National Amphetamine-Type Stimulant Strategy Background Paper: Monograph Series No. 69
2.4 At-risk populations
Table of contents
Young people
The 2004 NDSHS reported on the use of illicit drugs by the population aged 12 years and older. Use of meth/amphetamine was reported by 0.7% aged 12-15, 3% aged 16-17, and 8.8% aged 18-19 (Australian Institute of Health and Welfare, 2005a). Rates for ecstasy used were similar, reported by 0.6% aged 12-15, 2.8% aged 16-17 and 8.8% aged 18 to19. While this survey is conducted with the general population, the Australian Secondary Students’ Alcohol and Drug (ASSAD) Survey reports the use of over-the-counter and illicit drugs among students aged 12 to 17 years attending grades 7 to 12 across Australia. The 2005 ASSAD found that the vast majority (95%) of secondary school students had never used amphetamine (White & Hayman, 2006). By the age of 17, 7% of students reported some experience with amphetamine and approximately 3% of students 14 years and over reported using amphetamine in the month before the survey. Of the 4% of students who used amphetamine in the year before the survey, 39% of males and 48% of females indicated that they had used them once or twice. While there was no change in the proportion of 12 to15 year-olds or 16 to17 year-olds using amphetamine in their lifetime between 2002 and 2005, there was a significant decrease between 1999 and 2005 for both age groups. However, there was no change in the proportion of students in both age groups using amphetamine in the month prior to the survey between 1996 and 2005. Only 4% of students had ever used ecstasy and recent use was not common among any age group. 2% of students aged 16 to17 had used ecstasy in the month prior to the survey.Results from the 2005 ASSAD Survey also indicate that poly-drug use is frequent among secondary students aged 12 to 17 years. Students who had used cannabis, amphetamine, hallucinogens or ecstasy reported on other drugs used concurrently. Between 53% and 68% used alcohol concurrently with these four drugs and between 41% and 48% used tobacco. Over one-third of students using amphetamine, hallucinogens or ecstasy also used cannabis concurrently. One-quarter of students using hallucinogens, one-fifth of students using cannabis, 18% of students using amphetamine and 17% using ecstasy did not use any other substance.
In their submission, the Youth Substance Abuse Service (YSAS) in Victoria reported on an analysis of the primary drug of choice being used by young people presenting over the past five years. Results demonstrate that presentations for heroin use dropped markedly, while there were corresponding increases in cannabis, alcohol, and ATS use during this period. This submission reported that presentations for heroin treatment decreased from 48% in 2001-02 to 19% in 2005-06, while presentations for ATS increased from 7% in 2001-02 to 8.5% in 2005-06. These findings are contrary to those reported by the Ted Noffs Foundation (TNF) (see www.noffs.org.au/programs/palm.shtm). TNF provides youth-specific programs including Adolescent Drug Withdrawal Unit (ADWU), which is a 2-week residential program for withdrawal and longer residential treatment in the rehabilitation program called Program for Adolescent Life Management (PALM). PALM is designed for 14 to 18 year olds with serious alcohol, or other drug-related difficulties. Research found that 21.8% of admissions in 2001 nominated ATS as their primary drug of concern, compared with 41.7% in 2004. This was higher than for heroin, and second only to cannabis. Further, it also found that, between 2001 and 2006, a sample of 566 clients with ATS as the primary or secondary drug of concern were more likely to be female, have injected any drug, had suicidal thoughts in the last 3 months, had made a suicide attempt, reported self harm and scored higher on depression, anxiety, hostility, paranoia and psychoticism on the Brief Symptom Inventory (BSI). These users were also more likely to have lived in more places in the six months prior to treatment entry, were more likely to have been sexually and physically assaulted by a stranger or by a known person, been violent and aggressive as a consequence of their drug use, and been involved in a greater variety of crime.
