Prevalence and correlates of simultaneous, multiple substance injection (co-injection) among people who inject drugs in Melbourne, Australia

Anna Palmer, Peter Higgs, Nick Scott, Paul Agius, Lisa Maher, Paul Dietze

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10 Citations (Scopus)


Aims: To estimate the prevalence of and risk factors associated with concurrent injection of multiple substances (co-injection) among a community-recruited cohort of people who inject drugs. Design: Cross-sectional study. Setting: Melbourne, Australia. Participants: A sample of 720 actively injecting participants from the Melbourne Injecting Drug User Cohort Study (33% female) was extracted. Measurements: We constructed two statistical models: a logistic regression model analysing correlates of co-injection of any substance combination in the past month and a multinomial logistic regression model analysing correlates of three mutually exclusive groups: heroin–diphenhydramine co-injection only, co-injection of other substances and no co-injection. Risk factors examined included drug use characteristics, demographic characteristics, health service use, hepatitis C status, injection risk behaviours and previous experience of non-fatal overdose. Findings: One-third [n = 226, 31%; 95% confidence interval (CI): 28–34%] of participants reported co-injecting substances within the past month, with equal numbers of participants reporting injecting combinations of heroin–diphenhydramine (n = 121, 54%; 95% CI = 48–60%) and heroin–methamphetamine (n = 121, 54%; 95% CI = 48–60%). In logistic regression analyses, reporting co-injection of any substance combination was associated with male sex [adjusted odds ratio (aOR) = 1.80, 95% CI = 1.18–2.74, P = 0.006] and injecting daily or more frequently (aOR = 2.04, 95% CI = 1.31–3.18, P = 0.002). In multinomial logistic regression analyses, participants reporting heroin–diphenhydramine co-injection only were significantly more likely to report groin injecting [adjusted relative risk ratio (aRRR) = 6.16, 95% CI = 2.80–13.56, P < 0.001] and overdose (requiring an ambulance) in the past 12 months (aRRR = 2.81, 95% CI = 1.17–6.72, P = 0.021) compared with participants reporting no co-injection or co-injection of other substances. Conclusions: A substantial proportion of people who inject drugs report co-injection of multiple substances, which is associated with a range of socio-demographic, drug use and health service use risk factors.

Original languageEnglish
Pages (from-to)876-888
Number of pages13
Issue number4
Publication statusPublished - Apr 2021


  • Co-injection
  • diphenhydramine
  • methamphetamine
  • opioids
  • overdose
  • polydrug use

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