Heroin part VIII

Ha - you didn't think I'd finished with my little saga, did you? Too bad if you did - there are a few parts to go yet. Frankly, I'm brain dead from digesting all the research papers, and am finding it hard to whip up the enthusiasm to get to the finish line. Remember, our aim here is to try and work out whether Bob Carr's idea of a safe injecting room in Kings Cross was a good idea or not. 

Here's a bit of thinking that I haven't seen in any of the research - a simple division of the population of NSW into four broad categories. (Oh crikey, it's the BCG matrix all over again). 

In the top right hand corner, we have people like me and most of my friends and associates - and presumably most of the readers of this blog. Normal, law-abiding citizens. People with jobs and families and maybe a few speeding tickets to their name, but nothing else. They might have done drugs in their younger days (when they were party people), but now they have straightened out and are taking their kids to church on Sunday.

Below them we have the "party people" quadrant. This is where most of my group was 10-20 years ago. We were law abiding (in the main), but liked to party like there was no tomorrow. For some, that meant popping pills, doing a few lines and for the very rare specimen, sticking a needle in their arm. After a Friday and Saturday night bender, they'd be back at work on Monday, putting in a long week to pay the mortgage. Once they started having kids, the benders and the drugs were mainly history.

In the top left quadrant we have old fashioned crooks - crims who prefer beer rather than drugs. 

And in the bottom quadrant, we have the customers of the safe injecting room - junkies. We're talking about heavy drug users who support their habit by bludging on the dole and stealing from the rest of us. 

Here's my completely unscientific representation of how big these populations are in relation to each other. Various surveys have estimated that 1-2% of the Australian population have tried heroin at some point. Other surveys have estimated that there were around 20,000 regular heroin users in NSW at the turn of the century. I'm assuming that number has been stable since then.

By my reckoning, the great majority of the population are normal people. They're too young or too grown up to do drugs. The party people population is a reasonable size - that's your 18-29 demographic essentially.

The number of junkies is pretty small really. The population of NSW was over 7.2 million in 2010. We're talking about 0.3% of the population - a tiny fraction.

However, that "tiny fraction" is capable of doing a huge amount of damage when it comes to crime and the consequences, plus all the associated health and social welfare costs. People like me (and hopefully you) contribute a lot to society. We do useful work, pay lots of taxes and do our best to avoid being a deliberate dead weight drag on the public purse. Party people might increase the cost of cleaning the footpaths in our cities (ie, hosing off the vomit on Saturday morning), but apart from a few emergency visits to have the odd stomach pumped and face stitched back together, they aren't much of a drag as well.

Old fashioned crims cost plenty - fraud, robbery, housebreaking etc all adds up to plenty of money each year.

However, it's my belief that the junkies take the cake. They have the worst health problems. They are almost never employed. They have the worst social and family problems, thus requiring huge amounts of support from an army of social workers and charities. They tie up masses of Police, court and jail time. In NSW alone, the 20,000 junkies need to find up to $1 billion each year to fund their habit, and they get that by sitting on the dole and stealing from the rest of us. If you added on all the other social costs, the total becomes horribly large.

We can represent this by the wealth transfers between these groups. There is a massive transfer of wealth each year from normal people (and party people) to crims and junkies. There is a direct transfer to junkies in NSW of at least a billion through fraud and break and enter and the like (assuming you believe that junkies need at least $50,000 each per year to fund their habit). Given that fenced goods are worth a fraction of their purchase price, unless they are committing masses of credit card fraud, they would have to steal several times that amount in order to raise that billion dollars. Then there is the indirect transfers that include things like us paying for their medical treatment - and paying for somewhere for them to shoot up safely.

So, given all of the above, is a safe injecting room still good policy? What does it do to stop a junkie from walking down Glebe Point Rd when I'm having dinner in a restaurant, and smashing my car window to get at my GPS? Does it do anything to reduce the enormous burden on the public?

Heroin - part VIII

In one of my recent posts, I tried to trawl through the research to determine how much heroin is consumed in NSW each year, and what that costs. Depending on what assumptions you make about how many addicts there are, how much they inject each time and how many times they inject per day, it could be anywhere between 1.2 and 3 tons per year. Or it could be way outside those boundaries.

Without going down to Kings Cross and trying to score, I have to base the retail price on what the research tells me - that it's around $320 per gram.

1.2 tons is 1.2 million grams.

3 tons is 3 million grams.

That puts the retail trade in NSW as somewhere in the vicinity of $390 to $960 million per year. Or it could be way outside those boundaries.

