Elsevier

Drug and Alcohol Dependence

Volume 179, 1 October 2017, Pages 291-298
Drug and Alcohol Dependence

Full length article
Trends in heroin and pharmaceutical opioid overdose deaths in Australia

https://doi.org/10.1016/j.drugalcdep.2017.07.018Get rights and content

Highlights

  • Increases in pharmaceutical opioid (PO) deaths, largely driven by accidental overdose.

  • PO deaths 2.5 times the incident rate of heroin deaths in 2012.

  • PO deaths more likely among males than females.

  • Fentanyl deaths per 100,000 Oral Morphine Equivalent (OME) grams increased, from a comparatively low rate.

  • Heroin deaths declining in 15–24 year olds, increasing in 35–54 year olds.

Abstract

Background

There has been international concern over the rise in fatal pharmaceutical opioid overdose rates, driven by increased opioid analgesic prescribing. The current study aimed to examine trends in opioid overdose deaths by: 1) opioid type (heroin and pharmaceutical opioids); and 2) age, gender, and intent of the death assigned by the coroner.

Methods

Analysis of data from the National Coronial Information System (NCIS) of opioid overdose deaths occurring between 2001 and 2012.

Results

Deaths occurred predominantly (98%) among Australians aged 15–74 years. Approximately two-thirds of the decedents (68%) were male. The heroin overdose death rate remains unchanged over the period; these were more likely to occur among males. Pharmaceutical opioid overdose deaths increased during the study period (from 21.9 per million population in 2001–36.2), and in 2012 they occurred at 2.5 times the incident rate of heroin overdose deaths. Increases in pharmaceutical opioid deaths were largely driven by accidental overdoses. They were more likely to occur among males than females, and highest among Australians aged 45–54 years. Rates of fentanyl deaths in particular showed an increase over the study period (from a very small number at the beginning of the period) but in 2012 rates of morphine deaths were higher than those for oxycodone, fentanyl and tramadol.

Conclusions

Given the increase in rates of pharmaceutical opioid overdose deaths, it is imperative to implement strategies to reduce pharmaceutical opioid-related mortality, including more restrictive prescribing practices and increasing access to treatment for opioid dependence.

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.

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