National Amphetamine-Type Stimulant Strategy Background Paper: Monograph Series No. 69
4.3 Reducing associated problems
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While many campaigns are directed toward reducing the appeal of drugs and preventing, or delaying, the onset of use, others aim to reduce specific drug-related problems and risky behaviours among current users. Thus, the prevention of drug-related problems needs to be able to identify and reduce significant patterns and contexts of risky drug use. Adapting a classification system developed by the World Health Organisation (WHO), Loxley and colleagues (2004) outlined four main categories of drug use patterns that need to be addressed in terms of related risks and potential harms. These are: mode of administration (e.g., swallowing, inhaling, smoking, injecting); intoxication; regularity of use; and, dependence. Each of these categories may have effects in several domains, such as: developmental effects (e.g., use during pregnancy); physical health effects (e.g., blood borne virus transmission, nutritional deficiencies); personal safety issues (e.g., injury to self and/or others); mental health effects (e.g., depression, psychosis); and impact on social wellbeing (e.g., legal problems; financial issues).
The key aims of such strategies have been described to include: preventing harm to other people; preventing transition to injecting drug use; promoting healthy lifestyles and drug-free activities; raising awareness of the harms and negative consequences of drug use; and, informing users of the legal implications of their use (e.g., see NSW Health, 2005). Thus, it is argued, important aims are to: inform users about the risks of, and other consequences (e.g., legal) of, use; identify high-risk users and prevent their transition from occasional use to heavy use patterns and/or riskier methods of use, such as injecting and, in the case of crystalline methamphetamine, smoking; and prevent harm to other parties (e.g., children; parents/carers; associates and friends).
To reduce harms among those already engaged in regular ATS use, attention to date has included reducing the risk of infectious disease, managing sleep and nutritional disorders, and helping avoid and manage relationship problems. With specific regard to the recent use of crystalline methamphetamine, examples of possible targets for campaigns include information about the particular risks of smoking and injecting, information on blood borne viruses, amphetamine-induced psychosis, depression, and anxiety, awareness of the consequences of the ‘binge-crash’ cycle, and improving contact with health care services. In order to achieve this, it will be necessary to explore users’ own perceptions of what information is important to them and identify the current barriers to service use.
As identified in the Inquiry into Amphetamines and ‘Party Drug’ Use in Victoria (Drugs and Crime Prevention Committee, 2004) a range of harm reduction strategies have been employed with ATS. These have included:
- Mass media education and information campaigns;
- Safe rave or safe dance party guidelines aimed at club owners and rave promoters;
- The use of outreach workers to provide support and assistance to those who use ‘party drugs’ (often located at raves and venues);
- Testing stations or kits for ‘party drug’ pills and tablets;
- ‘Self regulation’ harm reduction measures of users themselves;
- Information pertaining to harm reduction and ‘safe’ drug use provided and shared at international and national conferences and seminars; and
- Harm reduction strategies and education campaigns that are targeted at particular times of the year where it is thought (‘party’) drug use may be particularly prevalent. (p.502).
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Targeted campaigns
As with prevention campaigns, strategies aimed at reducing harms associated with ATS use need to be targeted toward those known to be at risk of such harms or towards high risk behaviours/contexts of use (e.g., use in relation to driving; use at work). Thus, campaigns may be targeted toward particular sub-populations such as gay, lesbian and transgender populations, injecting drug users and ecstasy users, or toward particular types of ATS, with regard to form and content or to particular settings such as entertainment venues or in relation to particular work practices.The issue of targeting specific risk and harm factors was raised in a number of written submissions. NDARC made mention of the need to reduce the risk of blood borne virus (BBV) transmission among injecting ATS users, and targeting messages warning of the risks associated with BBV infections toward young people prior to uptake of injecting ATS use. Also, the need to address sexual risk behaviour was emphasised, particularly among methamphetamine injectors who report higher levels of such behaviour than other injecting drug users, and among men who have sex with men. Because of the particular risks associated with certain patterns of ATS use, the Australian Drug Foundation (ADF) highlighted a need to target strategies that address polydrug use and bingeing among ATS users. In their submission, the private company ‘Convenience Advertising’, suggested that it was important to disseminate strategically planned public health communication programs, termed ‘narrowcasting’, in campaigns to target ATS use, particularly for young people, men who have sex with men, and those working in the hospitality industry.
