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New working papers
Two new working papers are available; one is an analysis of ways to prevent an influx of users to the ACT if a heroin trial eventuated and the second examines the potential effects of a trial on the illicit drug market.
How could an influx of users be prevented if Canberra introduces a trial of controlled availability of heroin?
Gabriele Bammer, Deborah Tunnicliff and Jennifer Chadwick-Masters
The potential problem of a trial of controlled availability of heroin attracting heroin users to Canberra has three dimensions: the number of people who might move in, the length of time they might stay and the consequences of their movement. Possible negative effects are an increase in visibility of the illicit drug 'scene', an increase in crime, an increased demand on drug-related and other services and increased health problems.
These issues were investigated by examining factors which influence migration, so-called push-pull factors, and by analysing situations which provide analogies to what may happen in Canberra. These included migration to Brisbane and Canberra when there was an attempt to close down methadone programs in Sydney in 1978-85 and an investigation of factors causing open drug scenes in Zurich and Nimbin.
It seems that visibility of illicit drug users is more likely to result from an atmosphere of permissiveness towards illicit drug use than from immigration per se. Thus tackling permissiveness rather than immigration is central to avoiding this problem.
Preventing immigration is the best safeguard against the other potential problems of increased crime, increased demand on services and increased health problems. Attention to trial security and continuation of normal law enforcement against illicit drug use and associated crimes would also minimise possible effects on crime.
While there is some risk of an influx of users to Canberra if a trial of controlled availability of heroin proceeds, it is likely that this influx could be kept to a minimum using residency criteria and a tightly controlled trial design with a limited number of participants. An influx of heroin users to Canberra would be minimal and should not constitute a barrier to a trial proceeding, if the following conditions are adhered to:
Finally, if a trial was to go ahead, the Australian Capital Territory Drug Indicators Project should be recommenced to allow the evaluation of effects on immigration (as well as on drug use among people not participating in a trial and on the number of illicit heroin users). For the collection of baseline data, the project should be recommenced at least one year before a trial started.
How would the controlled availability of heroin affect the illicit market in the Australian Capital Territory? An examination of the structure of the illicit heroin market and methods to measure changes in price, purity and availability, including heroin-related overdoses.
Gabriele Bammer and Ayse Sengoz with assistance from Aaron Stowe, Iain Anderson, Corinna Lee, Deborah Tunnicliff and Remo Ostini
In order to assess the likely impact of a trial of controlled heroin availability on the illicit drug market, we conducted three studies: an examination of the structure and functioning of the ACT illicit drug market, collation and analysis of data on fatal and non-fatal overdoses and development of a new methodology for measuring changes in price, purity and availability.
The study of the structure and functioning of the ACT illicit drug market used four data sources, namely detailed interviews with seven people who had been involved in dealing drugs, interviews with two members of the ACT drug squad, a survey of ACT-based heroin users and published information. The hierarchical nature of the market was examined, as were factors potentially affecting the market, especially user demand, the link between the Canberra and (particularly) the Sydney markets, manipulation of the market by dealers, police activity and time of year. We also investigated the dynamics of the market, including reasons why people start and stop dealing, whether or not dealers specialise, the process of buying and selling, competition between dealers, violence, testing and cutting, and geographical specificity. We concluded that, although there is much about the illicit drug market which is unknown, it seems to be highly flexible and adaptable. For this reason, current systems of law enforcement are limited in their effectiveness, so that it may be worth trying new approaches such as controlled availability.
Despite the potential importance of overdoses as an adverse health consequence of heroin use, little is known about them. We examined data about both fatal and non-fatal overdoses in the ACT. While the main aim was to ascertain whether or not overdoses are a reliable indicator of the purity of illicit heroin, we also examined how the data sources could be improved and how overdoses could be more effectively prevented. Apart from examining available data about overdoses, we also followed-up three fatal overdoses which the media attributed to increased heroin purity in the ACT, analysed the records of the ACT Ambulance Service regarding non-fatal overdoses, and surveyed dependent heroin users in the ACT regarding the experience of overdosing.
Fatal overdoses are relatively rare events. The analysis of the cluster of three deaths which occurred in late-1992 suggests that without knowledge of the circumstances of fatal overdoses, the conclusions which can be drawn about the state of the illicit heroin market are limited and likely to be inaccurate.
We undertook what appears to be the first-ever analysis of data about non-fatal overdoses from the records of an ambulance service and the first survey of heroin users about the experience of overdosing. An examination of ACT Ambulance Service data from August 1990 to July 1993 showed that there was a dramatic increase in the number of overdoses in the second half of 1992 and, especially, the first half of 1993. The user survey showed that about a third of the people interviewed had experienced one or more overdoses in the last 12 months, which indicates that this is an important adverse health effect of heroin use. There were some important differences in the picture about overdoses obtained from an examination of the records of the ACT Ambulance Service and from the results of the user survey. In particular, a higher percentage of cases attended by the Ambulance Service were taken to hospital than of the cases in the survey who were attended by an ambulance. In addition, a higher proportion of cases from the Ambulance Service attributed their overdoses to a combination of heroin and other drugs than was the case for those surveyed. This may simply indicate that the group surveyed was very unrepresentative, but it also suggests that the topic of non-fatal overdoses would benefit from further investigation, particularly if such overdoses are to be used as a surrogate measure for the state of the illicit drug market.
