Alcohol, tobacco & other drugs in Australia

In Australia, pharmaceutical drugs are available via a prescription from a registered healthcare professional or over-the-counter (OTC) from a pharmacy, and are widely used to prevent, treat and cure injury and illness. When used appropriately, pharmaceutical drugs are associated with considerable reductions in morbidity and mortality and are an important pillar of public health. However, pharmaceutical drugs are subject to misuse (see Box PHARMS1 for more information).

Pharmaceutical non-medical use refers to the consumption of a prescription or over-the-counter drug for non-therapeutic purposes or other than directed by a registered healthcare professional (Larance et al. 2011). People may misuse pharmaceutical drugs for a range of reasons including to induce euphoria, to enhance the effects of alcohol and other drugs, to self-medicate illness or injury, to mitigate the symptoms of withdrawal from alcohol and other drugs, or to improve performance.

The non-medical use of pharmaceutical drugs is an ongoing concern internationally, with different pharmaceutical opioids being misused in different regions (UNODC 2020). The use of opioids in Australia and New Zealand also remains much higher than the global average (3.3 per cent of the adult population), with the non-medical use of pharmaceutical opioids being the most commonly used opioid (UNODC 2020).

Dramatic increases in opioid-related deaths associated with rising use in the US have led to the problem being declared an 'epidemic' (CDC 2017; U.S. Department of Health & Human Services 2017). In the US in 2018, an estimated 9.9 million people aged 12 and older misused prescription pain relievers at least once in the past year—representing 3.6% of the population (SAMHSA 2019).

Availability

Data from the Pharmaceutical Benefits Scheme (PBS) indicates that there has been an increase in the prescribing of pharmaceutical opioids in Australia (AIHW 2018).

• The number of prescriptions dispensed for opioids rose between 2012–13 and 2016–17 from 13.08 million, a rate of 57,522 per 100,000 population, to 15.42 million, a rate of 63,429 per 100,000 population (Figure PHARMS1). This represents an 11% rise in the rate of opioid prescriptions dispensed over this period.
• Oxycodone was the most commonly dispensed opioid, with 5.7 million prescriptions dispensed (a rate of 23,515 prescriptions dispensed per 100,000 population), followed by codeine (3.7 million prescriptions, or a rate of 15,216 prescriptions dispensed per 100,000 population) and tramadol (2.7 million prescriptions, or a rate of 11,147 prescriptions dispensed per 100,000 population) (tables S2.7 and S2.8).

Analysis of 2010–11 to 2014–15 PBS data indicates that there had been a decrease in the prescribing on benzodiazepines:

• In 2014–15, about 4.86 million prescriptions were dispensed for benzodiazepines, a rate of 19,911 per 100,000 population. Between 2010–11 and 2014–15, the number of prescriptions dispensed for benzodiazepines remained relatively stable, but the rate fell from 21,800 per 100,000 population.
• In 2014–15, more than one-third (37%) of dispensed benzodiazepine prescriptions were for diazepam (1.81 million prescriptions). Since 2010–11, diazepam has been the only form of benzodiazepine for which the number (up 14%) and rate of prescriptions dispensed rose substantially (from 6,950 to 7,440 per 100,000 population) (AIHW 2017) (tables S2.9 and S2.10).

PBS data from 2017–18 show that the most commonly prescribed benzodiazepine continues to be diazepam with just under 1.7 million prescriptions in 2017–18 (DoH 2019).

The Australian Criminal Intelligence Commission’s (ACIC) Illicit Drug Data Report includes data on prescription pharmaceutical detections at the Australian border (ACIC 2020a). The importation of prescription pharmaceuticals is primarily undertaken by individuals for personal use and without criminal intent (ACIC 2020a).

The number of pharmaceutical detections reported at the Australian border only reflect detections of benzodiazepines and opioids (including morphine, buprenorphine, methadone and oxycodone) (ACIC 2020a). In 2018–19 there were a total of 1,156 pharmaceutical detections, an increase of 98% since 2009–10 (585 detections) (ACIC 2020a). The majority (79%) of these detections were for benzodiazepines (912 in 2018–19). However, though they remain the minority of overall pharmaceutical detections, there has been an 8,033% increase in the number of pharmaceutical opioid detections over the past decade (3 in 2009-10, increasing to a record high of 244 in 2018–19) (ACIC 2020a).

Consumption

Data from the 2019 NDSHS showed that:

• nearly 1 in 25 (4.2%) Australians aged 14 and over had used a pharmaceutical for non-medical purposes in the previous 12 months (Table S2.32)
• 1 in 9 (11.7%) Australians aged 14 and over had used a pharmaceutical for non-medical purposes in their lifetime (Table S2.31)
• 1 in 5 (21%) used pharmaceutical drugs daily or weekly for non-medical purposes
• pharmaceutical pain-killers/pain-relievers and opioids (excluding over-the-counter) are the most common pharmaceuticals used for non-medical purposes (2.7%), followed by tranquilisers/sleeping pills (1.8%) (table S2.32; AIHW 2020b).