The issue of the diversity of patterns of ATS use demanding diverse responses was noted in the written submission from the Victorian Alcohol and Drug Association (VAADA):
- Given the diversity of patterns of ATS use, it is highly unlikely that any blanket response to ATS use would be successful. ATS users are very diverse, and it is unlikely that they all have the same treatment needs. Potential ATS users will be drawn from a similar assortment of social groups, and it is improbable that a monolithic treatment campaign would effectively target all the different people who might potentially use ATS.
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Gay, lesbian, bisexual and transgender populations
As noted in Chapters 2 and 3, global research indicates an association between drug taking and unsafe sexual practices among men who have sex with men (MSM). In particular, methamphetamine use has been associated with increasing STI/HIV transmission rates among this population (Boddiger, 2005; Halkitis et al., 2001). This highlights the need for prevention campaigns targeted specifically at ATS use within these populations, particularly in light of the social stigma experienced by these groups that creates difficulties in access and delivery of services.In 2005, ACON and NDARC conducted research of crystal methamphetamine and GHB use among gay, lesbian, bi-sexual and transgender populations (GLBT) in NSW (Degenhardt et al., 2005). This report identified the following key issues for GLBT:
- Limited understanding of psychosis amongst those using methamphetamine;
- Consumers presenting to GPs did not disclose their methamphetamine use;
- There was an increase in consumers seeking treatment for methamphetamine use, however few treatment modalities and culturally appropriate interventions are available;
- Community concern tends to focus on drug use among gay men, however, use of crystal methamphetamine appears to be as prevalent among lesbian and bisexual women;
- More information on methamphetamine and associated harms needs be provided to consumers, frontline services and workers in the HIV sector; and
- Culturally sensitive GLBT training needs to be conducted with generalist AOD services.
Interventions have been demonstrated to reduce risks, and drug treatment services are an effective site for intervening in high-risk behaviours and in particular reducing HIV risk behaviours among methamphetamine users. In particular, cognitive behaviour therapy (CBT) -based treatment approaches have been developed specifically to reduce sexual risk behaviour among gay and bisexual males (Shoptaw et al., 2005). A recent study by Mausbach and colleagues (2007) examined the efficacy an intervention for reducing sexual risk behaviour among HIV-positive, methamphetamine-using MSM within the context of ongoing drug use. That is, the exclusive focus was on changing sexual behaviour only. The study found that those assigned to the safer sex behavioural intervention engaged in significantly more protected sex acts at both 8-month and 12-month assessment times (Mausbach et al., 2007). However, in general, there are few HIV prevention interventions that target drug-using MSM, particularly non-injectors.
Injecting Behaviours
Injecting behaviours are a particular concern in relation to people who are dependent on ATS (generally, dependent on methamphetamine). In Australia, the majority of dependent methamphetamine users inject the drug, and methamphetamine accounts for around onethird of injecting drug use in Australia (Iverson et al., 2006). This has important implications for the spread of blood-borne viruses, such as HIV and particularly hepatitis C, which is endemic among injecting drug users in Australia (National Centre in HIV Epidemiology and Clinical Research, 2007).While earlier research suggested that those who inject methamphetamine do not appear to differ in their level of HIV risk behaviour compared to their heroin injecting counterparts (Hall et al., 1993), some evidence indicates that those who use ATS have a lower perception of risk. For example, HIV is perceived as a risk for people who inject heroin, as opposed to a risk for those who inject any drug, including amphetamine (e.g., Vincent et al., 1999). Consequently, it has been argued that a comprehensive strategy needs to be maintained to reduce the risk of blood borne virus transmission among all injecting drug users, including those who inject methamphetamine.
Harm reduction messages warning of the risks of blood-borne viral infections (BBVIs) associated with injecting drug use are also indicated. These messages should, perhaps, particularly target young people prior to their uptake of injecting drug use, because much of the literature indicates that early onset injecting drug users are also higher risk takers in relation to their health (such as increased risk of sharing needles) (Fennema et al., 1997; Battjes et al., 1992). Thus, newer and younger initiates to injecting drug use are at greater risk of contracting and transmitting blood borne viruses.
