Many more Indigenous people than non-Indigenous people use injecting drugs. Disadvantage in areas such as education, employment and income contribute to the greater use of illicit drugs.
Injecting drug use refers to the use of a needle to administer a drug; the drug may be administered intravenously (via a vein), intramuscularly (directly into a muscle), or subcutaneously (just under the skin). Injecting drug use became possible in the late 19th century with the development of the hypodermic needle. The most commonly injected illicit drugs are opiates (heroin), amphetamines (speed) and cocaine .
In addition to bacterial diseases and tissue damage, injection carries with it an increased risk of addiction (drugs are absorbed rapidly when administered by injection and the more rapidly a drug is absorbed the greater the risk of addiction), an increased risk of contracting blood borne viruses (BBV), and the risk of overdose .
In 2005, there were 410 deaths involving illegal drugs; opioids (such as heroin) accounted for the largest number of deaths (374), followed by amphetamines (26) and cocaine (10)  . National data on mortality among Indigenous people are not available , but data collated by the Health Department of Western Australia found that the deaths of 26 Indigenous males and 14 Indigenous females in 1990-99 had been attributed to the use of drugs other than alcohol or tobacco (age-standardised rates were 11.1 and 5.9 per 100,000 population respectively) . These death rates are similar to those for the total Australian population in 1999: 14 per 100,000 population for males and 5 per 100,000 for females .
In Australia in 2005-06, 8,389 people attended hospital for reasons relating to illegal drug use. The main drugs involved were heroin, amphetamine, cannabis and cocaine .
The only detailed information about hospitalisation as a result of illicit drug use among Indigenous people was compiled as a part of reporting against the Aboriginal and Torres Strait Islander health performance framework . Hospitalisation rates for drug-related causes were generally higher for Indigenous people than for non-Indigenous people living in Queensland, Western Australia, South Australia and the Northern Territory in July 2002 to June 2004 (comprising about 60% of the total Indigenous population), particularly for mental/behavioural disorders relating to use of cannabinoids (4.8 times the non-Indigenous rate), and multiple drugs and psychoactive substances (3.0 times the non-Indigenous rate).
A concerning proportion of Indigenous users of amphetamines and opiates inject their drugs, with a high level of users sharing needles . Findings from a South Australian study on Indigenous injecting drug users found that the people who regularly shared needles (12% of the surveyed participants) were more likely to be dependent, heavy polydrug users and frequent users of amphetamines . These findings have implications for the spread of blood-borne viruses such as Hepatitis C and HIV/AIDS.
Although poor reporting systems make it difficult to determine the rate of viral infection among Indigenous drug users , the ‘HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia, Annual Surveillance Report 2007’ found that in the most recent five-year period (2002-2006), the rate of hepatitis C diagnosis increased in both the Indigenous and non-Indigenous population in the Northern Territory (in contrast with a decreasing trend nationally), but was lower in the Indigenous population. The rate of newly diagnosed hepatitis C infection in the Indigenous population of Western Australia and South Australia was between two and three times, and five and 10 times higher respectively than that in the non-Indigenous population . This is likely to be a significant underestimation given that as recently as 2005 Indigenous status was not recorded for 65% of new Hepatitis C notifications .
Similarly, despite the equivalency in HIV infection rates between Indigenous and non-Indigenous Australians, Indigenous Australians are more likely than non-Indigenous Australians to contract HIV infection through the use of shared needles. In the most recent five-year period (2002-2006), the ‘HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia, Annual Surveillance Report 2007’ reveals a three-fold increase in the proportion of HIV infections attributed to injecting drug use among Indigenous Australians since the 2000 report (18% compared with 6%), while the non-Indigenous rate has remained unchanged at 3%  .
The National Drug and Alcohol Research Centre (NDARC), in their report ‘Findings from the Illicit Drug Reporting System’ (IDRS), found that 56% of participants using heroin and other opioids in 2007 had overdosed at some point in their lifetime. For participants who used amphetamines, 6% reported overdosing at some point in their lifetime . In 2005, 46% of injecting drug users surveyed in Australia had overdosed at some point in their lifetime .
