THE INJECTION OF

METHADONE SYRUP

IN SYDNEY, AUSTRALIA

Shane Darke, Joanne Ross

&
Wayne Hall

National Drug and Alcohol Research Centre

1995

Technical Report No. 30

ISBN

© National Drug and Alcohol Research Centre

 TABLE OF CONTENTS

ACKNOWLEDGMENTS .............. ........................ ........................ ........................ ........ vi

EXECUTIVE SUMMARY .............. ........................ ........................ ........................ .......vii

1.0 INTRODUCTION .............. ........................ ........................ ........................ ......... 1

1.1 Study aims .... ........................ ........................ ........................ ........................ ...................... 2

2.0 METHOD .... ........................ ........................ ........................ ........................ ...................... 3

2.1 Procedure...... ........................ ........................ ........................ ........................ ...................... 3

2.2 Structured interview............ ........................ ........................ ........................ ......... 3

2.2.1 Demographic characteristics ............ ........................ ........................ ......... 3

2.2.2 Drug use history ........ ........................ ........................ ........................ ...................... 3
2.2.3 Heroin dependence... ........................ ........................ ........................ ......... 4
2.2.4 Health. ........................ ........................ ........................ ........................ ......... 4
2.2.5 Psychological functioning................. ........................ ........................ ......... 4
2.2.6 Heroin overdose ........ ........................ ........................ ........................ ...................... 4
2.2.7 Needle risk behaviours ..................... ........................ ........................ ...................... 4
2.2.8 Criminal behaviours . ........................ ........................ ........................ ......... 4
2.2.9 Initiation of methadone injecting .... ........................ ........................ ......... 5
2.2.10 Methadone injecting procedures .... ........................ ........................ ......... 5
2.2.11 Most recent methadone injection episode ............. ........................ ......... 5

2.3 Analyses........ ........................ ........................ ........................ ........................ ...................... 5

3.0 RESULTS ..... ........................ ........................ ........................ ........................ ...................... 6

3.1 Sample characteristics ......... ........................ ........................ ........................ ...................... 6

3.2 Drug use history ................... ........................ ........................ ........................ ............ ......... 7

3.3 Heroin dependence.............. ........................ ........................ ........................ ......... 9

3.4 Prevalence of methadone injecting ............ ........................ ........................ ......... 9

3.5 Frequency of methadone injecting ............. ........................ ........................ ....... 10

3.6 Characteristics of methadone injectors...... ........................ ........................ ....... 12

3.6.1 Demographics............. ........................ ........................ ........................ ....... 12

3.6.2 Area of residence........ ........................ ........................ ........................ .................... 12
 3.6.3 Methadone maintenance ................... ........................ ........................ ...................... 1 ......... 4
3.6.4 Drug use history ......... ........................ ........................ ........................ .................... 15
3.6.5 Heroin dependence.... ........................ ........................ ........................ ....... 15

3.7 Initiation of methadone injecting ............... ........................ ........................ ....... 15

3.8 Methadone injecting procedures ................ ........................ ........................ ....... 17

3.9 Most recent methadone injection episode ........................ ........................ ....... 18

3.10 Correlates of methadone injecting ............. ........................ ........................ ....... 21

3.10.1 Health ........................ ........................ ........................ ........................ ....... 21

3.10.2 Heroin overdose ....... ........................ ........................ ........................ .................... 21
3.10.3 Psychological functioning ............... ........................ ........................ ....... 23............
3.10.4 Needle risk behaviours .................... ........................ ........................ .................... 23
3.10.5 Criminal behaviours ........................ ........................ ........................ ....... 23

3.11 Predictors of current methadone injecting ........................ ........................ .................... 23

4.0 DISCUSSION ...................... ........................ ........................ ........................ .................... 25 ...................

4.1 Major findings of the study ........................ ........................ ........................ ....... 25

4.2 Data validity and representativeness of sample ............... ........................ ....... 25

4.3 Prevalence of methadone injecting ............ ........................ ........................ ....... 26

4.4 Methadone injecting procedures ................ ........................ ........................ ....... 26

4.5 Methadone maintenance and methadone injecting ........ ........................ ....... 27

4.6 Area of residence and methadone injecting ...................... ........................ .................... 27

4.7 Sources of methadone for injecting ............ ........................ ........................ ....... 28

4.8 Harms associated with methadone injecting .................... ........................ .................... 28

4.9 Implications.. ........................ ........................ ........................ ........................ ....... 29

4.10 Conclusions .. ........................ ........................ ........................ ........................ .................... 29

5.0 REFERENCES ...................... ........................ ........................ ........................ .................... 31

 LOCATION OF TABLES

Table 1: Demographic characteristics of 312 heroin users . ........................ ......... 7

Table 2: Drug use history of 312 heroin users...................... ........................ ...................... 9

Table 3: Prevalence of methadone injecting ........................ ........................ .................... 10

Table 4: Frequency of methadone injecting among current methadone

injectors in preceding six months .. ........................ ........................ ........................ ....... 11

Table 5:Demographic characteristics of respondents who had

injected methadone versus those who had not .... ........................ ........................ ...................

Table 6: Area of residence and methadone injecting .......... ........................ .................... 14

Table 7: Circumstances of initial methadone syrup injection .................... ....... 16

Table 8: Methadone syrup injection procedures ................. ........................ ....... 18

Table 9: Circumstances of most recent methadone injection ..................... .................... 20

Table 10: Correlates of current methadone injecting ............ ........................ ....... 22

Table 11:Multiple logistic regression predicting injection of

methadone syrup in the preceding six months .... ........................ ........................ ...................
 ACKNOWLEDGMENTS

This research was funded by the Drug and Alcohol Directorate of New South Wales.
The authors would like to thank the following organisations for their assistance in this
study: Liverpool Hospital Drug and Alcohol Unit, Canterbury Hospital Drug and
Alcohol Unit, Kullaroo Clinic, the Central Coast Needle Exchange, We Help Ourselves,
St Mary's Needle Exchange and SWAP. In particular, we would like to thank Karen
Becker, Mario Fantini, Bruce Flaherty, Anna Haining, Gayle Kennedy, Lisa Maher,
Dorothy Oliphant, Suzanne van Opdorp, Helen Polkinghorn, Garth Popple and Sandra
Sunjic.

vi
 EXECUTIVE SUMMARY

A sample of 312 heroin users was interviewed regarding the injection of methadone
syrup. Methadone syrup injecting was widespread, with 52% of the sample having
injected methadone syrup, 29% in the preceding six months. Males and females were
equally likely to report having ever injected methadone syrup, and to have done so in
the six months preceding interview. Among current methadone injectors, frequent
methadone injecting was common, with 40% reporting weekly or more frequent
injecting in the preceding six months.