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It is recognised that some young people who engage in drug use are at risk of developing chronic patterns of use, including frequent, harmful binge use (Mattick & Darke, 1995). For some vulnerable young people, drug use may contribute to social exclusion and difficulties related to school, poverty, and involvement in criminal activities (NSW Health, 2005). For those young people who do seek help for illicit drug problems, research cited above suggests that ATS are increasingly becoming the major drug of concern. Within this drug class, different types of ATS may present distinct challenges for interventions. For example, a recent study conducted in the United States with a sample of 23,645 young people aged 18 to 25 years investigated risk and protective factors for both methamphetamine use and nonmedical use of prescription stimulants. This study reported differences in associations among these various drugs. Methamphetamine use was more common among females, individuals not enrolled in college, and those who had been arrested, whereas nonmedical prescription stimulant use was associated with psychological distress, sensation seeking, binge drinking and college enrolment (Herman-Stahl et al., 2007). Such findings highlight the importance of tailoring intervention strategies to particular groups of young people and particular drug types/problems.
Recent research in Australia investigated the predictors and effects of early-onset amphetamine use in a representative cohort of young people followed up over an 11-year period in Victoria (Degenhardt et al., 2007a&b). A sample of 1943 adolescents was recruited at age 14 to15 years and interviewed on eight occasions, with 78% follow-up at final interview. Use of amphetamine in young adulthood was strongly predicted by adolescent drug use and associated with current other drug use, while psychological distress was not found to be an independent predictor (Degenhardt et al., 2007a). Adolescent amphetamine use by young adulthood increased the likelihood of meeting criteria for dependence on a range of drugs, poorer mental health and limitations in educational attainment (Degenhardt et al., 2007b). However, these associations were not sustained after adjustment for earlyonset cannabis use, leading the authors to conclude that the problems associated with adolescent amphetamine use were largely accounted for by their even earlier onset of cannabis use (Degenhardt et al., 2007b). Such findings highlight the need for studies to take into consideration the use of other drugs in ATS-related research.
The submissions and consultations noted that changes in patterns of drug use by young people highlight the importance of remaining abreast of drug use changes and reconfiguring services to meet new demands, for example, behavioural impacts resulting from specific drug types. In particular, there was some concern that ATS use among young people presented some particular challenges. For example, the submission from YSAS noted that:
- Our research and practice experience suggests the key issues for YSAS in managing and treating heroin and cannabis use are very different to the treatment needs of those using ATS.
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Concern was also expressed about the use of MDMA by young people. The submission
from Headscape noted that:
- ecstasy doesn’t generate the same emotional response...thought of as a ‘party drug’ – not presenting with problems, don’t impact on services, not in contact with criminal system...use is normalised, swallowing seen as attractive and easy method of administration. Concerns are what’s in the pills and this makes use unsafe, e.g., PMA – issue of pill testing. …. Ecstasy not viewed as having any related harms or problems, but more as a social drug with use becoming more normalised. Also of concern is lack of research about long-term effects of ecstasy.
The submission from Headscape noted that:
- Young people, aged 12- 25 year (sic), should be identified as a priority target group in the ATS strategy. It is clear from available research that this is the time when recreational drug use is initiated. Early and appropriate intervention into drug misuse and abuse impacts on young people’s choices around ongoing or prolonged use of drugs and therefore the longer term impact on the health system.
Aboriginal and Torres Strait Islander community
There is relatively little prevalence data on ATS use by Aboriginal and Torres Strait Islander people. One source of such data is the Statistics on Drug Use in Australia 2002, which found that 13% of Indigenous Australians reported using an illicit drug other than cannabis in the last 12 months compared to 8% of other Australians (Australian Institute of Health and Welfare, 2003). Evidence suggests that methamphetamine use is increasing in Aboriginal communities and a preference among Indigenous injecting drug users for methamphetamine over heroin (Nicholas & Shoobridge, 2005).There is variation in substance use across geographical locations, and ATS are more commonly used among Aboriginals living in urban areas (Australian Institute of Health and Welfare, 2006b). When police were asked about the prevalence of amphetamine in Indigenous communities, 57% reported that it was commonly used in urban areas and 25% reported it was commonly used in non-urban areas (Putt, Payne & Milner, 2005). The 2004-05 National Aboriginal and Torres Strait Islander Health Survey found that, in non-remote areas, amphetamine use in the previous 12 months among Indigenous males had increased from 5% in 2002 to 10% in 2004-05, but remained at 5% for Indigenous females (Trewin, 2006a). While the consultation process also referred predominantly to use among Indigenous people in metropolitan centres and larger country towns, concern was expressed regarding remote communities located near major industries (e.g., mining).
