Full length articleTrends in heroin and pharmaceutical opioid overdose deaths in Australia
Introduction
Research has found that among illicit drugs the opioids make the largest contribution to the global burden of disease (Degenhardt et al., 2013). This is largely because of the substantial contribution that opioids make to premature mortality from fatal opioid overdoses, liver and cardiovascular disease, motor vehicle accidents, homicide and assault (Degenhardt et al., 2011).
In the United States and parts of Canada, the type of opioid predominantly involved in overdose deaths shifted from heroin in the 1990s to pharmaceutical opioids by 2002 (Paulozzi et al., 2006; Fischer and Rehm, 2011; Fischer et al., 2012; Rudd et al., 2016). Several factors have driven this trend. Firstly, pharmaceutical opioid prescribing has increased dramatically in both the United States and Canada (Bohnert et al., 2011, Valenstein et al., 2011Bohnert et al., 2011, Valenstein et al., 2011; Fischer and Rehm, 2011). Second, pharmaceutical opioid use has increased among people who use illicit drugs, with North American data showing that pharmaceutical opioid use among this group had surpassed that of heroin (Fischer and Keates, 2012, Fischer et al., 2013).
There has been an almost four-fold increase in pharmaceutical opioid utilisation in Australia between 1990 and 2014 (Karanges et al., 2016). In 2013, codeine, oxycodone, and buprenorphine were the most commonly sold opioids (Degenhardt et al., 2016). Non-medical use of analgesics has increased over time, predominantly among Australians aged 30–49 years (Australian, 2014). Non-medical use of pharmaceutical opioids among people who inject drugs constitutes a minority of opioid use (ranging from 10% for fentanyl to 27% for morphine). Heroin continues to dominate as the opioid of choice (46%) and the opioid most prevalently injected (56%) (Stafford and Breen, 2016). Research among Australians prescribed pharmaceutical opioids for chronic non-cancer pain shows that significant minorities of this population meet criteria for lifetime (8.5%) and past year (4.7%) pharmaceutical opioid dependence, and that the consumption of higher doses is associated with higher odds of opioid dependence (Campbell et al., 2015). In addition, those consuming higher doses had considerably more complex profiles with respect to physical and mental health, and greater social disadvantage. These findings together indicate the emergence of problematic use of pharmaceutical opioids in Australia, and a broader public health burden with respect to reduced functioning and markers for increased risk of opioid overdose (Campbell et al., 2015). This paper examines fatal overdoses related to opioids within Australia. Given that heroin continues to be the predominant opioid used among people who inject drugs in Australia, the paper compares rates of fatal heroin and fatal pharmaceutical opioid overdose.
This paper documents trends in heroin and pharmaceutical opioid overdose deaths in Australia during the period 2001–2012. In particular, it examines differences in heroin and pharmaceutical opioid overdose deaths with respect to age, gender, and whether the death was assigned as intentional or accidental by the coroner.
- 1)
To examine trends in opioid overdose deaths for the period 2001–2012, attributable to heroin and pharmaceutical opioids;.
- 2)
To examine trends in rates of pharmaceutical opioid overdose deaths per 100,000 Oral Morphine Equivalent (OME) grams dispensed each year; and.
- 3)
To examine trends in opioid overdose deaths by age, gender and intention (accidental, intentional, or not determined).
Section snippets
National coronial information system
We extracted data on opioid overdose deaths from the National Coronial Information System. This is an online database that records all deaths referred to the coroner. Deaths are referred to a coroner in Australia where they are unexpected, due to an accident or injury, or the person died in an unnatural way. The NCIS includes records of deaths that occur in hospital following an overdose. Drug related deaths are defined as being an unnatural cause of death. The data contain results of
Results
There were a total of 8547 opioid overdose deaths identified during the period 2001–2012 among Australians aged 15–74 years. Approximately one-third (34% − n = 2895) were categorised as heroin overdose deaths. In 9% (n = 277) of heroin deaths, the presence of a pharmaceutical opioid (predominantly methadone) was also recorded. Just over half (58% n = 4963) of all deaths were categorised as pharmaceutical opioid overdose deaths, and the remaining 8% (n = 689) were categorised as heroin/morphine overdose
Discussion
Rates of pharmaceutical opioid overdose deaths increased in Australia by approximately 1.6 times the rate recorded in 2001 (21.87 per million) to 36.27 in 2012. These deaths were more likely to occur among males than females, and among Australians aged 45–54 years. Despite the higher prevalence of pharmaceutical opioid overdose deaths among males, the increase in rates of these deaths was slightly higher among females (6% each year) than males (5% each year) over the period. Rates of heroin
Conclusions
There have been marked increases in rates of pharmaceutical opioid overdose deaths in Australia between 2001 and 2012, and these increases are largely being driven by accidental overdose. Death rates due to pharmaceutical opioid overdose were higher among males than females, but increases were slightly higher among females over the eleven year period. Pharmaceutical opioid overdose deaths were significantly higher than heroin deaths during the entire study period. Rates of fentanyl deaths per
Conflict of interest
SP is a member of the Drug Utilisation Sub-Committee of the Australian Pharmaceutical Benefits Advisory Committee (PBAC). The views presented are those of the authors and do not reflect those of the PBAC. LD has received untied educational grants from Reckitt Benckiser/Indivior for post-marketing surveillance of buprenorphine-naloxone tablets and film in the treatment of opioid dependence in Australia, development of an opioid-related behaviour scale, and a study examining opioid substitution
Role of funding source
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. NG and LD are supported by NHMRC research fellowships (#1091878 and #1041472). The National Drug and Alcohol Research Centre is funded by the Australian Government Department of Health.