Methadone injecting was more common in western Sydney, both in lifetime prevalence
(58% v 45%) and within the preceding six months (36% v 21%). Frequent injecting was
also more common in the western suburbs. Recent methadone injecting was more
common among respondents currently enrolled in methadone maintenance (34% v
23%). Both area of residence and treatment status were independent predictors of
current methadone injecting.

The two most common sources for obtaining methadone for injection were
friends/partners or respondents' own prescribed take-away doses. Illicit methadone
was considered easy to obtain by 87% of respondents. The average price of methadone
was 50c per milligram in the western suburbs and $1 per milligram in other regions of
Sydney.

There were clear harms associated with methadone syrup injecting. Current
methadone injectors were in poorer general health than other respondents, and had
more symptoms related to injecting. A history of methadone injecting was associated
with abscesses and infections in injection sites, and having been diagnosed with a
venous thrombosis. Those with a history of methadone injecting were also more likely
to have overdosed (70% v 52%), with current injectors being more likely to have
overdosed in the preceding six months (26% v 14%). Current methadone injectors also
showed higher levels of current psychological distress, were more likely to have
recently passed on used injecting equipment and to have recently committed criminal
acts.

The results of the present study raise questions about ways in which to reduce the
harms associated with methadone syrup injecting. Issues that require attention include:
policies on the provision of take-away methadone doses; strategies such as diluting
methadone syrup to expand the volume of a methadone dose; and education of
methadone maintenance clients on the harmful effects of methadone injecting.

vii
1.0 INTRODUCTION

Orally delivered methadone maintenance has been repeatedly demonstrated to be the

most cost effective, efficacious treatment for opioid dependence1. Enrolment in
methadone maintenance had been associated with reduced frequency of injecting,
reduced frequency of needle sharing, a reduced risk of HIV infection and a reduced
risk of heroin overdose1,2. Methadone maintenance services have expanded rapidly in
Australia since 1987, with approximately 17,000 people now enrolled on methadone
maintenance3.

A great deal of recent clinical concern has arisen, however, about the injection of
methadone syrup. Anecdotal evidence has linked this practice to the western suburbs
of Sydney in particular, with needle exchanges in this region reporting an increased
demand for 10 ml and 20 ml syringes and vein infusion sets, equipment thought to be
employed to inject methadone syrup.

The major health concern raised by the injection of methadone syrup is the
development of venous thrombosis. The viscous nature of the syrup makes it difficult
to inject and, as such, greatly increases the risk of thrombosis after delivery into the
vascular system. It should be noted that the development of thrombosis has also been
associated with injection of temazepam capsules, like methadone a viscous liquid4,5.

Direct damage arising from repeated injections with large gauge needles is also of
concern, with cases of fistulas having been reported to have arisen from the repeated
injection of methadone syrup6. Repeated injections may be necessary in order to inject
the large volume of methadone syrup and water needed for intoxication.

The use of large sized syringes to inject methadone is also a cause for concern in
relation to the spread of blood borne viruses. It has been shown that the risk of passing
on blood through needle sharing substantially increases as the size of the syringe
increases7. These authors estimated that 10 times more blood is transferred when using
a 2 ml syringe as opposed to the more common 1 ml syringe. The use of 10 ml and 20
ml syringes for methadone syrup injections clearly would exacerbate this problem if
needles were being shared.

Despite these concerns, to the authors' knowledge, no study on the illicit injection of
methadone syrup has been conducted to date in Australia. Several studies outside
Australia have reported on the use of illicit methadone, but these have not focussed on
the injection of methadone syrup8-12. Inciardi8, in 1977, reported 46% of a large sample
of U.S. heroin users had used illicit methadone during the week prior to interview,
with 70% of respondents having used illicit methadone in the three months prior to
interview. Daily use of methadone was rare, with 5% of respondents reporting daily
use in the preceding three months, 40% weekly or more frequent use, and 55% less
than weekly use. No data on route of administration was provided. Weppner et al12

1
reported a lifetime prevalence of illicit methadone use of 43% among patients admitted
to Lexington hospital for opiate detoxification.

Sapira et al10 reported in 1968 on 25 methadone dependent males admitted to

Lexington hospital. Less than half (36%) of these patients used methadone orally, with
40% using intravenously and a further 24% intramuscularly.

A third (34%) of methadone patients interviewed in Spunt et al11 reported having ever
diverted their methadone dose. More recently, Lauzon et al9 reported a lifetime
prevalence of illicit methadone use of 59% among a sample of Canadian heroin users.
In the six months preceding interview, 42% of these respondents reported having used
illicit methadone. No data were given on route of administration.

The current study aimed to provide data on the prevalence of methadone syrup
injecting among a sample of Sydney heroin users, and the procedures and problems
associated with this practice.

1.1 Study Aims

The major aims of the study were as follows:

1)To determine the extent of methadone injecting, and the factors associated with it;

2)To examine methadone injecting procedures;

3)To examine problems associated with the injection of methadone.

2
2.0 METHOD

2.1 Procedure

All respondents were volunteers who were paid A$20 for their participation in the
study. Recruitment took place from January to October of 1995, by means of
advertisements placed in rock magazines, a users group magazine, needle exchanges,
methadone maintenance clinics and by word of mouth.

Respondents contacted the researchers, either by telephone or in person, and were

screened for eligibility to be interviewed for the study. To be eligible for the study
respondents had to either be in treatment for heroin dependence, or have used heroin
during the preceding three months, or both. Those respondents who had injected
methadone were questioned in detail about their experience in doing so (see below).

Each interview was conducted in a location determined by the subject in an attempt to

minimise any hesitation they might have about participating. Consequently, interview
sites ranged from pubs, coffee shops, parks, shopping centres, to respondents' homes
and the researchers' workplace (National Drug & Alcohol Research Centre). All
respondents were guaranteed, both at the time of screening and interview, that any
information they provided would be kept strictly confidential and anonymous. All
interviews were conducted by one of the research team and took between 45 and 60
minutes to complete.

2.2 Structured Interview

A structured interview was constructed that addressed the following areas:

demographic characteristics, drug use history, heroin dependence, health,
psychological functioning, heroin overdose, needle risk behaviours, criminal
behaviours, the initiation of methadone injecting, methadone injecting procedures and
the most recent methadone injection episode. The questionnaire was pilot tested on 10
heroin users, and refinements were made on the basis of this. The areas covered by the
interview are outlined in detail below.

2.2.1 Demographic characteristics

The demographic details obtained included: the respondent's gender, age, suburb of
residence, level of high school and tertiary education, employment status, current form
of drug treatment and prison record.

2.2.2 Drug use history

In order to gain an indication of overall drug use, respondents were asked which drug
classes they had ever used, which ones had they ever injected, and which ones had

3
they injected in the last 6 months. An estimation of how many days they had used each
of the drug classes during the 6 months preceding interview was also sought. Further
questions were asked about the first drug ever injected and how old they were when
they first injected heroin.