We developed a promising method for measuring changes in the illicit drug market, which could be used to monitor the effects of a 'heroin trial' if it eventuated. This involved interviewing people at regular intervals about the price, purity and availability of a range of illicit drugs. Difficulties with the method and possible ways of overcoming them are discussed. There needs to be further research to develop reliable indicators and the implementation of a fully valid and reliable system would require a substantial commitment of resources.
We also explored the possibility of developing a less expensive system, which would use five data sources:
We conclude that at this stage there are too many unknowns about the illicit drug market and that there are potential dangers in perturbing a system which is poorly understood. Therefore, it would be prudent for an ACT-based trial, if it eventuates, to be modest in its aims and, in the first instance, to focus on the effects of controlled availability of heroin at the level of individual trial participants, rather than attempting to influence the market for illicit drugs. Indeed, a trial should be structured to have minimal impact on the illicit drug market. The most effective way to do this would be to limit participation in a trial to people currently on the methadone program, as many of them will have severed or be reducing ties with the illicit heroin market.
Evaluation Proposal
The analyses in working papers 8 (on statistical considerations for trial evaluation), 9 (on preventing migration to the ACT) and 10 (on the potential effects of a trial on the drug market) all suggest that one specific method for trial evaluation has a number of scientific and logistic advantages. This proposal is outlined below.
The research questions:
1. Does the provision of injectable heroin improve outcomes over and above improvements obtained with oral methadone alone? Outcomes include health, HIV risk behaviours, criminal behaviour, social functioning and licit and illicit drug use.
and
2. Does the provision of injectable heroin attract back into treatment people who have dropped out of oral methadone treatment?
The study population will be drawn from volunteers from two groups:
To deter immigration to Canberra, volunteers will also need to prove ACT residency since at least 1993.
Randomised controlled trial
Volunteers would be randomly allocated to one of two groups. The 'control' group will receive oral methadone, the current 'gold standard' for the treatment of heroin dependence. The 'expanded availability' group will have a choice between injectable heroin only, injectable heroin and oral methadone and oral methadone only and can move at will (within limits of safety) between those choices. This is illustrated diagrammatically below. This randomised controlled trial design provides for the most stringent evaluation.
The proposal has a number of advantages and disadvantages which are not discussed here. It has the broad support of the Feasibility Study's Advisory Committee. An information sheet has been prepared and widely circulated in the heroin using community and has been the basis for both formal and informal discussions.
Police Workshop
An information sheet has also been prepared about policing issues and is being circulated for comment among ACT police. Responses are being co-ordinated by Detective-Superintendent Ted Foster, OIC Drug Operations.
He and Chief Inspector Frank Hansen of the NSW police are co-organising a small workshop on policing issues which will be held in late May and which will be attended by both ACT police and representatives of police from other states.
"ATTITUDE"
The ABC television series Attitude is producing a program about the process of the Feasibility Study which is scheduled for screening on Wednesday June 1 at 9.30 pm. This is before our announcement of whether or not controlled availability of heroin is feasible. The program will concentrate on the process of reaching the decision and not the decision itself.
We have decided to cooperate with the program because we understand that they are taking an even- handed approach showing both the advantages and disadvantages of the proposal for controlled availability of heroin for dependent users. We believe that this is an opportunity to provide information to the general public which will aid rational discussion about illicit drug policy and proposals for policy reform. There has been a call for informed public debate about drug policy in each of the ten major government-sponsored reports about drugs, drug use, and ways of ameliorating the effects of drug use which have been produced since 1971.
The recommendation about whether or not the trial should go ahead
Unforseen delays have occurred in completing the research projects and hence getting together the information needed to make a recommendation. It is therefore unlikely that we will be able to make a recommendation about the logistic feasibility of a trial in June as planned. There will be an update about this in the next newsletter.
Changes to the advisory committee
The Advisory Committee has two new members: Ms Amanda Corkery of Dependency Care Foundation, and Ms Tarquin McPartlan of the ACT IV League.
Changes to the research team
Both Deborah Tunnicliff and Miriam Hazel have left the project as funding has come to an end.
Further Information
For further information about the feasibility research contact: Dr Gabriele Bammer National Centre for Epidemiology and Population Health Australian National University Canberra ACT 0200
Phone: (06) 249 0716 Fax: (06) 249 0740
New Publications
Working Papers
* Bammer, Gabriele, Deborah Tunnicliff and Jennifer Chadwick-Masters 1994. How could an influx of users be prevented if Canberra introduces a trial of controlled availability of heroin? Feasibility Research into the Controlled Availability of Opioids Stage 2 Working Paper Number 9.
* Bammer, Gabriele and Ayse Sengoz with assistance from Aaron Stowe, Iain Anderson,
Corinna Lee, Deborah Tunnicliff and Remo Ostini 1994. How would the controlled
availability of heroin affect the illicit market in the Australian Capital Territory?
An examination of the structure of the illicit heroin market and methods to
measure changes in price, purity and availability, including heroin-related
overdoses. Feasibility Research into the Controlled Availability of Opioids
Stage 2 Working Paper Number 10.