The limited evidence base makes it very difficult to determine the need, and if need is identified, the nature of any intervention. However, some people have emphasised the importance of peer pressure. For example, at the 2005 Nimmityjah Consultation Forum, it was reported that peer pressure was a strong influence on Indigenous young people.
Indigenous populations of Australia have been reported as starting using drugs from early to mid-teens, at an age that is generally younger than other Australians (Australian Institute of Health and Welfare, 2005a). In considering this, it is important to note that the median age of Indigenous people is 21 years, compared to the general population of 36 years.
Concern about the spread of methamphetamine in remote Indigenous communities was expressed in consultations and with key law enforcement personnel. These concerns have been raised in a major study of policing implications of illicit drug use in Indigenous communities. Delahunty and Putt (2006) reported that 56% of all police (48% in non-urban areas) stated that local amphetamine use among Aboriginal and Torres Strait Islander people had ‘increased’ or ‘greatly increased’ in the past three years. However, non-urban police perceived alcohol (80%), cannabis (44%), inhalants (33%) and petrol (18%) to represent more serious problems for local Indigenous groups than amphetamine (11%).
Consultations in the regional and remote areas suggested that meth/amphetamine represented much less of a problem, with remote communities continuing to struggle with the influx of cannabis and its role in compounding alcohol related problems. It was reported that communities in one region were being affected by amphetamine and there was growing acceptance of amphetamine and of injecting. One consultation noted that meth/amphetamine were in regional towns and around mines, and young Aboriginal people working in the mining industry were being exposed to such use and, as noted earlier, were particularly susceptible to peer pressure. Dealing in drugs was also seen as a way of making money in the absence of employment opportunities. Finally, in some communities concern was raised that some Indigenous women may be drawn to use ATS as a form of self-medication for living in intolerable circumstances.
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Gay, lesbian, bisexual, transgender community
The Sydney Gay Community Periodic Survey 1996-2005 reported that 20% of gay men in Sydney had used crystal methamphetamine in the past six months (Hull, Rawstorne et al., 2006a), while the rates among gay men in Queensland, Melbourne and Perth were lower, at between 12-16% (Hull, Brown et al., 2005; Hull, Prestage et al., 2006; Hull, Rawstorne et al., 2006b). It has been observed that methamphetamine use is associated with increased sexual activity, particularly among gay and bisexual men and men who have sex with men (MSM). In particular, it has been associated with increased numbers of sexual partners (including high numbers of anonymous partners), increased sexual activity, decreased condom use, and high rates of unprotected vaginal and oral sex (Lee et al., 2007). The associated risks of ATS use among this population are outlined in Chapter 3 (‘Effects of ATS’).The Sydney Gay Community Periodic Survey 1996-2006 found that about 47% of the respondents reported use of MDMA in the six months prior to the survey (Zablotska et al., 2006). Other commonly reported drugs included cannabis (38%), powder (26%), cocaine (22%) and crystal methamphetamine (22%). Approximately 4.5% of the men who completed the questionnaire in February 2006 had injected at least one drug in the six months prior to the survey and the most commonly injected drugs were crystal methamphetamine, speed and steroids (Zablotska et al., 2006).
The AIDS Council of NSW (ACON) has undertaken significant work in addressing drug use for these communities. Research identifies that gay and lesbian people have higher rates of drug use than the general population (Degenhardt, 2005). There are varying reasons as to why this is the case. The written submission from ACON commented that, historically, the gay, lesbian, bisexual, transgender (GLBT) community has met within bars and clubs that can be conducive to the use of alcohol and illicit drugs. In addition, these substances may play a pivotal role in self and community management of the impacts of discrimination and oppression. Predisposing factors in substance use may therefore include increased risktaking behaviours, higher levels of depression, and a social subculture that incorporates substance use.