2.2.3 Heroin dependence

Current dependence on heroin was measured using the Severity of Dependence Scale
(SDS)13. This is a 5-item scale, with scores ranging from 0-15. Higher scores are
indicative of a higher degree of dependence.

2.2.4 Health

The Health Scale of the Opiate treatment Index (OTI)14 was used to gain some
indication of the respondent's current state of health. This scale is divided into items
addressing signs and symptoms in each of the major organ systems, with one section
specifically focusing on injection-related health problems. The higher the score
obtained, the poorer the overall health of the subject.

Respondents who had injected methadone were also asked about specific health
problems related to the injection of methadone, and whether they had consulted
medical practitioners about these problems.

2.2.5 Psychological functioning

Psychological adjustment was assessed using the 28 item version of the GHQ15. This
scale gives a global measure of non-psychotic psychopathology and is made up of the
following 4 sub-scales: Somatic symptoms, Anxiety, Social dysfunction and
Depression. Global scores range from 0-28, with 4/5 being the most commonly used
cut-off point in determining the number of `cases' of psychopathology in a sample.

2.2.6 Heroin overdose

Respondents were asked how many times they had overdosed, how long since they
had last overdosed and whether they had ever been administered naloxone.

2.2.7 Needle risk behaviours

The HIV Risk-taking Behaviour Scale (HRBS), a component of the OTI was used in
assessing injecting behaviours in the month preceding interview that placed
respondents at risk of either contracting or transmitting blood borne viruses.

2.2.8 Criminal behaviours

4
Using the Criminality Scale of the OTI, a record was taken of any property crimes, drug
dealing, fraud and violent crimes committed during the month preceding interview.
Higher scores on the Criminality Scale denote greater criminal involvement. As in the
OTI, respondents were also asked whether they were currently facing any charges.

2.2.9 Initiation of methadone injecting

Respondents were asked when they had commenced injecting methadone, whether
they were in methadone maintenance at the time, their reason for injecting methadone
and the source of the methadone used for initial injection. The frequency of injecting of
`street' and personal methadone, the use of physeptone, and the availability and cost
of `street' methadone were also recorded.

2.2.10 Methadone injecting procedures

Respondents were asked about the procedures they employed in injecting methadone
syrup. Specifically, the average and maximum amounts of methadone injected, the use
of vein infusion sets ("butterfly clips"), and the size of syringes used to inject
methadone. "Butterfly clips" are the street name for vein infusion sets. A vein infusion
set consists of a needle attached to a length of plastic tube, to which a syringe is
attached. They may be occluded between injections to prevent blood loss through the
inserted needle, and improve stability for the use of larger sized syringes.

2.2.11 Most recent methadone injection episode

Respondents were asked about the details of their most recent injection of methadone.
Specifically, questions included time since last methadone injection, treatment status,
amount injected, ratio of water to methadone, source of methadone, size of syringe,
number of injections, and the use of infusion sets.

2.3 Analyses

For continuous variables t-tests were employed. Categorical variables were analysed
using chi2, and corresponding odds ratios (O.R.) and 95% confidence intervals (C.I.)
were calculated. Where distributions were highly skewed, medians were reported.
Highly skewed continuous data were analysed using the Mann-Whitney U statistic, a
non-parametric analogue of the t-test. In order to determine which factors were
independently associated with the injection of methadone, multiple logistic regressions
were conducted. Backwards elimination of variables was used to select the most
appropriate models. In analyses where "current users" of methadone were compared to
other respondents, current use was defined as use within the six months preceding
interview. All analyses were conducted using SYSTAT16.

5
3.0 RESULTS

3.1 Sample Characteristics

The sample consisted of 312 respondents, recruited from all areas of Sydney (Table 1).
Males constituted 61% of the sample. The mean age of respondents was 28.8 years (SD
6.9, range 16-48), with males being significantly older than females (29.8 yrs v 27.3 yrs,
t310=3.1, p<.005). Approximately half of the respondents were currently enrolled in
treatment for opioid dependence (53%). Females were significantly more likely to be
currently enrolled in treatment (66% v 46%, O.R. 2.4, 95% C.I. 1.5-3.9). Almost all of
those in treatment were currently enrolled in methadone maintenance programmes
(166/168). The mean methadone dose was 64.1 mg (SD 31, range 10-150). The median
length of time enrolled in current treatment was 24 months (range 1-144). Two thirds
(63%) of the sample had previously been enrolled in drug treatment.

The mean years of formal school education was 9.7 (SD 1.5, range 3-12). A fifth (22%) of
respondents had completed a trade or technical course, with 5% having completed a
university or college course. The majority of respondents (80%) were currently
unemployed, with only 4% in full-time employment, and a further 10% in part-
time/casual employment.

Nearly half of respondents (44%) had a regular sexual partner who was an injecting
drug user (IDU), but significantly more females than males had IDU partners (57% v
36%, O.R. 2.4, 95% C.I. 1.5-3.9).

A large proportion of respondents reported having a prison record (45%), with males
significantly more likely than females to report having been imprisoned (55% v 30%,
O.R. 2.8, 95% C.I. 1.7-4.5).

6
Table 1: Demographic characteristics of 312 heroin users

Males Females Persons

N=190 N=122 N=312

Age in years (Mean)# 29.8 27.3 28.8

Employment: (%)

Not employed 83 75 80
Full time 6 1 4
Part time/casual 11 9 10
Student 0 3 1
Home duties 0 12 5
School Education (Mean years) 9.6 9.7 9.7
Tertiary Education: (%)

No tertiary education 75 73 74
Trade/technical 22 21 22
University/college 3 4 4
Trade & college 0 2 1
Currently in treatment (%)# 46 66 53
IDU partner (%)# 36 57 44
Prison record (%)# 55 30 45

# Statistically significant difference between males and females

3.2 Drug use history

The mean age of first injection of any drug was 18.2 (SD 3.9, range 10-35). Heroin was
the first drug injected by only 53% of the sample, with 41% reporting amphetamine as
the first drug injected. The mean age of initiation of heroin use was 18.5 (SD 3.8, range
10-35).

At the time of interview, the mean length of heroin use career was 10.3 years (SD 7.1,
range 0-28). Males had significantly longer heroin using careers than females (11.1 v
9.0, t310=2.6, p<.05).

7
The majority (73%) of those respondents who were currently in treatment had used
heroin in the preceding six months. However, respondents currently in treatment had
used heroin on a median of 6 days, compared to 100 days for the non-treatment
respondents.

Poly-drug use was common among the sample (Table 2). The median number of drug
classes ever used by respondents was 10, a median of 5 having been used in the six
months preceding interview. A median of 4 different drug classes had ever been
injected, with a median of 2 in the six months preceding interview.

The use of opiates other than heroin was common in the preceding six months (40%).
Alcohol (75%) and benzodiazepines (71%), also both central nervous system
depressants, were also widely used. Poly drug use was not restricted to central nervous
system depressants, with significant proportions of respondents having recently used
cannabis (80%), amphetamines (41%), cocaine (26%) and hallucinogens (19%).