Between 2016 and 2019, there was a significant decrease in the use of pharmaceuticals for non-medical purposes (from 4.8% to 4.2%) (Table S2.32). This was driven by a decrease in the use of pain-killers/pain-relievers and opioids (excluding over-the-counter) (from 3.6% to 2.7%)—in particular, the proportion of people using codeine for non-medical reasons halved in this period (decreasing from 3.0% in 2016 to 1.5% in 2019) (AIHW 2020b). This aligns with restrictions to codeine being introduced in 2018 (see Policy context: Restricting access to codeine).

The 2019 NDSHS showed that people who use pharmaceutical drugs for non-medical purposes were older than people who use illicit drugs (excluding pharmaceuticals) (median ages of 40.7 and 30.7 years, respectively). However, the recent non-medical use of pharmaceuticals was most common among those aged 20–29 (6.4%) (Figure PHARMS2; AIHW 2020b).

Data from the 2019 NDSHS showed that a higher proportion of Australians aged 14 and over approved the regular adult non-medical use of prescription pain-killers/pain-relievers (12.4%) and tranquilisers/sleeping pills (9.3%) than all illicit drugs except for cannabis (19.6%). However, support for the non-medical use of pharmaceuticals was lower than approval for the use of tobacco (15.4%) and alcohol (45%) (AIHW 2020a).

Geographic trends

Findings from the 2019 NDSHS (AIHW 2020b) showed:

• the significant decrease between 2016 and 2019 in the use of pain-killers/pain-relievers and opioids (excluding over-the-counter) for non-medical purposes that was observed at the national level also occurred in Victoria (from 3.4% to 2.6%), Queensland (from 4.1% to 2.7%), South Australia (from 4.3% to 2.9%) and the Northern Territory (from 4.2% to 1.9%; note, the 2019 estimate for the Northern Territory has a relative standard error of 25% to 50% and should be used with caution). As noted previously, these decreases align with restrictions to codeine being introduced in 2018 (see Policy context: Restricting access to codeine)
• there was a significant increase in the proportion of people living in Victoria who had recently used tranquillisers/sleeping pills for non-medical purposes (from 1.7% in 2016 to 2.4% in 2019)
• between 2016 and 2019, there were significant decreases in the use of pain-killers/pain-relievers and opioids (excluding over-the-counter) for non-medical purposes in Major cities (from 3.3% to 2.6%) and Inner regional areas (from 3.6% to 2.5%) (Table S2.12)
• people living in Remote and very remote areas were about 1.5 times as likely as those from Major cities to have recently used pain-killers/pain-relievers and opioids (excluding over-the-counter) for non-medical purposes in 2019 (4.1% compared with 2.6%)
• the proportion of people who recently used pharmaceuticals for non-medical purposes was similar for those living in Major cities (4.3%) and Remote and very remote areas (4.8%) (Figure PHARMS3). Note, the estimates for Remote and very remote areas have a relative standard error of 25% to 50% and should be used with caution. These findings were still apparent after adjusting for differences in age (AIHW 2020b)
• between 2016 and 2019, there were significant decreases in the non-medical use of pain-killers/pain-relievers and opioids (excluding over-the-counter) for people living in both the most disadvantaged (from 4.8% to 3.0%) and the most advantaged (from 2.6% to 1.8%) socioeconomic areas (Table S2.13). This is consistent with findings at the national level and aligns with restrictions to codeine being introduced in 2018 (see Policy context: Restricting access to codeine)
• people living in the most disadvantaged socioeconomic areas were 1.6 times as likely as those from the most advantaged socioeconomic areas to have used pain-killers/opiates for non-medical purposes (3.0% compared with 1.8%). Conversely, people living in the most advantaged areas were twice as likely as those from the most disadvantaged socioeconomic areas to have recently used tranquilisers for non-medical purposes (2.6% compared with 1.2%) (Table S2.13). These findings were still apparent after adjusting for differences in age (AIHW 2020b)
• there was a significant decrease in the non-medical use of pharmaceuticals for people living in the most disadvantaged socioeconomic areas (from 6.0% in 2016 to 4.0% in 2019). This resulted in the proportion in 2019 being similar to that for people in the most advantaged socioeconomic areas, even after adjusting for differences in age (Table S2.13; AIHW 2020b).

The National Wastewater Drug Monitoring Program (NWDMP) data indicate the population-weighted average consumption of fentanyl and oxycodone decreased in both capital city and regional sites when comparing December 2019 and April 2020 data. Average fentanyl and oxycodone consumption was higher in regional sites than capital city sites. Overall, consumption of fentanyl and oxycodone has decreased considerably since December 2018. Notably, wastewater analysis cannot differentiate between prescribed and illicit use (ACIC 2020b).