Since retail purity is around the 50% mark, that means only half those amounts of pure heroin need to be imported each year.

And how is all that funded?

Heroin users are prone to resort to crime to fund their purchases of heroin.  Law  estimate that the number of dependent heroin users in Australia increased from about 670 in 1967 to about 67,000 by 1997.  Heroin dependence has been a particularly prominent problem in NSW.  This State has about a third of Australia’s population but, between 1979 and 1995, accounted for more than half of all those placed on methadone treatment and just under half of all fatal opioid overdoses.

Proceeding on this basis we estimate that, since 1966, each 10 per cent increase in the annual number of dependent heroin users has led to a 6 per cent increase in the NSW robbery rate.  By comparison, each 10 per cent decrease in the robbery clear-up or imprisonment rate has led to a 3-4 per cent increase in robbery.

Also:

A significant proportion of the funds expended on purchases of heroin are raised through the commission of property crime.  A 1984 survey of imprisoned NSW property offenders, for example, found that 50 per cent of those who identified themselves as regular heroin users stated that heroin use had increased the amount of property crime they committed.
 
Those who described themselves as ‘heavy’ users of heroin committed armed robberies 1.8 times more frequently and break, enter and steal offences 1.7 times more frequently than those who described themselves as ‘light’ users of heroin.  

The observation that regular heroin use amplifies of ending frequency amongst those involved in crime has been confirmed in other studies.  

Blumstein, Cohen, Roth and Visher, for example, cite evidence that daily heroin users committed robberies and burglaries, respectively, at rates which were 2.9 and 4.7 times higher than ‘infrequent’ users of the drug.

And another income source:

The majority of the sample (86%) reported that  they were currently unemployed or receiving government benefits. Seventy-nine percent of the sample  reported that their main source of income over the preceding month had been a pension or government benefit, while 7% reported a wage or salary, 9% nominated criminal activity and 3% reported sex work

The libertarian in me says that if you want to snort, smoke or inject heroin, then that's your business and I really don't give a rat's. I like this view of libertarianism:

"Libertarianism is the view that each person has the right to live his life in any way he chooses so long as he respects the equal rights of others"

Respecting the equal rights of others means not breaking into their property and stealing their stuff, or accosting them on the street and robbing them, or committing fraud against other taxpayers (ie, the government) or businesses. I am not very worried about heroin use; what I can't stand is the consequences - the screwed up children of addicts, the billions poured into social services, the heavy handed policing and the property crime that is a major embuggerance to every citizen.

I can't stand the idea that I am paying taxes to support a class of bludgers who, when freed of the need to do 35-40 hours of paid employment each week (plus the time required to travel to and from work) have plenty of free time to steal from the rest of us.

But this series is not about me ranting about certain things. It's about questioning whether a safe injecting room in Kings Cross is good public policy. Given the crime stats that I've just quoted, the first question that comes to mind is, "What impact does a safe injecting room have on the crime stats?"

Over to you.

Heroin - part VI

But wait - there's more!

We've had a look at estimates of how many heroin users there are in NSW (and the numbers are pretty old). Now let's  have a look at how often they stick a needle in their arm.

Frequency of heroin use

• Once a week – 9%

• More than once a week – 20%

• Daily – 16.5%

• More than once a day – 46%

Mean expenditure – about $1000 per week (2005).

Here's the bit that all law-abiding, tax-paying householders and shopkeepers will love:

Three-quarters of PS users reported committing at least one crime in the previous 30 days

It's worth noting that the information on the NSW Druginfo site is a bit contradictory in places:

During the 1980s and 1990s research suggested the numbers of heroin dependent users in Australia rose from around 34,000 in the mid 1980s to about 74,000 estimated in 1997, when the last major study was conducted.  At that time, the research suggested there may have been up to 35,000 dependent users in NSW.   

NDARC has described a dependent heroin user as one who uses 2-3 times per day.  Dependent users consume about 85 percent of heroin imported.  

In addition, NDARC estimates that there are as many as 2-3 times the number of dependent users who use occasionally, perhaps once per week.

So exactly how many bloody users are there in NSW today?

After a fair bit of Googling, the answer seems to be "buggered if I know", because there hasn't been any published research in the last 9 years. The numbers might have gone up, or they might have gone down.

So let's go with the estimate of 20,000 dependent users in NSW as that's what the latest research in 2002 said, and let's go with the definition of "dependent" as someone who uses 2-3 times per day (because as the research says, this lot use 85% of all heroin).

If they're shooting up 2-3 times per day, that equates to about 50,000 hits per day. For a user, that's 15-20 injections per week.

