being distributed. The present study by Degenhardt et al. (2005) of the effects of a sharp decrease in heroin supply, with multiple measures of its impact on users and the community in place, may be unique in the scientific literature. Any comment should begin by commending the authors and their colleagues for this and related important contributions dealing with such an episode of reduced heroin supply in Australia (Degenhardt et al. 2005; Gibson et al. 2005). Degenhardt and colleagues provide some assurances that one of the possible unintended consequences of reduced heroin supply will not materialize. Over the past 15–20 years, heroin users in the United States and the United Kingdom have increasingly shifted from injecting opiates to using them intranasally (snorting) or inhaling them (chasing the dragon) (Griffiths et al. 1994). About 50–60% of heroin users on the east coast of the United States who seek treatment claim that they use heroin exclusively by the intranasal route (Neaigus et al. 2001). This shift in preferred route of administration has been driven largely by concerns about HIV infection and has taken place even though sterile injection equipment has become more widely available. Most probably it has also been facilitated by the declining price of illicit heroin that is occurring, even though resources devoted to supply reduction have increased substantially. This decline in the price of heroin in the United States is likely to have been a factor in a resurgence of heroin use among some young people. There is concern in the United States, however, that a sharp decrease in availability or a substantial increase in price could lead to increased injection use because of the greater efficiency of this route. Degenhardt and coworkers suggest that this should not be a major concern because during the heroin shortage in Australia all the indices of drug injecting dropped, including the distribution of sterile needles, and no sharp increase in the demand for treatment ensued. This study also indicates that the expected increases in acquisitive crime are only transient. However, another report on the Australian heroin shortage (Gibson et al. 2005) takes a somewhat different tone, describing the burdens experienced by treatment personnel trying to cope with a new wave of amphetamine- and benzodiazepine-induced toxicities as heroin users substituted those drugs for heroin. Nevertheless, even without a formal cost–benefit analysis, the findings appear to provide support for an overall benefit from decreasing heroin availability. That much said, we should also note that the decrease, although sustained for several months, did not persist. The illicit trade rose again. As it is difficult to predict when such reductions in availability can again be achieved we would do well to continue to improve our capacity to reduce heroin-related harms in the presence of continued availability. It would be important to try to confirm the findings of this landmark study. In contrast to the situation in 1972, the United States now has in place many of the monitoring systems that would allow a comparable assessment of the impact of a sharp curtailment in the supply of heroin. Now what we need is a sharp and sustained shortage.

Age differentials in the impacts of reduced heroin: Effects of a “heroin shortage” in NSW, Australia

Background : This paper uses a unique event, the Australian heroin shortage, to see whether an abrupt, substantial and sustained change in heroin supply had different effects on harms related to heroin use among younger and older heroin users. Method : Indicator data were examined by age group on the number of persons entering treatment for heroin and amphetamine dependence, arrests for heroin use/possession and number of drug related deaths in NSW, Australia. Data were analysed using times series analysis. Results : There was a 41% reduction in the number of new registrations for opioid pharmacotherapy per month among 25–34 year olds, and a 26% reduction among 15–24 year olds, but no apparent changes among older age groups. Similarly, reductions in the number of non-pharmacological heroin treatment episodes were most pronounced among younger age groups. There was a 49% reduction in the number of heroin possession/use offences among those aged 15–24 years, compared to declines of 31–40% among older age groups. Declines in heroin related deaths were greatest among 15–24 year olds (65% reduction). There was no change in other drug related deaths in any age group. Conclusions : A reduction in heroin supply was followed by greater reductions in heroin related harms among younger than older people, across a number of outcome domains.

Evaluating explanations of the Australian ‘heroin shortage’

In this paper we outline and evaluate competing explanations for a heroin shortage that occurred in Australia during 2001 with an abrupt onset at the beginning of 2001. We evaluated each of the explanations offered for the shortage against evidence from a variety of sources: government reports, police and drug law enforcement documents and briefings, key informant (KI) interviews, indicator data and research data. No similar shortage occurred at the same time in other markets (e.g. Vancouver, Canada or Hong Kong) whose heroin originated in the same countries as Australia's. The shortage was due most probably to a combination of factors that operated synergistically and sequentially. The heroin market had grown rapidly in the late 1990s, perhaps helped by a decline in drug law enforcement (DLE) in Australia in the early 1990s that facilitated high-level heroin suppliers in Asia to establish large-scale importation heroin networks into Australia. This led to an increase in the availability of heroin, increasingly visible street-based drug markets, increased purity and decreased price of heroin around the country. The Australian heroin market was well established by the late 1990s, but it had a low profit margin with high heroin purity, and a lower price than ever before. The surge in heroin problems led to increased funding of the Australian Federal Police and Customs as part of the National Illicit Drug Strategy in 1998-99, with the result that a number of key individuals and large seizures occurred during 1999-2000, probably increasing the risks of large-scale importation. The combination of low profits and increased success of law enforcement may have reduced the dependability of key suppliers of heroin to Australia at a time when seized heroin was becoming more difficult to replace because of reduced supplies in the Golden Triangle. These factors may have reduced the attractiveness of Australia as a destination for heroin trafficking. The Australian heroin shortage in 2001 was due probably to a combination of factors that included increased effectiveness of law enforcement efforts to disrupt networks bringing large shipments of heroin from traditional source countries, and decreased capacity or willingness of major traffickers to continue large scale shipments to Australia.

Reliability of heroin users’ reports of drug use behaviour using a 24 month timeline follow-back technique to assess the impact of the australian heroin shortage

Background: In early 2001 Australia experienced a dramatic disruption to heroin supply. In order to investigate the impact of this phenomenon, heroin users were interviewed retrospectively to determine drug use behaviour over a two year period.Aim: To examine the reliability of the timeline follow-back (TLFB) technique in determining heroin users’ patterns of drug use and related behaviours over a 24 month period.Method: 27 current heroin users were recruited through drug use services and interviewed about their drug use behaviour retrospectively using the calendar method of the TLFB. Test–retest reliability was measured over seven days.Results: Recall of regular drug use was generally reliable. Recall was poorest during January–April 2001, the peak period of the heroin shortage. Recall of criminal activity and weekly expenditure on drugs was variable, though generally poor. Recall of treatment entry and drug related health problems such as overdose was also variable.Conclusion: The 24 month TLFB did not obtain information reliable enough to examine sporadic drug use or overall changes in the patterns of drug use associated with the heroin shortage. To avoid this situation cohorts of injecting drug users need to be established as these phenomena cannot be accurately studied retrospectively.