8
Table 2: Drug use history of 312 heroin users

Drug Class Ever Ever Used lst 6 Injected Days

Used Injected months lst 6 Used
months lst 6
% months*
% % %

Heroin 100 100 86 85 72

Other Opiates 82 66 40 23 7
Amphetamines 97 90 41 37 4
Cocaine 75 62 26 20 3
Hallucinogens 88 29 19 4 4
Benzodiazepines 94 28 71 13 20
Barbiturates 22 8 1 0 2
Alcohol 99 N/A 75 N/A 14
Cannabis 99 N/A 80 N/A 90
Inhalants 60 N/A 13 N/A 3
Tobacco 98 N/A 94 N/A 180

Poly-drug use 10 4 5 2 -
(mdn no. drugs)

* Median number of days used in the last 6 months by those who had used the drug class in
that period

3.3 Heroin dependence

The mean score on the SDS was 7.9 (SD 4.5, range 0-15). There was no significant
difference in levels of dependence on heroin between males and females (7.7 v 8.2).

3.4 Prevalence of methadone injecting

Table 3 presents the prevalence of methadone syrup injecting among the sample. A
half (52%) of the sample reported having ever injected methadone syrup, with 29%
having injected methadone syrup in the preceding six months. More specifically,

9
`street' methadone (methadone purchased illicitly) had been injected by a third of
respondents (34%), 18% having done so in the six months preceding interview.

Of those respondents who had ever been enrolled in methadone maintenance, 50% had
injected their own prescribed methadone. Almost a third (31%) of respondents
currently enrolled in methadone maintenance had injected their prescribed methadone
in the preceding six months.

Of those who had injected methadone syrup, 47% had also injected physeptone tablets,
a tablet form of methadone hydrochloride.

Table 3: Prevalence of methadone injecting

Males Females Persons

N=190 N=122 N=312

Ever injected 51 53 52
methadone syrup (%)
Injected methadone 30 27 29
syrup in last 6 months
(%)
Ever injected `street' 34 34 34
methadone syrup (%)
Injected `street' 18 17 18
methadone syrup in last
6 months (%)
Ever injected own 53 46 50
prescribed methadone
syrup* (%)
Injected own prescribed 38 25 31
methadone syrup in last
6 months** (%)

* Percentage of those ever in methadone:

Males n=131, Females=94, Persons n=225
** Percentage of respondents currently enrolled in methadone:
Males n=85, Females n=81, Persons n=166

10
3.5 Frequency of methadone injecting

A quarter (26%) of those who had injected methadone syrup reported weekly or
more frequent methadone injecting over their entire methadone injecting careers.
Less than a fifth (17%) reported having injected methadone syrup once only. There
were no differences between genders in lifetime frequency of methadone injecting.

The frequency of methadone injecting in the preceding six months among current
methadone injectors is presented in Table 4. Forty percent of respondents who had
injected methadone in the preceding six months had done so on a weekly or more
frequent basis. The same proportion (40%) reported less than monthly use over that
period. There were no differences between males and females in the frequency of
methadone injecting in the preceding six months.

The median number of days that `street' methadone had been used in the preceding
six months was 4, with 17% of those who had used `street' methadone using it
weekly or more often. Personal prescribed methadone was injected on a median of
18 days in that period, with 50% injecting it weekly or more often.

Table 4: Frequency of methadone injecting among current methadone injectors

in preceding six months

Frequency of methadone Males Females Persons

injecting
N=57 N=33 N=90

Daily (%) 5 6 6

More than weekly (%) 21 30 24

Weekly (%) 11 9 10

Less than weekly (%) 21 18 20

Less than monthly (%) 42 36 40

11
When asked how easy it was to obtain illicit methadone syrup, 87% stated that it was
either easy or very easy to obtain. Respondents who had injected methadone were
asked about the price of illicit methadone syrup. The most common price cited was
50c per milligram (40%), with a further 32% citing $1 per milligram.

12
3.6 Characteristics of methadone injectors

3.6.1 Demographics

Table 5 presents the demographic characteristics of those respondents who had ever
injected methadone and the remainder of the sample. Methadone injectors were
significantly older than other respondents (29.7 yrs v 27.9 yrs, t310=-2.3, p<.05) and
were more likely to have been imprisoned (55% v 34%, OR 2.4, 95% CI 1.5-3.7). There
were no other significant demographic differences between methadone injectors and
other respondents.

Table 5: Demographic characteristics of respondents who had injected

methadone versus those who had not

Injected methadone Never injected

methadone
N=161
N=151
Mean age (yrs)# 29.7 27.9
Sex (% males) 60 62
Education (yrs) 9.5 9.8
Unemployed (%) 81 78
Prison record (%)# 55 34
IDU partner (%) 46 42

# Statistically significant difference between groups

3.6.2 Area of residence

For the purposes of analysis, and the clinical concerns raised about methadone
injecting in western Sydney, respondents' areas of residence were divided into
western Sydney (including south western suburbs), and the remainder. There were
approximately equal proportions of respondents in the two groups, with 53% of
respondents residing in western Sydney, and 47% in other suburbs. There were no
significant differences between western Sydney and other respondents in age (29.5 v
28.0) or the proportions in methadone treatment (58% v 48%). There were, however,
significantly more males in the western Sydney group (67% v 54%, OR 1.8, 95% CI
1.1-2.8).

13
Respondents residing in western Sydney were more likely to have ever injected
methadone (58% v 45%, OR 1.7, 95% CI 1.1-2.6) and to have injected methadone
syrup in the preceding six months (36% v 21%, OR 2.1, 95% CI 1.3-3.5) (Table 6). A
significantly larger proportion of western Sydney respondents reported having
injected methadone syrup on a weekly or more frequent basis over the preceding six
months (14% v 3%, OR 5.3, 95% CI 2.0-14.5).

In order to further explore the differences regional differences in the prevalence of

methadone injecting, the injection of both `street' and personally prescribed
methadone were analysed. There were no significant differences between the two
groups in the proportion of respondents who had ever injected `street' methadone,
or had injected it in the preceding six months. Among those who had ever been
enrolled on methadone maintenance, however, a higher proportion of western
Sydney respondents reported having ever injected personally prescribed methadone
(56% v 41%, OR 1.8, 95% CI 1.04-3.05). Furthermore, among those currently enrolled
in methadone maintenance, a higher proportion of western Sydney respondents had
injected personally prescribed methadone in the preceding six months (43% v 16%,
OR 4.1, 95% CI 1.9-8.9).

It should be noted that the cost of `street' methadone was significantly cheaper in the
western suburbs, with a reported median price of 50c compared to $1 in other
regions of Sydney (U=3263, p<.001).