How much in a hit? What do I look like - a drug encyclopedia?

If heroin costs about $300 per gram (as it did during the drought in 2001) and junkies are spending $1000 per week on heroin, then we can calculate an intake of 3.3 grams per week, or about 0.2 grams per hit - although heavy users might consume lots more than that.

So by those rough calculations, those 20,000 users are going through at least 60,000 grams per week in NSW - or 60 kilos. That's 3 tons per year.

This has to be taken with a pinch of salt though, as a more recent study puts average drug expenditure at $56 per day, or $392 per week. That's about 1.2 grams per week, or 1.2 tons per year.

To put that in perspective, a huge drug seizure in Australia is 400kgs - and that was back in 1998.

But let's go back to Bob Carr's statements about the benefits of a safe injecting room:

There have been approximately 600,000 visits over 10 years. There are about 200 injections a day – that is, with medical supervision on hand, whereas without the centre…? 

To reinforce this point, the number of drug overdoses successfully managed stands at more then 3,500. 

Now this is also important : there have been more than 8,500 referrals for addiction treatment, mental health, homelessness or acute medical problems. We always envisaged this as a portal to treatment. 

Like I said above, the junkies of NSW are putting away 50,000 hits per day. That's 18,250,000 per year. The safe injecting room has been open for 10 years and has seen 600,000 injections. In that time, all the other junkies in NSW have stuffed a needle into their arm 182,500,000 times. What is 600,000 divided by 182,500,000? It's not a lot. It's 0.00328 - that's what it is.

Is that good policy, or just pissing in the wind?

Interestingly enough, the ABS hasn't provided any updated numbers on drug deaths or the number of heroin users in about a decade, so we can't tell what's happening to the addict population. If there were 19,900 heroin users in NSW when the injecting rooms opened for business a decade ago, and they've made 8,500 referrals for treatment, then one would expect that the number of addicts would have continued to decline sharply due to more and more of them getting treatment etc etc.

I doubt very much that has happened.

Heroin - part V

Just what is an overdose, and how does it kill you?

This part of my research was quite fascinating. Until now, I had no idea what an overdose was all about. Here's some interesting bits and pieces for you:

• Some studies estimate that up to 60% of all heroin users have experienced at least one overdose. 
• people being released from custody are at a greater risk of overdose because of a tendency to binge on alcohol and drugs shortly after release without taking into account their reduced tolerance from a reduction in drug use whilst in custody.
• Despite a perception that young inexperienced users make up the greatest number of heroin related overdoses, research evidence clearly shows that older long-term users are more susceptible to heroin related overdoses.
• It is estimated that there are between 12,000 and 21,000 non- fatal overdoses in Australia annually.
• Victims of overdose are predominately single, unemployed men aged in their late 20s and early 30s, with a long history of heroin dependence.
• Concomitant alcohol or benzodiazepine use, and recently depleted tolerance, are significant risk factors for overdose. 
• Death from overdose is rarely instantaneous. Overdose most commonly occurs in a private home, with or near other people. Witnesses of overdose are reluctant to seek help.
• Overdose fatality is not a simple function of heroin dose or purity. There is no evidence of toxicity from contaminants of street heroin in Australia.
• only 2% of heroin-related deaths  in New South Wales in 1992 were in methadone maintenance at the time of death, while seventy-five percent of fatalities had never been in methadone treatment.  
• Enrolment in methadone maintenance has been found to be protective against overdose in spite of continued use of heroin, probably reflecting a combination of reduced heroin use while in treatment and/or a higher tolerance to opioids while being maintained on methadone. 
• In the majority of cases death occurs two or more hours after administration. The majority of deaths occur in a private home. 
• Studies typically report that approximately half of all overdose fatalities occur in the own home of the victim, while a quarter occur in the home of a friend or relative. This pattern also holds true for non-fatal overdose, with only 10% of users reporting that their last overdose occurred on the street. 
• Approximately one in ten overdoses ends fatally.

This was all news to me. From reading the rather dry medical reports, I started to get this picture of a recently released crook who heads down to the Cross for a post-prison bender. He (and most are male) gets on the turps, then takes a few pills, and then shoots up. The alcohol and pills both suppress the respiratory system - and this bloke doesn't have good lungs to start with because almost all junkies are also heavy smokers (I read that too) and they suffer all sorts of bronchial-pulmonary problems. So his lungs are buggered, he's full of booze (which shuts down your breathing a bit), then he takes pills (which shuts it down more) and then he tops it off with heroin, which shuts them down even further. And then he dies - that's an overdose.