Illicit drug use is consistently reported as higher among homosexual than heterosexual females. In relation to drug and alcohol use, homosexual females were significantly more likely to report higher levels of risky drug use compared to heterosexual females (Hillier et al., 2003). This included risky alcohol use (7% compared to 3.9%), marijuana use (58.2% compared to 21.5%), use of other illicit drugs (40.7% compared to 10.2) and injecting drug use (10.8% compared to 1.2%). However, the second national report on the sexuality, health and well-being of same sex attracted young Australians, noted a decline in the use of all drugs between 1998 and 2004 (Hillier et al., 2005) . The proportion of those injecting drugs decreased from 11% in 1998 to 4% in 2004, and in 1998 and 2004 young females were more likely to have used marijuana and tobacco and to have injected drugs than young males.
Recommendations for support for this group came from ACON who requested that GLBT be explicitly identified as target groups in the Strategy. ACON cited evidence from the NSW Health (2005) publication, ‘Amphetamines, Ecstasy and Cocaine: A Prevention and Treatment Plan 2005-09’, and suggested this be reflected in the National Framework. Additionally, ACON recommended that any funding arising for initiatives should include allocation for approaches that specifically target GLBT people and any programs should be developed with community based organisations.
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Use in the workplace
The use of alcohol and illicit drugs in relation to work can compromise safety and productivity as much through mental and physical impairment as through absenteeism. Bywood and colleagues (2006) drew on the 2004 NDSHS survey of 29,445 Australians of whom approximately 50% over 14 years of age were employed to explore the issue of drug use in the workforce. The study found that, in the previous 12 months, those in the paid workforce were more likely to have used illicit drugs (17.3%) than those not in the paid workforce (11.8%). This was true for amphetamine and ecstasy, with use of both these drugs in the previous 12 months reported by around 4% of those in the paid workforce compared to around 2% of those not in the paid workforce. Significantly more male (20.3%) than female (13.4%) workers reported using any illicit drug, and 12% of male and 9.1% of female workers, aged 18-29 years, reported use of amphetamine.Differences were found according to industry type, with the hospitality industry highest in use of all drug types. The most common industries for amphetamine use were hospitality (9.3%), transport (5.4%), construction (5.2%), agriculture (4.9%) and retail (4.6%). The most common industries for ecstasy were hospitality (10%), finance (5.6%), retail (5.5%), construction (4.7%), manufacturing (4.6%) and wholesale (4.6%). Occupational differences were also found with ATS use reported mostly by tradespeople (6.1% amphetamine, 5.2% ecstasy) and unskilled workers (4.9% amphetamine, 5.6% ecstasy).
Using the Australian and New Zealand Standard Industrial Classification codes to examine more narrowly defined industries, workers in commercial fishing (40.5%) had the highest level of use of at least one illicit drug (Roche, 2007). Other groups reporting relatively high levels of use (30-37%) included employees in motion picture, radio and television services; accommodation, cafés and restaurants; libraries, museums and the arts; and construction trade services (Roche, 2007).
Roche (2007) found a strong association between use of illicit drugs and absenteeism:
- Almost 1% of the workforce (1.2% males; 0.7% females) reported taking days off due to their drug use. This was most prevalent among 14-17-old workers, and more common among males than females. Among amphetamines users, absenteeism levels were particularly high with 13.4% of amphetamine users reporting a drug-related day off in the past three months, compared to 4.5% among users of any drug. Workers who use illicit drugs were also significantly more likely to report days off due to any illness or injury in the past three months (48.1% of drug users overall and 56.8% of amphetamine users) compared to workers who report no drug use (p.19).
It was suggested that there is a need to undertake more research into the nature and impact on health and productivity of employees’ drug taking. Measures for dealing with drug taking in the workplace were discussed during the consultations and included innovative approaches of the kind outlined by Harris (2007) and those instigated through some union and non-union workplace agreements. These relate to provision of leave to attend rehabilitation; the implementation of employee assistance programmes; disciplinary, counselling and testing protocols; and zero tolerance policies in industries where employee or public safety is at risk. According to Harris (2007), workplace agreements, particularly in the building and construction, mining, manufacturing and transport industries, increasingly address drug and alcohol issues.
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