14
Table 6: Area of residence and methadone injecting

Western Sydney Other regions

N=147 N=165
Ever injected methadone 58 45
syrup (%)#
Injected methadone 36 21
syrup in last 6 months
(%)#
Weekly or more frequent 14 3
methadone injections in
last 6 months (%)#
Ever injected `street' 38 29
methadone syrup (%)
Injected `street' 20 15
methadone syrup in last 6
months (%)
Ever injected own 56 41
prescribed methadone
syrup* (%)#
Injected own prescribed 43 16
methadone syrup in last 6
months** (%)#

# Statistically significant difference between groups

* Percentage of those ever enrolled in methadone maintenance:
Western Sydney n=133, Other regions n=92
** Percentage of respondents currently enrolled in methadone maintenance:
Western Sydney n=95, Other regions n=71

3.6.3 Methadone maintenance

A third (34%) of current methadone clients had injected methadone syrup

(prescribed and/or illicit) in the six months preceding interview. There was no
significant difference in the proportions of male and female clients who had injected
methadone in that period (40% v 28%). Current methadone clients who had injected
methadone in the preceding six months were on significantly higher methadone
doses than other methadone clients (75.0 mg v 58.3 mg, t164=-3.4, p<.005). There was

15
no difference in the time enrolled in current methadone treatment between those
who had injected and other methadone clients, with both groups having been
retained for a median of 24 months.

Of those respondents not currently enrolled in methadone maintenance, 23% had

injected methadone syrup in the preceding six months. As was the case for
methadone clients, there was no significant difference in the proportions of males
and females who had injected methadone in that period (22% v 24%).

Respondents currently enrolled in methadone maintenance were significantly more

likely than those not currently in methadone treatment to have injected methadone
syrup in the preceding six months (34% v 23%, OR 1.8, 95% CI 1.1-3.0).

3.6.4 Drug use history

There was no significant difference between those who had injected methadone
syrup and others in age of first heroin use (18.9 v 18.1). Those respondents who had
ever injected methadone had used a significantly higher median number of drug
classes (10 v 9, U=8870, p<.001) and injected significantly more of drug classes (4 v 3,
U=7190, p<.001) than respondents who had not injected methadone. Current
methadone injectors had used a higher median number of drug classes in the
preceding six months (6 v 5, U=7025, p<.001) and had also injected more drug
classes in that period (2 v 1, U=5612, p<.001).

3.6.5 Heroin dependence

Current injectors of methadone syrup (those who had injected in the preceding six
months) had significantly higher SDS scores than non-injectors (8.7 v 7.6, t310=-2.1,
p<.05), indicating higher levels of current heroin dependence.

3.7 Initiation of methadone injecting

Those respondents who had injected methadone syrup were asked details about the
first injection episode (Table 7). The mean age of respondents at first methadone
injection was 24.5 years (SD 5.5, range 12-42), with females initiating injection at a
significantly younger age (23.2 v 25.3, t159=2.4, p<.05). The mean interval between
first injection of heroin and initial methadone injection was 6.3 years (SD 4.8, range
0-24), with females reporting a significantly shorter interval (5.4 yrs v 7.0 yrs,
t159=2.3, p<.05). Only one subject reported having injected methadone prior to
injecting heroin.

Forty per cent of methadone injectors reported having been enrolled in methadone
maintenance at the time of their first methadone injection.

16
The major sources of methadone at initial injection were friends/partners (54%) and
respondents' own take-away doses (31%). Diversion of a patient's own methadone
dose from the dosing room was rare, with 3% reporting this as the source of
methadone for the initial injection. Only 9% reported obtaining methadone syrup
from a dealer for their initial injection.

The most frequently given reason for initiating methadone injecting was because
respondents were in heroin withdrawal (31%) and could not obtain heroin. Closely
related to this reason was heroin substitution (18%), where respondents used
methadone as a substitute, but were not in withdrawal. Together, these two
circumstances of heroin substitution were given by 49% of respondents as the reason
for initial injection. Experimentation ("wanting to see what it was like") was given by
29% of respondents, while 22% nominated the fact that others were doing it, and
recommended it.

Table 7: Circumstances of initial methadone syrup injection

Males Females Persons

N=97 N=64 N=161

Mean age at initial 25.3 23.2 24.5
injection (yrs)#
Mean interval initial 7.0 5.4 6.3
heroin and methadone
injections (yrs)#
Enrolled in methadone at 37 45 40
time (%)
Source of methadone (%):

Friend/partner
Own take away doses 55 55 54
Own dose (diverted) 30 33 31
Dealer 1 5 3
Other 10 6 9
4 1 3
Reasons for first injecting
methadone (%)*:

In heroin withdrawal

17
 Heroin substitute 28 36 31
Experimentation 22 13 18
Others were doing it 32 23 29
Other reasons 17 30 22
12 15 13

# Statistically significant difference between males and females

* More than one reason could be given

3.8 Methadone injecting procedures

The median amount injected by those who had injected methadone syrup was 50
mg, there being no difference between males and females (Table 8). Nearly a fifth,
however, reported that they used more than 100 mg on an average use day.
Respondents were also asked the most methadone syrup that they had ever injected
in a day. The median reported maximum was 70 mg, with 40% having injected more
than 100 mg in a day. Again, there was no significant gender difference.

Larger sized syringes (10 ml and 20 ml) were the most popular sizes used to inject
methadone syrup, with 46% (10 ml) and 44% (20 ml) of methadone injectors having
used the larger syringes. However, methadone injecting was not restricted to the
larger syringes, with significant proportions of respondents having used 1 ml, 2 ml
and 5 ml syringes to inject methadone.

Infusion sets had been used to inject methadone syrup by 57% of respondents. Those
respondents who had used infusion sets reported using a median of 50 mg of
methadone on an average occasion compared to 30 mg for those who had not used
infusion sets to inject methadone (U=1520, p<.001). They had also reported a
significantly higher maximum amount ever injected in a day (105 mg v 40 mg,
U=1320, p<.001).

The most widely used infusion set was the 25 mg gauge (orange), with nearly half of
methadone injectors having used this gauge. The larger 23 gauge (blue) infusion sets
had been used by a quarter (27%) of methadone injectors to inject methadone. Few
methadone injectors had injected with the 21 gauge (green) infusion sets (3%).

18
Table 8: Methadone syrup injection procedures

Males Females Persons

N=97 N=64 N=161

Amount injected per 50 mg 43 mg 50 mg
average day (Mdn)
Maximum ever 75 mg 68 mg 70 mg
injected in a day
(Mdn)
Size of syringes ever
used (%)*:

1 ml 24 22 23
2 ml 19 14 17
5 ml 26 27 26
10 ml 52 38 46
20 ml 46 39 44
Ever used infusion sets 60 53 57
(%)
Size of infusion sets
ever used (%):

Orange (25 gauge) 46 50 48

Blue (23 gauge) 31 22 27
Green (21 gauge) 3 3 3

* Does not sum to 100% as subjects may have used more than one size of syringe.