It's not the heroin that's killed him. It's the combination of poor health and at least one other suppressant that's done him in.

So, how does an injecting room help out here?

I can see how having medical staff on hand with a few tubes of Narcan would stop idiots like the one described above from killing themselves when on a bender. The good citizens of the Cross wouldn't have to step over another body on the way to work in the morning. But does it do anything to treat the underlying problems that led this goose into going on a booze, pill and heroin bender to the point where he overdid it and would have died unless a medic had rammed a needle into him?

heroin - part IV

In the last post, I noted that the deaths from heroin overdoses went from 6 in 1964 to 737 in 1998. Why the sudden increase?


Some clever people sat down about 10 years ago and wrote a paper entitled Estimating the number of current regular heroin users in NSW and Australia 1997-2002. Here are their median estimates for that period for NSW:


1997 - 35,300
1998 - 48,000
1999 - 48,200
2000 - 43,900
2001 - 22,100
2002 - 19,900


On page 19 of the report we find this fascinating graph - "Number of opioid overdose deaths among persons aged 15-54 years, 1980-2002". It covers both NSW and the rest of Australia. 

What the table of heroin users and the graph shows is that the number of deaths (and presumably users) started to take off in the mid 1990s, reaching a peak in 1999 before dropping sharply in 2001. The primary reason for the fall seems to be a heroin drought around that time.


Let's go back to one of Bob Carr's justifications for the injecting room:

The ultimate argument ? It might just save lives – the lives of people who are using heroin until a time ( often their late 30s ) when they get sick of it and decide to make a break with that life. We need to sustaint them till they reach that point. 

After looking at the graph above, if you ask me, the biggest life saver in the last decade has been a shortage of heroin, which has more than halved the number of users in NSW. If the estimates are correct and users dropped from 48,200 at their peak to 19,900 just a few years later, then that would produce a 60% drop in deaths from overdoses. That's mighty powerful stuff.


But does that make an injecting room poor policy? My mind is still open - there is more to come.

Heroin - part III

We don't hear much about heroin overdoses and deaths these days - they rarely seem to interest the media anymore unless they relate to a celebrity. However, back in 1999, it was a different story. Heroin use had exploded, as had the number of overdoses and deaths.

The Australian National Council on Drugs reported that:

The number of deaths associated with heroin overdose has increased markedly in the past 25 years. National Drug and Alcohol Research Centre publications record that the number of deaths in the 15-44 year old age group has increased from 6 people in 1964 to 737 people in 1998. Recent reports further suggest that this figure has again increased in 1999. The 1998 figure equates with almost 9% of all deaths in this age group being attributed to heroin related overdose.

Some studies estimate that up to 60% of all heroin users have experienced at least one overdose. Each heroin related overdose potentially represents another fatality

That's quite an increase - from 6 deaths in 1964 to 737 in 1998. It's worth noting that:

The highest rate of fatal overdose occurs in New South Wales. In 1998, overdose fatalities in NSW accounted for 48.6% of all fatal overdoses nationally.

That's why we ended up with a Drug Summit - heroin was killing a lot of people back then. One of the outcomes of the Summit was a safe injecting room in Kings Cross. The question is - did the safe injecting room make a difference? Did it materially reduce the number of deaths from heroin overdoses once it opened?

Heroin - part II

Why did we a supervised injecting room in Kings Cross? The answers can be found in the 60-odd pages of the 1999 paper The NSW Drug Summit: Issues and Outcomes. It's actually worth reading - it's well put together and it has input from a wide range of characters.

I had a good laugh reading the first few pages, as they catalogued a series of knee jerk reactions from the government of the day to adverse media reports. I'm old enough to remember the following photo:

On 31 January 1999, a photograph of a teenage boy engaged in injecting drug use in a lane-way in Redfern, appeared on the front page of a Sydney newspaper.  This acted as the catalyst leading to the establishment of the Summit.   In the articles which accompanied this photograph the age of the boy was given as 12 or 13 (he was subsequently identified and his age confirmed as being 16 ), and it was asserted that the injecting equipment was obtained from a near-by needle exchange (a NSW Department of Health report into the incident later revealed that the boy did not obtain any injecting drug equipment from the near-by needle exchange outlet ).  

-----

The then Minister for Health, Hon A Refshauge MP, reacted by immediately closing down the needle exchange outlet, and ordering a review of the $9 million statewide needle exchange program

Not long after that:

On 25 February a youth welfare group, Open Family, announced its intention to open rooms in its Cabramatta and Footscray offices for young heroin users to inject drugs.  Open Family’s plan was partially supported by Footscray’s local council, but met widespread condemnation from other drug welfare groups and the  local community.   In Sydney the Carr government condemned the plan as ‘irresponsible, dangerous and illegal’. 

