Illicit opioids, including heroin

Opioids refer to a class of drugs that are naturally or synthetically derived from the opium poppy plant (ACIC 2019; NSW Ministry of Health 2017). Diacetylmorphine, commonly known as heroin, is a derivative of morphine, an alkaloid contained in raw opium (ACIC 2020).

This section focuses on the harms, availability and consumption of illicit opioids including heroin, as distinct from pharmaceutical opioids such as morphine, methadone and oxycodone. See the section on the non-medical use of pharmaceutical drugs for recent trends and data in relation to the use and harms for pharmaceutical opioids.

Key findings

View the Illicit opioid (heroin) in Australia fact sheet >

Availability

The availability of heroin in Australia has fluctuated over time. In the early 2000s, there was a rapid and considerable reduction in the availability of heroin in Australia (commonly referred to as the heroin shortage or drought) and this was associated with dramatic reductions in heroin-related overdoses (Degenhardt et al. 2004).

Since then, the availability of heroin has steadily increased. Prior to COVID-19 in 2020, the Illicit Drug Reporting System (IDRS) showed no significant changes in the perceived availability, pricing and purity of heroin in Australia, as reported by people who inject illicit drugs (Peacock et al. 2019). This suggests that the Australian heroin market was highly stable (Table S2.11). In 2020, the price of heroin remained relatively stable compared to other years. However, there were some changes in the perceived purity and availability of heroin. More specifically, in 2020:

  • There was a significant reduction in the proportion of people who believed heroin was ‘very easy’ to obtain (35%, compared to 54% in 2019).
  • A higher proportion of people perceived heroin as being ‘difficult’ to obtain (19%, compared to 9% in 2019).
  • Over 2 in 5 (44%) participants believed the purity of heroin was ‘low’, an increase from 27% in 2019 (Peacock et al. 2021).

Notably, IDRS interviews were conducted from June–September 2020, after COVID-19 restrictions were introduced in Australia (Peacock et al. 2021). This should be taken into account when comparing these data with previous years.

The number of heroin detections at the Australian border has fluctuated over the past decade, with the long-term trend remaining relatively stable. The number of heroin detections at the Australian border has decreased 26% over the last decade, from 250 in 2009–10 to 184 in 2018–19. However, the weight of heroin detected has increased 141% over the same period, from 117.5 kilograms in 2009–10 to 283.4 kilograms in 2018–19. There has also been an increase in both the number and weight of national heroin seizures over the past decade. Between 2009–10 and 2018–19 the number of national heroin seizures increased 32% from 1,582 up to 2,080, while the weight of heroin seized increased 165% from 74.7 kilograms to 197.7 kilograms (ACIC 2020).

Consumption

The National Drug Strategy Household Survey (NDSHS) shows that heroin use among the general population has remained low in Australia between 2001 (0.2%) and 2019 (less than 0.1%) (Figure HEROIN1). However, between 2016 and 2019, more people reported heroin to be the drug of most concern to the community (7.5% compared with 8.5%) and thought it caused the most deaths (10.6% compared with 11.9%) (tables S2.37 and S2.70; AIHW 2020).

Figure HEROIN1: Lifetimeᵃ and recentᵇ use of heroin, people aged 14 and over, 2001 to 2019 (per cent)

This figure shows the proportion of lifetime and recent use of heroin for people aged 14 and over between 2001 and 2019. In 2019, only 0.1% of people aged 14 and over reported using heroin in the last 12 months and this has remained stable since 2001. Lifetime use of heroin has been decreasing since 2007, from 1.6% to 1.2% of people aged 14 and over.

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Geographic trends

The National Wastewater Drug Monitoring Program (NWDMP) indicates that heroin consumption in Australia is relatively low, but has increased over time. The estimated weight of heroin consumed has steadily increased from 750 kilograms in 2017–18 to 1,021 kilograms in 2019–20 (ACIC 2021; Figure HEROIN2). In 2020, the estimated population-weighted average consumption of heroin reached its highest level since the program commenced, both in regional areas (April 2020) and capital city sites (August 2020) (ACIC 2021).

Data from the most recent NWDMP reports show that nationally:

  • In December 2020, the estimated population-weighted average consumption of heroin was higher in capital cities than regional areas.
  • In both regional areas and capital cities, heroin consumption reached record high levels in August 2020, before decreasing from August to December 2020 (ACIC 2021a, 2021b).
  • Heroin consumption reported a further decrease between December 2020 and February 2021 in capital cities (ACIC 2021b).

Between August 2019 and August 2020, heroin consumption increased in both regional areas and capital cities (ACIC 2021a).

For state and territory data, see the National Wastewater Drug Monitoring Program reports.

Figure HEROIN2: Estimated consumption of heroin in Australia based on detections in wastewater, 2019 to 2020

This infographic shows that Australians consumed an estimated 1,021 kilograms of heroin in 2019–20. Heroin consumption is typically higher in capital cities than regional areas. Between August 2019 and August 2020, average consumption of heroin increased in Major cities and Regional areas.