3.9 Most recent methadone injection episode

Details of respondents' most recent methadone injection episode are presented in

Table 9. The median time since last injection was 4 months, with 38% of methadone
injectors injected the drug in the month preceding interview, and 54% in the
preceding six months. The majority (60%) were enrolled in a methadone
maintenance program at the time of their most recent methadone injection.

19
The median amount injected at the most recent injection episode was 50 mg, with
15% of methadone injectors having injected more than 100 mg on that occasion. A
median of two injections was used to inject the methadone syrup on that occasion.

The most frequently used syringes on the most recent occasion were 20 ml (37%) and
10 ml (26%) syringes, although over a third (37%) had used smaller sized syringes.

Infusion sets were used by approximately half (48%) of methadone injectors on the
most recent injecting occasion. Orange (25 gauge) infusion sets were used by 36% of
methadone injectors on the most recent occasion, with 12% using the blue (23 gauge)
infusion sets. No respondent reported using the larger 21 gauge green infusion sets.
Respondents who had used infusion sets reported having used a higher median
amount of methadone (52.5 mg v 30 mg, U=1731, p<.001) than those who did not use
infusion sets, and a higher proportion had used 10 ml or 20 ml syringes (90% v 37%,
OR 15.3, 95% CI 6.5-36.1). Nearly a fifth (19%), however, had injected with 10 ml or
20 ml syringes and not used an infusion set.

Respondents were asked about the ratio of methadone syrup to water for their most
recent injection. The most common ratio was equal proportions of methadone and
water (34%). A quarter (25%) of methadone injectors reported that they had injected
undiluted methadone syrup at their most recent injection.

The major sources of methadone for the most recent injection were friends or
partners (48%) and respondents own methadone take-away doses (40%). As was the
case with the initial injection, diversion of the patient's own dose from the dosing
room was rare, with 3% reporting this as the source for their most recent injection.
Only 8% of methadone injectors reported that they had obtained methadone from a
dealer for their most recent injection.

20
Table 9: Circumstances of most recent methadone injection

Males Females Persons

N=97 N=64 N=161

Median time since last injection 2.5 5.3 4
(Mths)
Enrolled in methadone at time 63 55 60
(%)
Median amount injected (Mgs) 50 40 50

Number of injections (Mdn) 1 2 2

Size of syringe used (%):

1 ml 12 20 16
2 ml 6 11 8
5 ml 10 17 13
10 ml 33 16 26
20 ml 38 36 37
Infusion sets used (%) 51 44 48

Size of infusion sets used (%):

Orange (25 gauge) 31 41 36

Blue (23 gauge) 19 3 12
Green (21 gauge) 0 0 0
Ratio methadone/water (%):

100/0 27 22 25
75/25 31 25 29
50/50 33 37 34
25/75 10 16 12
Source of methadone (%):

Friend/partner 43 55 48
Own take away doses 40 39 40
Own dose (diverted) 2 3 3

21
 Dealer 11 3 8
Other 4 0 1

3.10 Correlates of methadone injecting

3.10.1 Health

Current injectors of methadone syrup had significantly higher scores on the OTI health
scale (18.0 v 15.5, t310=-2.4, p<.05) and the injection-related problems sub-scale (1.3 v 0.9,
t310=-3.6, p<.001), indicating poorer current general health and more injection-related
health problems than the rest of the sample (Table 10).

Respondents who had ever injected methadone were significantly more likely to report
having had abscesses and infections from injecting (23% v 11%, OR 2.4, 95% CI 1.3-4.4),
and to have been diagnosed with a thrombosis from injecting (16% v 8%, OR 2.2, 95%
CI 1.1-4.6).

Over a half (55%) of respondents stated that they had experienced difficulties
specifically related to injecting methadone syrup. The most commonly reported
problems were burning/stinging (30%) and collapsed veins (27%).

3.10.2 Heroin overdose

Those respondents who had ever injected methadone were significantly more likely to
report having had a heroin overdose (70% v 52%, OR 2.2, 95% CI 1.4-3.5) and to have
been administered the opioid antagonist naloxone (NARCAN®) than other
respondents (40% v 30%, OR 1.6, 95% CI 1.0-2.6).

Current methadone injectors (those who had injected in the preceding six months)
were more likely to have overdosed within the preceding six months (26% v 14%, OR
2.5, 95% CI 1.4-4.6) and to have been administered naloxone in that period (14% v 6%,
OR 2.5, 95% CI 1.1-5.6) (Table 10).

22
Table 10: Correlates of current methadone injecting

Current methadone Other respondents

injectors
N=90 N=222
Health

OTI Health total# 18.0 15.5

OTI Injecting sub-total# 1.3 0.9

Heroin overdose
(% in last 6 months)

Overdosed# 26 14

Naloxone administered# 14 6
Psychological functioning

GHQ total# 10.2 7.8

"Psychiatric" cases (%)# 67 54

Needle risk
(% in last month)

Borrowed needles 13 10

Lent needles# 28 16
Criminal behaviours
(Last month)

OTI crime total# 2.5 1.3

Any crime (%)# 68 43

# Statistically significant difference between groups

23
3.10.3 Psychological functioning

Current injectors of methadone had significantly higher GHQ total scores than other
non-injectors (10.2 v 7.8, t310=-2.6, p<.01), indicating higher levels of psychological
distress (Table 10). A significantly higher proportion of current injectors had scores
over the diagnostic cut-off for `cases' of psychopathology (67% v 54%, OR= 1.7, 95%
CI 1.0-2.8).

Current injectors had higher scores on the depression (2.3 v 1.6, t310=-2.6, p<.01),
anxiety (3.1 v 2.4, t310=-2.5, p<.05) and social dysfunction (2.4 v 1.8, t310=-2.1, p<.05)
sub-scales. There was no significant difference between groups on the somatic
symptoms sub-scale.

3.10.4 Needle risk behaviours

There were no significant differences in the proportions of current methadone

injectors and other respondents who had borrowed used injecting equipment during
the month preceding interview (13% v 10%). However, current methadone injectors
were significantly more likely to have lent their used injecting equipment in that
period (28% v 16%, OR 2.0, 95% CI 1.1-3.6) (Table 10).

3.10.5 Criminal behaviours

Current methadone injectors had significantly higher OTI crime total scores (2.5 v
1.3, t310=-4.6, p<.001), indicating higher degrees of criminal involvement (Table 10).
Current methadone injectors were more likely to have committed any crime in the
preceding month (68% v 43%, OR=2.8, 95% CI 1.7-4.6), to have committed property
crimes (50% v 27%, OR=2.7, 95% CI 1.6-4.5), to have committed fraud (21% v 6%,
OR=4.3, 95% CI 2.0-9.2) and to have dealt drugs (43% v 28%, OR=1.9, 95% CI 1.2-3.2).