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Commencing in August 2002, AIVL conducted a research project to investigate the hepatitis C transmission risks amongst methamphetamine injecting drug users that was completed in March 2003. A questionnaire (the PSU Tool) was developed and 182 injecting psychostimulant users were interviewed across Australia. The findings were reported in the ‘National Snapshot on Hepatitis C Transmission Risks Amongst Injecting Psychostimulant Users’ (available from AIVL website). Among the main findings were that, although almost the entire sample reported seeing hepatitis C information, there were mixed levels of knowledge about the condition. In addition, approximately 29% were ‘concerned a great deal’ about contracting hepatitis C, while responses to other items revealed that many were engaging in unsafe injecting practices. One of the conclusions drawn from the research is that opiate users may be more aware of the risks associated with injecting than psychostimulant users, as opiate users have more commonly been the focus of harm reduction messages associated with blood borne virus transmission.
Sexual risk behaviour is a further consideration in the context of HIV transmission among those who inject methamphetamine because they report high levels of sexual risk behaviour, for example when compared to heroin or other injecting drug users (Klee, 1997; Vincent et al. 1999; Zule & Desmond, 1999). The risk of sexual transmission of HIV is further exacerbated by the concurrence of other sexually transmitted diseases, such as Chlamydia and Gonorrhea, which have recently been described as being at epidemic levels among injecting drug users in Australia (National Centre in HIV Epidemiology and Clinical Research, 2007).
With regards to strategies targeting injecting drug users, a number of participants in the national consultations noted the need for Needle and Syringe Programs (NSPs) to provide out-of-hours access to information and advice, and build links to other services, such as drug withdrawal and treatment services, especially for otherwise hard to reach groups that might not access treatment services. Also, given the high risk of BBVIs for those who do inject, it was argued that a variety of health and community services could enhance the provision of information about the risk of BBV and, where possible, particularly encourage at-risk groups, including health staff, to access Hepatitis B vaccinations.
Ecstasy users
A variety of ATS harm reduction strategies were implemented in the 1990s, mostly directed at the use of drugs such as ecstasy. Some related to adopting a ‘healthy settings approach’, which recognises that the effects of any particular setting on an individual’s health are related to the general conditions within that setting (WHO, 1997a). Focusing on ecstasy use within nightclubs, Bellis and colleagues (2002) illustrated the wide range of factors, in addition to any focus on drug use, which might need to be considered in an effective harm reduction approach:- Dehydration and hyperthermia;
- Fire risk;
- Noise levels and damage to hearing;
- Sexually transmitted infections (STIs) and unwanted pregnancy;
- Accidents;
- Violence;
- Drink/drug driving, and
- Tobacco use.
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Other researchers have likewise suggested a broad range of strategies to reduce drug related risks (in particular those associated with ATS use) at entertainment venues,
including:
- Preventing overcrowding;
- Managing ambient temperature at low risk levels;
- Providing cool or ‘chill-out’ areas;
- Providing free and ready access to water; and
- Providing a first aid room.
Similarly, Hando and colleagues (1998) argued that Australian protocols for entertainment venues (i.e., clubs and dance party) were needed to ensure the provision of adequate water, ensure effective ventilation and ambient temperature management, effective crowd control and provision of first aid areas, chill out rooms and regular monitoring of patrons well being. This led to work on Australian guidelines for rave promoters and nightclub owners to increase the safety of dance parties. The National Protocols for Conducting Safer Dance Parties were subsequently developed and made recommendations related to adequate provision of water, ventilation, ‘chill-out’ areas, medical assistance, security checks, and information for users.
Further guidelines were produced from the ‘Reducing Drug Harm in the Dance Party
Scene Project’ conducted Drug and Alcohol Services South Australia (DASSA) and South Australian Police. ‘The Guidelines for Safer Dance Parties’ related to:
- Basic safety;
- Temperature and ventilation;
- Chill-out areas;
- Availability of drinking water and food;
- Alcohol licensing;
- Venue capacity and crowd management;
- Security and door staff;
- Communication systems;
- First aid and medical emergency action;
- Community education;
- Toilets;
- Emergency service consultation;
- Cleaning up;
- Transport options, traffic management and signage;
- Insurance; and
- Consultation (DASSA & SA Police, 2006).
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These issues were also raised during consultations. It was proposed by a number of participants that entertainment venues should take more responsibility for looking after their patrons, for example, by providing water, and encouraging the presence of outreach workers in clubs and at dance event.