(a) “Average consumption” refers to estimated population-weighted average consumption.

Notes:

1. Data in Report 12 are from 56 wastewater treatment sites, covering approximately 56% of the Australian population in 2020.

2. Heroin data for August 2016 are not available.

Source: AIHW. Adapted from NWDMP Report 12.

Poly drug use

Heroin

Poly drug use is defined as the use of more than 1 illicit drug or licit drug in the previous 12 months. The 2019 NDSHS showed that cannabis (86%) was the most common substance used concurrently with heroin. Other drugs commonly used were tobacco (79%), pharmaceuticals (66%) and alcohol (65% exceeded the single occasion risk guideline at least monthly) (Table S2.68).

Data on alcohol and other drug-related ambulance attendances are sourced from the National Ambulance Surveillance System for Alcohol and Other Drug Misuse and Overdose. Data for 2020 are currently available for New South Wales, Victoria, Queensland and the Australian Capital Territory. Data are presented for 4 snapshot months per year, specifically March, June, September and December. Please see the data quality statement for further information.

In 2020, multiple drugs were consumed in at least 3 in 10 heroin-related ambulance attendances, ranging from 30% in Victoria to 40% in Queensland (Table S2.81).

Harms

For related content on illicit opioid (including heroin) impacts and harms, see also:

Heroin is a central nervous system depressant. Like other opioids, it binds to receptors in the brain, sending signals to block pain and slow breathing.

Heroin may be snorted, swallowed or smoked, but is most commonly melted from a powder or rock form and injected. Injection comes with a range of additional harms associated with the unsanitary sharing of injecting equipment, such as the transmission of blood borne viruses like Hepatitis C and HIV (Table HEROIN1).

Table HEROIN1: Short and long-term effects of heroin use

Short-term effects

Long-term effects

  • Analgesia
  • Cough suppressant
  • Euphoria
  • Dry mouth
  • Heavy feeling in hands and feet
  • Nausea and vomiting
  • Severe itch
  • Drowsiness
  • Respiratory depression resulting in fatal and non-fatal overdose, especially when used in conjunction with other sedative substances including benzodiazepines and alcohol
  • Severe constipation
  • Tooth decay (from lack of saliva)
  • Irregular menstrual periods in females
  • Impotence in males
  • Loss of appetite and weight
  • Neurochemical changes in the brain
  • Memory impairment
  • Mental health issues including depression
  • Physical dependence and associated withdrawal, which manifest as flu-like symptoms

Source: Adapted from ACIC 2019a; Nielsen & Gisev 2017; NSW Ministry of Health 2017.

Burden of disease and injury

The Australian Burden of Disease Study 2018 – Key findings report was released in August 2021. Full results from the Study, including more detailed reports, methods and interactive data visualisations, are planned for release in November 2021.

The Australian Burden of Disease Study, 2015, found that opioid use was responsible for 1.0% of the total burden of disease and injuries in Australia in 2015 and 37% of the total burden due to illicit drug use (Table S2.69).

Most of the burden due to opioid use was due to 2 linked diseases: poisoning and drug use disorders (excluding alcohol). Poisoning contributed to 20%, and drug use disorders (excluding alcohol) to 31%, of the total burden due to opioid use. A further 2.9% of the burden due to opioid use was attributable to suicide and self-inflicted injuries (AIHW 2019a).

Ambulance attendances

Data on alcohol and other drug-related ambulance attendances are sourced from the National Ambulance Surveillance System for Alcohol and Other Drug Misuse and Overdose.

In 2020, for heroin-related ambulance attendances:

  • The rate of attendances ranged from 3.6 per 100,000 population in Queensland to 16.5 per 100,000 population in the Australian Capital Territory.
  • The majority of attendances were for males, ranging from 62% of attendances in the Australian Capital Territory to 73% of attendances in Victoria.
  • The median age of patients was similar across jurisdictions—39 years in New South Wales and the Australian Capital Territory and 40 years in Victoria and Queensland.
  • Heroin-related attendances where multiple drugs (excluding alcohol) were present ranged from 30% of attendances in Victoria to 40% of attendances in Queensland (Table S2.81).

The characteristics of heroin-related ambulance attendances varied by region in 2020:

  • Higher rates of attendances were reported in metropolitan areas than in regional areas in New South Wales (7.8 per 100,000 population and 3.3, respectively), Victoria (15.4 per 100,000 population and 5.3, respectively) and Queensland (5.7 per 100,000 population and 1.7, respectively).
  • A higher proportion of attendances were transported to hospital in metropolitan areas than in regional areas for New South Wales (70% and 59% respectively).
  • Higher proportions of attendances were transported to hospital in regional areas in Victoria (66% regional and 56% metropolitan) and Queensland (84% regional and 79% metropolitan).
  • In the Australian Capital Territory (metropolitan only), 44% of attendances were transported to hospital (Table S2.81).

Hospitalisations

Opioid poisoning can result in significant harm, including respiratory failure, aspiration, hypothermia and death.