3.11 Predictors of current methadone injecting

In order to determine which demographic factors were independently associated

with having injected methadone syrup in the preceding six months, multiple logistic
regressions were performed. Variables entered into the initial model were age, sex,
area of residence, years of school education and current methadone maintenance
status.

Table 11 presents the final model. Currently being enrolled in methadone

maintenance treatment and residing in the western suburbs were independent
predictors of having injected methadone syrup in the preceding six months. After
controlling for the effects of other variables in the model, residing in the western
suburbs increased the probability of having recently injected methadone syrup by
100%. Similarly, being currently enrolled in methadone treatment increased the odds

24
of having recently injected methadone syrup by 70%. The regression equation was
significant (χ2, 2df= 12.5, p<.005), and had a good fit (Hosmer-Lemeshow χ2=1.4,
p<.25).

Table 11: Multiple logistic regression predicting injection of methadone syrup .... in the prece

Variable O.R. 95% C.I.

Area of residence 2.00 1.20-3.34

Methadone maintenance 1.70 1.02-2.83

status

Hosmer-Lemeshow χ2=1.4, p<.26 (Note: High p-values indicate better goodness of fit)

25
4.0 DISCUSSION

4.1 Major findings of the study

The major finding of this study was the widespread prevalence of methadone syrup
injecting among this sample of Sydney heroin injectors. A half of the sample
reported having injected methadone syrup, with 29% having injected methadone in
the preceding six months. Methadone injecting was evenly represented between the
sexes, with males and females equally likely to report having ever injected
methadone syrup, and to have done so in the six months preceding interview.
Among current methadone injectors, frequent methadone injecting was common,
with 40% reporting weekly or more frequent injecting in the preceding six months.

The second major finding concerned the geographical distribution of methadone

injecting. Methadone injecting was more common in western Sydney, both in
lifetime prevalence and within the preceding six months. Frequent injecting was also
more common in the western suburbs. The relationship between methadone
injecting and the western suburbs remained significant, even after the effects of other
variables had been taken into account. However, while there was a higher
prevalence of methadone injecting in the western suburbs, substantial proportions of
methadone injecting was occurring in other regions. Hence, although methadone
injecting may be more prevalent in the western suburbs of Sydney, it is not restricted
to that region.

4.2 Data validity and representativeness of sample

The findings of this study are derived from data based upon self-reported
behaviour. Although the questions asked often required respondents to talk about
their involvement in various illegal and socially stigmatised activities, efforts were
made to ensure that valid data were obtained. Respondents were given strong
assurances that any information they divulged would be treated as strictly
confidential and anonymous. Other research on illicit drug use has shown that when
respondents are given such guarantees the data obtained are reasonably valid and
reliable17-19. In a recent Australian study on primary heroin users for instance, self-
reported drug use showed respectable validity when assessed against collateral
interviews and urinalysis results14.

In interpreting the results of the current study, it is appropriate to examine how

representative the sample is of heroin users in general. Even though multiple
recruitment methods were used in an attempt to access a broad spectrum of heroin
users, the fact that the sample was self-selected implies that its characteristics should
be borne in mind and care taken when generalising to other samples. At the same
time, it is difficult to conceive how it would be known if a sample of heroin users
was representative, given that the parameters of the population of heroin users are

26
unknown. However, it is important to note that the characteristics of the sample are
in accordance with those reported by other studies of Australian heroin users20,21.

4.3 Prevalence of methadone injecting

The results of this study indicate that the injection of methadone syrup is
widespread among heroin users, both among methadone maintenance clients and
heroin users not in treatment. A half of respondents who had been enrolled in
methadone maintenance had injected their own prescribed doses. A third of the
overall sample had injected illicit `street' methadone. Nor is this an historical
phenomenon. The median time since last injection was 4 months, and 29% of all
respondents had injected methadone in the preceding six months. The injection of
methadone syrup is clearly a widespread, and current, occurrence.

It is important to note that substantial proportions were injecting methadone syrup

frequently. It should be noted that of those who had injected methadone, only 17%
did so on only one occasion. Forty per cent of current injectors had done so on a
weekly or more frequent basis in the six months preceding interview. While daily
methadone injection was rare, a quarter of current injectors injected more than once
a week in that period. Thus, methadone injecting would appear to be both common
and frequent. The frequency data reported in this study are remarkably similar to
those reported by Inciardi8, where 45% of respondents injected methadone on a
weekly or more frequent basis. These data clearly have implications for the
identified harms associated with methadone syrup injecting, discussed below.

Methadone injecting initially occurred on average 6 years after the initiation of

heroin injecting, an identical figure to that reported recently in Lauzon et al9 among
Canadian heroin users. The time lag between heroin and methadone injecting in the
current study was significantly shorter for females, where the time lag was 18
months shorter than for males. The main reason given for initiation of methadone
injection was being in heroin withdrawal. It is relevant to note that methadone
injectors in the current study had significantly higher levels of heroin dependence
than other respondents. However, substantial proportions of respondents reported
that initial use was due to experimentation, and to the fact that others they knew
were doing it.

4.4 Methadone injecting procedures

Methadone injectors were injecting substantial amounts of methadone. The median

amount injected on the most recent injection occasion was 50 mg, with a median of
two injections required to inject the methadone. Fifteen per cent of injectors reported
having injected more than 100 mg on that occasion. In their methadone injecting
careers, 40% of injectors had injected more than 100 mg in a day. There were no
gender differences in the amount of methadone that respondents were injecting.

27
As expected, 10 ml and 20 ml syringes were most commonly used to inject
methadone syrup. However, all sizes of syringes had been used to inject methadone
syrup. Infusion sets had been used by a half of injectors at their most recent injection.
Injectors who used infusion sets injected significantly more methadone than other
methadone injectors. The most common infusion set used was the 25 gauge set.
Substantial numbers of injectors, however, had used the larger 23 gauge infusion
sets. While these larger gauge needles would facilitate the injection of a viscous
fluid, repeated use of larger gauge needles may result in a greater degree of vascular
damage.

At the most recent methadone injection, a quarter of injectors did not dilute the
methadone syrup prior to injection. Only 12% diluted the syrup with more water
than methadone. The data indicate that injectors are injecting a viscous liquid, rather
than a substantially diluted solution of reduced viscosity.

4.5 Methadone maintenance and methadone injecting

The results of this study show a clear link between enrolment in methadone
maintenance and the probability of injecting methadone syrup. This link was
independent of area of residence and other factors related to injecting methadone. A
half of respondents who had ever been enrolled in methadone maintenance had
injected their own doses and almost a third of currently enrolled clients had done so
in the preceding six months.

Those current methadone clients who had injected methadone syrup (either
prescribed or illicit) in the six months prior to interview, were on significantly higher
doses than other clients. This finding is consistent with the higher levels of heroin
dependence among methadone injectors.