Given that many ecstasy users do not come into contact with treatment services, targeting ecstasy users through peer education has also been utilised as a harm reduction strategy, as outlined earlier. Other harm reduction interventions have focused on information provision using various media to communicate information about particular risks. ‘Project E’, conducted in 1997, included the dissemination of brochures, fridge magnets and postcards providing information and advice to users. Street press, such as ‘Onion’ in South Australia and ‘Big Book on Party Drugs’ in Victoria have also been used to promote harm reduction messages. ‘Project E’, an ecstasy education kit was launched in 1997, and various information booklets are available such as ‘Rave Safe’ and ‘Ecstasy: Facts and Fiction’ (see Dillon, 2000). All these resources provide young people with information about the various drugs, the short- and long-term effects of use, associated risks, advice on how to increase the safety of use, and emergency responses to adverse effects (Stubbs et al., 2004). Finally, internet sites such as ‘Somazone’, ‘pillreports’ and ‘bluelight’ all provide information about drug content, the effects of ecstasy use, and how to reduce related problems. Unfortunately, as is the case across this area, comprehensive evaluation is limited and bold conclusions cannot be reached about the value of particular approaches.
New research by Duff and colleagues (2007) aimed to explore the social and cultural context of use of ecstasy and related drugs (ERDs) in Victoria. Using a combined research methodology consisting of participant observation by field workers, interviews with current users, case studies of current and ex-users and key expert interviews, the researchers proposed several recommendations for both prevention and harm reduction approaches to ERDs, as follows. Recommendations for prevention strategies are:
- Need to be sensitive to relevant cultural and contextual differences in relation to both populations and geographical regions;
- Involve more extensive and meaningful peer-to-peer components by integrating initiatives into existing peer networks;
- Include peer education strategies;
- Messages about potential risks associated with use must be evidence-based and even-handed;
- Emphasise the more ‘ordinary’ risks, such as social embarrassment, harm to relationships, comedown;
- School-aged prevention strategies should retain abstinence focus, while adhering to the recommendations above;
- Consider strategies to strengthen and improve communication between young people and their parents;
- Make use of information networks of most relevance to young people, such as the internet and mobile information technologies;
- Develop context-specific ERDs prevention materials (e.g., in bars and clubs, rural settings etc) further tailored to particular sexual and cultural communities; and
- Need specialised materials tailored to young and novice members of clubbing and rave communities.
- Focus on reducing the incidence and prevalence of polydrug use and binge ERDs use;
- Pilot a ‘clubsafe’ initiative to deliver ERDs-specific harm reduction materials in nonrave settings (e.g., clubs and bars);
- Continue collaboration with key stakeholders (e.g., club owners, DJs), including delivering harm reduction messages within venues;
- Convene local club and bar stakeholder working groups to oversee and coordinate all local ERDs initiatives in licensed settings;
- Undertake a formal pill-testing pilot in conjunction with Victoria Police Forensic Services;
- Develop context-specific ERDs harm reduction materials (e.g., in bars and clubs, rural settings etc) further tailored to particular sexual and cultural communities;
- Increase users’ awareness of the harms they are experiencing via delivery of a self assessment tool through the internet and general health services;
- Tailor interventions according to different points in drug use career; and
- Use a variety of formats, including improved electronic delivery.
Assessing the risks of illicitly manufactured drugs
One area of contentious debate has revolved around the fact that illicitly manufactured drugs are of varying potency and purity, and, it is argued, this is relevant for strategies that seek to prevent and reduce drug related problems. Due to their illicit status, ATS cannot be monitored and batches of illegal drugs, particularly adulterated ecstasy tablets, have been reported in relation to increased risk of morbidity and mortality. For example, the media reports of ‘Doctor Death’ refer to PMA (para-methoxyamphetamine) being sold as ecstasy and resulting in the death of a young person in Sydney. Thus, some have argued that more regular forensic analysis of seized drugs and information from health, police and consumer groups should be assessed and alerts made for particular risks and disseminated (e.g., see Webb, 2003).Variation in illicit drug potency and purity, and consequent variations in hazards has resulted in contention about the role of ‘pill testing kits’. Large scale testing of ecstasy tablets at parties and agencies of the Drugs Information and Monitoring System has been undertaken in the Netherlands since 1992. Laboratory analyses using gas chromatography and mass spectrometry have identified a range of substances including LSD, amphetamine, 4-MTA, DOB, 2CB, atropine and wide variations in the amount of MDMA detected (Henry-Edwards, 2001). Testing of tablets, by volunteers, has also been conducted in the US by the ‘Dance Safe’ organisation.