We then had an election on 27 March 1999, with Labor (led by Bob Carr) romping home against a rather useless Coalition.

Bob then convened the Drug Summit between 17 May and 21 May 1999. It's interesting to look back at the actions of the government just prior to the election, and what it actually did after that election.

Heroin - part I

Back in early May, Bob Carr wrote two pieces on his blog Thoughtlines about the safe injecting centre that was set up in Kings Cross during his tenure. You can read them here and here. I do enjoy Bob's blog, but he has a bad habit of leaving some of my comments in moderation forever - such as this one that I penned on the 12th of May.

But let's not get wrapped up in Bob's policy on comments. Maybe he's got better things to do these days than moderate comments from people like moi.

In his posts, Bob made a number of statements about the effectiveness of the injecting rooms. I thought I'd do a bit of reading and see how they stack up (yes, that's partly why I've been very quiet of late). Amongst other things, Bob wrote:

At the end of the 1999 drug summit convened by the government in parliament house two ministers, Craig Knowles and John Della Bosca, stood in my office with a proposal for a medically supervised injecting room and persuaded me. The ultimate argument ? It might just save lives – the lives of people who are using heroin until a time ( often their late 30s ) when they get sick of it and decide to make a break with that life. We need to sustaint them till they reach that point. 

The facility, as my government designed it, would be a gateway to treatment. It would mean paramedics would not be called to dark carparks or back alleys to rescue a victim of an overdose at the risk of needlestick injury to themselves. By taking injecting indoors it would mean the streets of Kings Cross would be improved.

and:

There have been approximately 600,000 visits over 10 years. There are about 200 injections a day – that is, with medical supervision on hand, whereas without the centre…? 

To reinforce this point, the number of drug overdoses successfully managed stands at more then 3,500. 

Now this is also important : there have been more than 8,500 referrals for addiction treatment, mental health, homelessness or acute medical problems. We always envisaged this as a portal to treatment. 

There are 90 supervised injecting centers in the world but not all of them provide such a gateway to treatment. 

By the way, there is no evidence of a “honey pot” effect, drawing addicts to Kings Cross.
All those injections – 200 a day – would have taken place in public places or, at least, without access to medical intervention. Kings Cross had the highest concentration of drug overdose deaths in the country. 

Good policy or not?

It was the last line that got me - "Good policy or not?" I'm going to make a big assumption here - Bob's blog is generally followed by fellow travellers, so most are likely to agree with the idea that it was good policy. Since Bob pushed that policy, he would also think it was a fabulous idea. Trouble is, there are pernickety people like me out there that like to test these assertions using things like evidence and logic instead of feelings.

As I write this, I haven't made up my mind as to whether it was good policy or not - that will come out as I examine each bit of evidence that I've trawled up over the last few weeks. I'll take you through what I've found, and you can make your own mind up.


I've read through quite a lot of stuff over the last few weeks, and here's a short list of the most relevant ones:

Heroin Related Overdoses Position Paper - this is where the recommendation for the supervised injecting room came from

The NSW Drug Summit: Issues and Answers - a good summary from the NSW Parliamentary Library

High Risk Groups and Behaviours - this explains everything you ever wanted to know about heroin overdoses in NSW


Psycho-stimulant use, health and criminal  activity among injecting heroin users - how often do heroin users shoot up, and how much do they spend on drugs?

Estimating the number of current regular heroin users in NSW and Australia 1997-2002 - also includes data on death rates from overdoses

The impact of heroin dependence on long-term robbery trends - in case you were wondering how junkies fund their habit

Heroin Overdose: Prevalence, Correlates, Consequences and Interventions (2000) - another paper that recommended the establishment of the supervised injecting rooms

Cost of heroin - pretty self evident what this is about

Drug Law Enforcement Policy and its Impact on the Heroin Market - also shows the impact of heroin use on property crime

So there's a bit of light reading if you're interested in this topic. Most of the research is from the late 1990s or early 2000s - I couldn't find anything really up to date. Either no one is funding such research, or it's a work in progress. However, I doubt the behaviour of heroin users has changed much since 1999, so let's not get our knickers in a knot about the research not being hot off the press. Note that I was looking for research that was specific to NSW - there is tonnes of stuff out there about the experience of other countries, but I wanted to stay focused on NSW.