Contributors
AR developed the idea for the manuscript in discussion with LD and WH, conducted analyses and drafted the manuscript for comment. WH provided comment on successive drafts of the manuscript. TD provided direction and expertise on statistical analysis, as well as providing comment on successive drafts of the manuscript. NG analysed PBAC data to inform the deaths data and provided comment on successive drafts. SP provided PBAC data to allow for analysis of deaths in the context of opioid
Acknowledgements
The authors would like to acknowledge Ms Emily Karanges for providing assistance with Drug Utilisation Sub-Committee data access as well as expertise on what this data contains.
References. (42)
- et al.
Use of and barriers to access to opioid analgesics: a worldwide, regional, and national study
Lancet
(2016) - et al.
National trends in pharmaceutical opioid related overdose deaths compared to other substance related overdose deaths: 1999–2009
Drug Alcohol Depend.
(2013) - et al.
Global burden of disease attributable to illicit drug use and dependence: findings from the Global Burden of Disease Study 2010
Lancet
(2013) - et al.
Abrupt decline in oxycodone-caused mortality after implementation of Florida’s Prescription Drug Monitoring Program
Drug Alcohol Depend.
(2015) - et al.
‘Opioid drought’, canadian-style? potential implications of the ‘natural experiment’ of delisting oxycontin in Canada
Int. J. Drug Policy
(2012) - et al.
Pilot of a brief, web-based educational intervention targeting safe storage and disposal of prescription opioids
Addict. Behav.
(2013) - Australian Bureau of Statistics (2012). Estimated Resident Population by Single Year of Age, Australia [data file]....
Australian Institute of Health and Welfare, 2014. National Drug Strategy Household Survey Detailed Report 2013
(2014)- et al.
Association between opioid prescribing patterns and opioid overdose-related Deaths
JAMA
(2011) - et al.
The utility of medico-legal databases for public health research: a systematic review of peer-reviewed publications using the National Coronial Information System
Health Res. Policy Syst.
(2016)
Pharmaceutical opioid use and dependence among people living with chronic pain: associations Observed within the Pain and Opioids in Treatment (POINT) Cohort
Pain Med.
The analysis of count data: a gentle introduction to poisson regression and its alternatives
J. Pers. Assess.
The ratio of non-fatal to fatal overdose
Addiction
Trends in opioid analgesic abuse and mortality in the United States
N. Engl J. Med.
Monograph No.10: Data Sources on Illicit Drug Use and Harm in Australia DPMP Monograph Series
Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta-analysis of cohort studies
Addiction
The extent and correlates of community-based pharmaceutical opioid utilisation in Australia
Pharmacoepidemiol. Drug Saf.
Opioid Analgesics Overview. Public Release Report; DUSC Meeting
European Drug Report 2016: Trends and Developments
Prescription Opioids Misuse, Harms and Control in Canada: A Research and Policy Issues Brief for the Department of Justice
Trends and changes in prescription opioid analgesic dispensing in Canada 2005–2012: An update with a focus on recent interventions
BMC Health Serv. Res.
Cited by (134)
Association of tramadol use with risk of hip fractures in patients with osteoarthritis: A systematic review and meta-analysis of observational studies
2024, International Journal of Orthopaedic and Trauma NursingPharmacological data science perspective on fatal incidents of morphine treatment
2023, Pharmacology and TherapeuticsCitation Excerpt :A similar picture emerges from other studies (Visconti, Santos, Lemos, Burke, & Coffin, 2015), such as a study of 331 people who died from accidental opioid overdose in San Francisco between 2010 and 2012. 331 people died from accidental opioid overdose, 310 of which were prescription opioids (26.9% morphine) and 31 of which were heroin (Roxburgh et al., 2017). In Australia, morphine was made responsible for more deaths than oxycodone, fentanyl, and tramadol, with the prescription opioid overdose mortality rate in 2012 being 36.2 per million population (Roxburgh et al., 2017).
Twenty-year trends in pharmaceutical fentanyl and illicit fentanyl deaths, Australia 2001–2021
2022, International Journal of Drug PolicyCitation Excerpt :The comparatively high toxicity of illicitly manufactured fentanyl relative to pharmaceutical fentanyl and heroin Suzuki and El-Haddad (2017) has exacerbated increases in opioid mortality rates across both countries. In contrast, Australian research documenting increases in fentanyl deaths between 2001 and 2012 (Roxburgh et al., 2013) showed deaths were attributable to pharmaceutical fentanyl and were largely occurring among people who inject drugs. Fentanyl has been readily available through prescription for chronic non-cancer pain since 2006 in Australia, with lower strength transdermal patches (12mcg/hr, 25mcg/hr and 25 mcg/hr) being the most commonly dispensed formulations (Rahman et al., 2022).
Acute Opioid Withdrawal Following Intramuscular Administration of Naloxone 1.6 mg: A Prospective Out-Of-Hospital Series
2022, Annals of Emergency MedicineCitation Excerpt :This study had some limitations, the major one being the predominance of heroin in the study, which may not translate to areas where the primary opioid of concern has a much longer half-life, such as methadone, is more potent like fentanyl, or where the primary opioid is oxycodone. Heroin is the main illicit opioid in Australia, although there is increasing misuse of prescription opioids.16,17 Australia has not yet experienced a rise in high-potency opioids such as fentanyl that has been seen in North America in recent years.