However, in Australia, unlike some areas of Europe, pill testing contravenes legislation regarding the possession and supply of controlled substances (Camilleri & Caldicott, 2005). Any pill testing in Australia has been conducted by volunteer harm reduction organisations and individuals conducting their own testing using the most common testing kit which employs a chemical mix called a ‘Marquis Reagent’. It can indicate the presence of MDMA-type substances (MDMA, MDA, MDE), amphetamine, 2CB/2CI, dextromethorphan (DXM) and opiates. The ‘Mandelin Reagent’ also tests for MDMA-type substances and amphetamine, so using the two tests in conjunction increases the reliability of the results for these two substances. In addition, the ‘Mandelin Reagent’ test indicates the presence of ketamine and PMA (Enlighten, 2005).
Although reagent pill testing kits provide some information about the content of pills, there are limitations in the information that such kits can provide. First, pills sold as ecstasy may contain more than one psychoactive compound, yet reagent testing kits will only indicate the most prominent substance. Second, while indicating the presence of a substance, testing kits are unable to indicate the amount in a pill so, critically, they do not provide information on purity. Third, there is concern about the subjective nature of the interpretation of test results, which may potentially lead to inaccurate conclusions. Fourth, the results of such analyses have varying degrees of reliability, depending on which substance is indicated, and the number of tests used. Finally, although both the Marquis and Mandelin kits can identify the presence of MDMA-type drugs (MDMA, MDA, MDE), they cannot differentiate between these drugs. Further criticism of ‘pill testing programs’ is that they could be interpreted as condoning drug use (Dundes, 2003; Murray et al., 2003; Winstock et al., 2001) and any implication they have ‘passed’ the pill test potentially offer an additional incentive to take the drug (Dundes, 2003; Murray et al., 2003; Winstock et al., 2001). It is also important to point out that while particular formulations and purity levels may be detectable, high levels of purity may still be associated with substantial drug, environmental and individual risk factors.
Despite these limitations, some people have argued that pill testing has potential as a harm reduction measure. It has been suggested that the approach can be viewed as consistent with the harm reduction perspective of promoting the right of drug users to make informed decisions about their own drug use and its consequences (EMCDDA, 2001). For example, some have proposed that on-site pill testing facilitates the avoidance of specific pills or may otherwise modify drug use based on test results. An unpublished study conducted at an outdoor rave in South Australia found that 83% of people who received an unexpected test result stated they would do something other than just take the pill, including the most common response to not take it (26%) (Caldicott, 2005, cited in Johnston et al., 2006). It has also been argued that potential users of ATS are likely to pay more attention to health messages if they are perceived as reliable and this may directly relate to the perception of obtaining accurate information about pill content. Others have suggested that pill testing programs have the capacity to function as early warning campaigns if pills are identified that pose an acute health threat (van de Wijngaart et al., 1999). Thus, on-site pill testing programs may facilitate links between event organisers, first aid and security staff through the exchange of information about the pills in circulation at events, and anticipated drugrelated problems (Benschop et al., 2002; European Monitoring Centre for Drugs and Drug Addiction, 2001; van de Wijngaart et al., 1999). They may also have the potential to enhance existing public health surveillance of synthetic drug markets (Benschop et al., 2002; European Monitoring Centre for Drugs and Drug Addiction, 2001; Spruit, 2001) by providing data collection opportunities.
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However, as already indicated, there is opposition to pill testing and examination of this is also pertinent. First, aspects of the procedures are contrary to some legislation. Second, many of the pill testing kits provide modest information, that may be quite risky if there is a lack of clarity about what the results do and do not tell a person. Third, even the knowledge that a pill is totally or mostly what the person thought it was (e.g., pure MDMA) does not confer an indication of safety – many adverse reactions to ecstasy have occurred as a consequence of consuming high purity MDMA. Fourth, the evidence about the alleged benefits is largely lacking and concerns about the potential negative effects (condoning use; encouraging use) not sufficiently allayed. For example, Winstock and colleagues (2001) noted:
- In a recent study of over 1000 UK clubbers, subjects were asked how the quality of ecstasy pills would influence the amount of drug they consumed. Subjects indicated that if the quality of pills was considered to have become worse over 20% would take more, just over a third would take less, with 40% reporting no impact upon their ecstasy use. Conversely, and perhaps more worrying, if pills were thought to improve, 40% reported they would take more, just over 10% would take less, with nearly half reporting that it would make no difference to their use (pp.1145-1146).