In 2018–19, drug-related hospitalisations with a principal diagnosis of opioid poisoning were more likely to involve pharmaceutical opioids than heroin.

  • Nearly half (46%) were due to natural and semi-synthetic opioids, 16% to synthetic opioids and methadone accounted for 7%.
  • Heroin accounted for 1 in 4 (25%) (Man et al. 2021).

The age-standardised rate of hospitalisations due to heroin poisoning increased from 3.2 per 100,000 in 2017–18 to 4.1 in 2018–19. Over the same period, the rate of hospitalisations due to natural and semi-synthetic opioids decreased from 8.1 to 7 per 100,000 population (Man et al. 2021).

Deaths

Drug-induced deaths are defined as those that can be directly attributable to drug use, as determined by toxicology and pathology reports (ABS 2017).

People who use heroin have a particularly high risk of overdose, especially when heroin is used in conjunction with other drugs like benzodiazepines (for example, alprazolam, diazepam) and alcohol. However, there are some challenges in interpreting the numbers of heroin deaths. Heroin can be difficult to identify at toxicology because it is rapidly metabolised to morphine by the body and these metabolites cannot be distinguished from other morphine sources (for example, codeine).

Opioids, including both licit and illicit substances, have been the leading class of drug present in drug-induced deaths in Australia for the last 2 decades. While illicit opioids include opium as well as heroin, most illicit opioid deaths involve heroin—99.5% of drug-induced deaths involving an illicit opioid in 2019 (Chrzanowska et al. 2021).

Of the 1,865 drug-induced deaths in Australia in 2019, 474 or 25% were due to heroin—the highest number of deaths attributed to heroin since 1997 (Table S1.1a). The rate of deaths involving heroin has overall declined since the late 1990s, when heroin consumption was at its peak in Australia (Degenhardt, Day & Hall 2004). However, deaths involving heroin have increased from 1.0 per 100,000 people in 2010 to 1.9 in 2019. Between 2017 and 2019, the rate has remained steady at 1.9 per 100,000 population (Figure HEROIN3; Table S1.1a).

In 2018, deaths with heroin identified had a median age at death of 41.2 years, lower than for pharmaceutical opioids (median 46.6 years) (ABS 2019).

Figure HEROIN3: Number or age-standardised rate (per 100,000 population) of drug-induced deathsᵃ for all opioids and heroin only, 1997 to 2019

The figure shows that the number of drug-induced deaths due to all opioids and heroin only steadily increased from 2006 to 2017. The number of deaths due to all opioids has decreased from 1,373 in 2017 to 1,129 in 2019, while the number of deaths due to heroin has increased from 444 to 474 in the same period.

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Treatment

The Alcohol and Other Drug Treatment Services National Minimum Data Set (AODTS NMDS) provides information on treatment provided to clients by publicly funded AOD treatment services, including government and non-government organisations. Data from the AODTS NMDS showed that heroin was the 4th most common principal drug of concern in closed treatment episodes provided to clients in 2019–20 (Figure HEROIN4). Heroin was the principal drug of concern in 5.1% of closed treatment episodes provided for clients’ own drug use—a similar proportion to 2018–19 (5.2%) (Table S2.76). In over three-quarters (78%) of these episodes, the method of use was injecting (AIHW 2021a).

In 2019–20, where heroin was the principal drug of concern:

  • Most (70%) clients were male and around 1 in 6 (18%) were Indigenous Australians (tables S2.77 and S2.78).
  • Over two-thirds of clients were aged 30–39 (38% of clients) or 40–49 (32%) (AIHW 2021a).
  • The most common source of referral was self or family (43% of closed treatment episodes), followed by a health service (32%) (Table S2.79).
  • Counselling was the most common main treatment type (24% of closed treatment episodes), followed by assessment only (19%) and support and case management (15%) (Table S2.80).

Figure HEROIN4: Treatment provided for own use of heroin, 2019–20 (per cent)

This infographic shows that heroin was the principal drug of concern in 5%25 of closed treatment episodes provided for clients’ own drug use in 2019–20. Around 1 in 6 clients were Indigenous Australians. The most common main treatment type provided to clients for their own heroin use was counselling (1 in 4 episodes).

Source: AIHW. Supplementary tables S2.76, S2.78 and S2.80.

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Treatment agencies whose sole function is prescribing or providing dosing services for opioid pharmacotherapy are excluded from the AODTS NMDS. Due to the multi-faceted nature of service delivery in this sector, these data are captured in the National Opioid Pharmacotherapy Statistics Annual Data (NOPSAD) collection.

NOPSAD data showed that nationally in 2020, 37% of clients reported heroin as their opioid drug of dependence. However, this data should be used with caution due to the high proportion of clients with ‘not stated/not reported’ as their drug of dependence in New South Wales (64%), Victoria (33%) and Tasmania (19%) (AIHW 2021b).

Further information on pharmacotherapy in Australia >

At-risk groups

  • Indigenous Australians are overrepresented in treatment services for heroin as the principal drug of concern. 
  • Heroin is commonly injected and so its use is overrepresented among people who inject drugs.