FEASIBILITY RESEARCH INTO THE CONTROLLED AVAILABILITY OF OPIOIDS - STAGE 2

NEWSLETTER NO.2 November 1992

This is the second in a series of occasional newsletters to provide up-to-date information about research into the feasibility of an ACT trial to provide heroin and other opioids to dependent users in a controlled manner. Included in this issue is a report on some of the projects listed in Newsletter Number 1.

An accurate estimate of the numbers of heroin users in the ACT is essential for determining the feasibility of a trial to provide opioids to dependent users in a controlled manner. Not only does it indicate whether or not the extent of the problems warrants a trial, but it is also vital for establishing the feasibility of proposed trial evaluation techniques. More refined techniques were used to add to estimates developed in the Stage 1 research. The ACT Drug Indicators Project data for 1988 and 1989 was examined using list-matching techniques (also known as capture-recapture and indicator/dilution). This gave an estimate of around 1000 people who see their heroin use as a 'problem', with a standard deviation of around 200. This is consistent with the 'best' estimates derived in Stage 1. We plan to further refine these estimates in a study of unmet treatment needs.

This research was conducted by Dr Ann Larson of NCEPH and supported by a grant from the Criminology Research Council. The results are available as Feasibility Research into the Controlled Availability of Opioids Stage 2, Working Paper Number 1.

We have recently completed a survey of 155 young people who are homeless or at risk of becoming homeless to examine whether or not a 'heroin trial' would need to accommodate this age group. We found that 8% of participants had ever tried heroin but that none had used heroin more than 8 times in the last 12 months. We concluded that there are likely to be very few young dependent heroin users who would be eligible for a trial.

The survey showed a disturbingly high prevalence of physical and sexual abuse (59% of young women and 24% of young men). Alcohol, tobacco and marijuana were frequently used with 70% or more having used these drugs in the last four weeks. On a day when alcohol was consumed, 75% of young women and 67% of young men reported that they had five or more drinks and more than half of this group had 9 or more drinks.

This work was conducted in collaboration with the Youth Affairs Network of the ACT, by Dr Beverly Sibthorpe and Ms Ayse Sengoz of NCEPH and Ms Jane Drinkwater and Ms Karen Gardner of YANACT. It was supported by a Youth Organisations Research and Development Grant (to NCEPH) and Burdekin Health Slippage Monies (to YANACT). The results will be available shortly in a working paper.

Fieldwork has been conducted in the United Kingdom, Switzerland, the Netherlands, Sweden, Austria, Germany and the United States of America to learn more about current, proposed and past experience with the controlled provision of heroin to dependent users.

Heroin is currently prescribed to about 120 dependent users in the United Kingdom with the largest programs being in the Widnes and Warrington areas. Heroin was more widely prescribed until the 1970s when policy changes and the introduction of methadone curtailed its use. Similarly, in Sweden there was one large-scale prescribing program in the early 1970s. A number of proposals for prescription were put forward in the United States and the Netherlands at that time. The Swiss plan to introduce five small-scale trials of heroin prescription early in 1993.

This fieldwork has reinforced the importance of a detailed understanding of local conditions when examining trial feasibility. Illicit drug use is greatly influenced by cultural and historical conditions and these in turn affect the success or failure of maintenance programs. Much can be learnt from overseas programs and they provide an important guide to local factors which need careful examination.

One of the most striking aspects of the fieldwork was the 'open drug scene' in ZŸrich, Switzerland. In the evenings, hundreds of people can be seen in certain areas dealing and injecting illicit drugs. This has resulted from a complex interplay of factors and the proposed introduction of heroin trials in Switzerland is seen as one measure to combat this situation. The open scene appears to have led to important changes in the drug markets which are proving to be difficult to reverse.

The fieldwork has also produced a large amount of practical information. For example, a visit to the United Nations International Drug Control Programme in Vienna confirmed that the interpretation made in Stage 1 of the implications for a 'heroin trial' of international treaty obligations was correct (this was that a trial that was conducted for a medical or scientific purpose would not place Australia in breach of international treaty obligations). Legal manufacturers of heroin have been identified and it was discovered that because of packaging requirements, injectable heroin costs twice as much to prescribe as injectable methadone.

The fieldwork was conducted by Dr Gabriele Bammer from NCEPH and supported by the Australian National University Strategic Development Fund. Some of the lessons learnt have been described in a paper entitled "Should the controlled provision of heroin be a treatment option? Australian feasibility considerations" which has been accepted for publication by the British Journal of Addiction. The fieldwork results will be described in detail in a working paper which will be available in 1993.

Data on the extent and nature of criminal activity in the community would provide important baseline information for assessing the impact of a trial, if it goes ahead. This is because a central rationale for the controlled provision of heroin to dependent users is that it would reduce the necessity to commit crime to obtain drugs or money for drugs. Household surveys of victims of crime are important information sources. They complement data available from police and courts as they reveal information on unreported offences.

No victims of crime data are currently available for the ACT. Discussions have been held with the Australian Bureau of Statistics (ABS) and appropriate ACT public service officers regarding the development of an ACT Victims of Crime Survey. The ABS will conduct a national victims of crime survey in 1993 and has agreed to use an ACT sample size which will be large enough to provide useable data at the ACT level. ABS will meet all the costs involved.

Mr David McDonald of the AIC has been primarily responsible for this work and other researchers at the AIC are currently examining options for examining commercial enterprises as victims of crime.

Dr Andy Butlin, Alcohol and Drug Service, ACT Board of Health Chief Inspector Frank Hansen, NSW Police Service (replacing Chief Inspector Christine Nixon) Dr Michael MacAvoy, Chair, National Drug Strategy Committee Mr Keith Simpson, ACT Attorney General's Department

Additions Ms Jennifer Chadwick-Masters, Research Assistant, NCEPH (residency criteria, drug screening) Ms Ayse Sengoz, Research Assistant, NCEPH (replacing Mr Remo Ostini)

Projects completed Ms Kate Elliott Dr Ann Larson Dr Keith Powell Ms Helen-May Timiney

A Youth Organisations Research and Development Grant of $8,028 was awarded for collaboration with the Youth Affairs Network of the ACT in a study of alcohol and other drug use among young people who are homeless or at risk of being homeless (see report above).

For further information about the feasibility research contact: Dr Gabriele Bammer National Centre for Epidemiology and Population Health Australian National University GPO Box 4 Canberra ACT 2601

Phone: (02) 6125 0716 Fax: (02) 6125 0740

Larson, A. 1992 'Estimating the numbers of heroin users in the ACT'. Feasibility Research into the Controlled Availability of Opioids Stage 2, Working Paper Number 1.

Hartland, N.; McDonald, D.; Dance, P.; Bammer, G. 1992 'Australian reports into drug use and the possibility of heroin maintenance'. Drug and Alcohol Review, 11, 175-182.

Preprints

Bammer, G. 'Should the controlled provision of heroin be a treatment option? Australian feasibility considerations'. British Journal of Addiction. Forthcoming 1993.

McDonald, D.; Stevens, A.; Dance, P; Bammer, G. 'Illegal drug use in the Australian Capital Territory - Implications for the feasibility of a heroin trial'. Australian and New Zealand Journal of Criminology. Forthcoming 1993.

Ostini, R.; Bammer, G.; Dance, P.; Goodin, R. 'The ethics of experimental heroin maintenance'. Journal of Medical Ethics. Forthcoming 1993.

Bammer, G. 1992 'A heroin trial for the ACT?' Centrelines. No.10 (June) 12-13. Reprinted in Australian Therapeutic Communities Association Magazine August 1992 34-35 and Drugwise June 1992 7-8