In 2001, a Western Australian study of 74 Indigenous people who inject drugs found that 24% of participants had overdosed at some time . The authors note that these findings contrast with the findings of Larson (1996), where 52% of Indigenous heroin users had personally experienced overdose, however the lower overdose rate in the Western Australian study was attributed to a lesser use of heroin . In 2002, a South Australian study of Indigenous injecting drug users found that 21% had overdosed after injecting, and in contrast to the Western Australian study, 97% of participants had used heroin in the last six months . These figures suggest the overdose rate for Indigenous injecting drug users is variable; being less than or equal to that of the general Australian injecting drug user population. The concern for Indigenous injecting drug users relates to the stigma and shame of injecting drug use and the associated increased risks of overdose when injecting alone to conceal drug use from family and friends .
The National Drug Strategy (developed by the Ministerial Council on Drug Strategy (MCDS)) is an umbrella framework which seeks to reduce the harmful effects of drugs and drug use through a series of national action plans addressing tobacco, alcohol, school-based drug education and illicit drugs .
Since 1985 Australia’s drug strategy has embraced the principle of harm minimisation to reduce drug-related harm. Harm minimisation refers to the policies and strategies of supply reduction, demand reduction and harm reduction which seek to reduce drug-related harm by improving the health, social, and economic outcomes for both the individual and the community .
Supply reduction strategies seek to reduce the production and supply of illicit drugs and to control and regulate licit drugs .
Research by Loxley and colleagues (2004) showed limited evidence for supply reduction strategies and highlighted the need for much more research into those strategies in use .
Those law enforcement strategies aimed at reducing demand among users which showed evidence for implementation included :
Demand reduction strategies seek to reduce demand for substances and include strategies aimed at preventing the uptake of harmful drug use as well as strategies aimed at reducing drug use .
Strategies include addressing the broader social determinants of health as well as health sector specific strategies focussing on education and information on the risks associated with drug use .
Harm reduction strategies seek to reduce drug-related harm for individuals and communities while not necessarily reducing drug use .
Loxley and colleagues (2004) noted the programs with the strongest evidential support for harm reduction were needle and syringe distribution to reduce the spread of blood-borne viruses, the use of methadone for opiate dependence to reduce the risk of overdose and blood-borne viruses, and hepatitis B vaccinations .
In 2005-06, the Drug and Alcohol Service Reporting found that 27% of services used harm reduction interventions (such as information about safe using practices) in relation to substance use, and approximately 1,170 Indigenous clients received sobering up/residential respite involving 5,220 episodes of care . In terms of injecting drug users, in 2003-04, 30 ACCHSs (22%) operated needle exchange programs .
According to recent population surveys (2004-2005 National Aboriginal and Torres Strait Islander Health Survey (NATSIHS); 2007 National Drug Strategy Household Survey (NDSHS)) the overall level of illicit drug use in the previous 12 months among the Indigenous population aged 15 years or older living in non-remote areas (28%) was more than twice the level of the general Australian population aged 14 years or older (13%) (Figure 1)  . The higher level of drug use applied across all drug types. Amphetamines were the most commonly used drug after cannabis  .
Figure 1 Proportions of illicit drug use in the previous 12 months for the Indigenous and general Australian populations, by drug type, Australia, selected years
Sources: 2004-2005 NATSIHS 2007 NDSHS 
Note: Proportions are for: (1) Indigenous people aged 15 years or older living in non-remote areas; and (2) general Australian population aged 14 years or older
The overall level of illicit drug use in the previous 12 months by Indigenous people aged 15 years or older living in non-remote areas was 4.7% higher in 2004-2005 than in 2002 (Figure 2) . This change reflects a 20% increase in the number of Indigenous people using illicit drugs in this 2-3 year period. The increase in cannabis use (18%) was around the same as the overall increase, but the increase in amphetamine use was much greater (46%) .
Figure 2 Changes in proportions of Indigenous people using illicit drugs, by drug type, Australia, 2002 and 2004-2005
Sources: 2002 NATSISS ; 2004-2005 NATSIHS
Note: Proportions are for Indigenous people aged 15 years or older living in non-remote areas
Emerging evidence supports a preference among Indigenous injecting drug users for amphetamines over heroin; this is most likely a reflection of the longer lasting euphoric effects of amphetamine and its economic affordability in comparison to heroin . With evidence that amphetamine use is increasing among Indigenous people there are fears that non-Indigenous suppliers will use the existing, largely Indigenous, cannabis networks in rural and remote communities for the flow of amphetamines .