The current data raise questions about policies on the provision of take-away
methadone doses. Given the large proportions of methadone clients and others
injecting take-away methadone doses, caution appears warranted in the provision of
take-away doses. It should be noted that the data for this study was collected prior to
a change in NSW Health Department policy governing take-away doses, which
restricted the eligibility of clients for take-away doses. The effects of these changes
are unknown, and clearly require evaluation.

The current data should not be taken as an indication of the failure of methadone
maintenance. As noted previously, methadone maintenance is associated with
reductions in harms such as HIV and overdose risk. However, it is clear that the
delivery system of methadone needs reappraisal.

4.6 Area of residence and methadone injecting

28
The data from this study confirm the perception of treatment providers that
methadone syrup injecting is widespread in the western suburbs of Sydney.
Methadone injecting was more common and more frequent in western Sydney than
in other regions. As noted above, the relationship between methadone injecting and
the western suburbs remained significant, even after the effects of other variables
had been taken into account. It is worth noting that illicit methadone syrup was
cheaper in the western suburbs, possibly reflecting its greater availability.

However, it cannot be concluded from this study that methadone syrup injecting is a
problem restricted to a particular region. Nearly a half (45%) of respondents from
other regions had injected methadone, 21% within the preceding six months. The
current data indicate that while methadone syrup injecting is more widespread in
the western suburbs, it is a problem throughout the Sydney region.

4.7 Sources of methadone for injecting

The two most common sources for obtaining methadone for injection were
friends/partners or respondents' own prescribed take-away doses. This was true
both for initial methadone injection and the most recent methadone injection. Buying
methadone from a dealer was rare, with less than 10% reporting doing so for their
last methadone injection. The illicit supply of methadone to those not currently in
methadone treatment would thus appear to be an informal black market revolving
around friends, rather than one organised by dealers. Illicit methadone was
considered easy to obtain. As noted above, the quoted average price of methadone
was 50c per milligram in the western suburbs, and $1 in the other regions of Sydney.
The cost for the average amount of methadone used at the last injecting episode (50
mg) would thus vary between $25 and $50.

4.8 Harms associated with methadone injecting

There were clear harms associated with methadone syrup injecting. Current
methadone injectors were in poorer general health than other respondents, and had
more symptoms related to injecting. A history of methadone injecting was associated
with abscesses and infections in injection sites, and having been diagnosed with a
venous thrombosis. Those with a history of methadone injecting were, in fact, over
twice as likely to have experienced a thrombosis. The results of this study indicate
that, like the injection of benzodiazepines, the injection of methadone can have
serious consequences for vascular health.

There was also a clear relationship between methadone injecting and opioid
overdose. Those with a history of methadone injecting were over twice as likely to
have overdosed, and one and a half times as likely to have been administered
naloxone for an overdose. This relationship is further illustrated by examining

29
current methadone injectors and recent overdose. Current injectors were more likely
to have overdosed in the preceding six months and to have been administered
naloxone in that period. Injection of methadone syrup would appear to be a risk
factor for overdose, in addition to the concomitant use of alcohol and
benzodiazepines that have been reported elsewhere20.

In addition to poorer physical health, current methadone injectors showed higher

levels of current psychological distress. These respondents had higher general levels
of distress, higher levels of depression and anxiety, and were more likely to meet the
criterion for a psychiatric "case" requiring attention than their peers who were not
currently injecting methadone.

Interestingly, current methadone injecting was not associated with an increased risk
of having borrowed used injecting equipment. However, current methadone
injectors were more likely to have passed on their used equipment. On a social
level, current methadone injecting was associated with higher prevalence and
frequency of recent criminal behaviours.

4.9 Implications

The results of the present study raise questions about ways in which to reduce the
harms associated with methadone syrup injecting. Based upon these results, one of
the issues that requires attention is policy on the provision of take-away methadone
doses. Take-away doses were the largest source of methadone for injecting in the
current study.

One possible intervention to reduce the prevalence of methadone injecting may be to

expand the volume of take away doses. Currently the ratio of milligrams to
millilitres is five to one. A dose of 50 mgs of methadone is thus equivalent to 10 mls
of liquid. If this ratio was raised substantially, the practicality of injecting methadone
syrup may be reduced, as the volume needed for intoxication may become too large
to inject. It is suggested that if volume expansion is adopted that water be used as
the diluting agent (rather than orange juice) to reduce the harm associated with the
preparation if it was injected, and to make the preparation less appealing to children
if stored at home.

Given the high prevalence of methadone syrup injecting, education on the harmful
effects of this practice would appear warranted. While education alone cannot be
expected to substantially reduce the harms of methadone injecting, a knowledge of
the potential harms would provide a basis for behaviour change, as has occurred
among injecting drug users in relation to HIV risk-taking. Such education should be
aimed at both treatment and non-treatment heroin users. Given the larger
proportions of methadone injectors in the western suburbs of Sydney, this region

30
would appear to be a priority in the provision of information on the potential health
effects of methadone injection.

4.10 Conclusions

In summary, the current study indicates that the injection of methadone syrup is a
widespread phenomenon throughout the Sydney region, among both heroin users
enrolled in methadone treatment and other heroin users. As anecdotal evidence had
suggested, the practice was more common in the western suburbs of Sydney. The
current study has documented specific harms associated with methadone injecting,
that are occurring among Sydney heroin users. It is clear that the prevalence of
methadone injecting, and its associated harms, constitute a problem that needs
urgent attention from methadone prescribers and policy makers.

31
5.0 REFERENCES

1. WARD, J., MATTICK, R. & HALL, W. (1992) Key Issues in Methadone Maintenance
Treatment (Sydney, University of New South Wales Press).

2. ZADOR, D., SUNJIC, S. & DARKE, S. (1995) Toxicological findings and

circumstances of heroin caused deaths in New South Wales, 1992. Medical
Journal of Australia, (In press).

3. TORRES, M., MATTICK, R., CHEN, R. & BAILLIE, A. (1995) Clients of treatment
service agencies. March 1995 census findings. Canberra: Australian Government
Publishing Service.

4. SCOTT, R.N., GOING, J., WOODBURN, K.R., GILMOUR, D.G., REID, D.B.,
LEIBERMAN, D.P. et al. (1992) Intra-arterial temazepam. British Medical
Journal, 304, 1630.

5. VELLA, E.J. & EDWARDS, C.W. (1993) Death from pulmonary microembolism
after intravenous injection of temazepam. British Medical Journal, 307, 26.

6. JENSON, S. & GREGERSON, M. (1991) fatal poisoning with intravenously injected

methadone and no fresh injection marks found. International Journal of Legal
Medicine, 104, 299-301.

7. GAUGHWIN, M., GOWANS, E., ALI, R. & BURRELL, C. (1991) Bloody needles:
The volumes of blood transferred in simulations of needlestick injuries and
shared use of syringes for injection of intravenous drugs. AIDS, 5, 1025-1027.

8. INCIARDI, J.A. (1977) Methadone Diversion: Experiences and Issues. National

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