Harms

There are a range of short and long-term health, social and economic harms associated with the misuse of pharmaceutical drugs (Table PHARMS1). People who use opioids for chronic pain are more likely than the general population to use pharmaceutical drugs for non-medical purposes (Currow, Phillips & Clark 2016; Vowels et al. 2015). Iatrogenic dependence occurs when patients become dependent on medications that they were medically prescribed for legitimate purposes. Iatrogenic dependence is an increasing concern among people living with chronic non-cancer pain.

Source: Adapted from Currow, Phillips & Clark 2016; DCPC 2007; Nicholas, Lee & Roche 2011; NSW Ministry of Health 2017.

Hospitalisations

A hospital separation is a completed episode of admitted hospital care ending with discharge, death, transfer, or a portion of a hospital stay. The AIHW’s National Hospital Morbidity Database (NHMD) showed that, in 2018–19, of all separations with a drug-related principal diagnosis:

• benzodiazepines and other sedatives and hypnotics (including barbiturates; excluding ethanol) accounted for 6.8% of all drug-related separations.
• 11% were for analgesics, with opioids (heroin, opium, morphine and methadone) accounting for half of this group (6.2% of all drug-related separations) (Table S1.8a).

Between 2014–15 and 2018–19, benzodiazepines and other sedatives and hypnotics (excluding alcohol) continued to result in more drug-related hospital separations than opioids. However, hospital separations for benzodiazepines have decreased in the past two years, falling from 6,361 separations in 2016–17 to 5,204 separations in 2018–19 (Table S1.8b).

In 2018–19, hospital separation rates (per 100,000 population) for benzodiazepines and other sedatives and hypnotics were 1.5 and 2.1 times higher, respectively, for people living in Major cities compared with Remote and very remote areas. Hospital separation rates (per 100,000 population) for opioids were 1.6 times higher for people residing in Major cities compared with Remote and very remote areas in 2018–19.

The rate of drug-related hospital separations for non-opioid analgesics was 1.7 times higher for people usually residing in Remote and very remote areas compared with those in Major cities (45.3 per 100,000 population compared with 26.0 per 100,000 population). The rate decreased between 2017–18 and 2018–19 in all regions, with the exception of Remote and very remote areas where the rate increased from 36.8 separations per 100,000 population to 45.3 per 100,000 population (Table S1.8c; AIHW unpublished).

Ambulance attendances

Data on alcohol and other drug-related ambulance attendances are sourced from the National Surveillance System for Alcohol and Other Drug Misuse and Overdose report. Data for 2019 are available for New South Wales, Victoria, Tasmania 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.

The rate of benzodiazepine-related attendances ranged from 14.2 per 100,000 population in Tasmania to 24.0 per 100,000 population in Victoria. The rates of attendances were higher for metropolitan areas (when compared to regional areas) for New South Wales, Victoria and Tasmania.

The majority of benzodiazepine-related attendances were for females, while the majority of opioid analgesic-related attendances in New South Wales and Tasmania were for males. The median age of benzodiazepine-attendances was similar across jurisdictions (35 to 38 years), however for opioid analgesic-related attendances, the median age ranged from 34 years in the Australian Capital Territory to 46 years in Tasmania.

Higher rates for benzodiazepine-related ambulance attendances were reported in metropolitan areas for New South Wales (17.4 per 100,000 population compared with 12.1 for regional areas), Victoria (24.3 per 100,000 population compared with 23.2 for regional areas) and Tasmania (Greater Hobart 19.8 per 100,000 population compared with 9.9 for regional areas).

Similar proportions of benzodiazepine-related attendances were transported to hospital in metropolitan and regional areas for New South Wales (90% and 91%, respectively), Victoria (90% and 92%, respectively) and Tasmania (~89% and ~83%, respectively) (Table S2.81) (Moayeri et al. 2020).

Deaths

Of the 1,740 drug induced deaths in 2018, the most common substance present was a benzodiazepine (51%)—this is consistent with findings from previous years (Figure PHARMS4). Between 2009 and 2018, the number of deaths where benzodiazepines were present rose by 70% (from 518 to 883 deaths) (Table S1.1).

It is important to note that benzodiazepines may not have been recorded as the underlying cause of death, as they often occur in the context of polysubstance use. Analysis by the National Drug and Alcohol Research Centre (NDARC) found that in 693 deaths in which opioids were deemed to be the underlying cause of death, benzodiazepines were recorded as contributing to the death (Man et al. 2019). In 2018, in over 97% of drug-induced deaths where benzodiazepines were present, they were taken in conjunction with other drugs, including alcohol (AIHW unpublished).

Over the past decade, drug-induced deaths were more likely to be due to prescription drugs than illegal drugs, and there has been a substantial rise in the number of deaths with a prescription drug present. For synthetic opioids (including fentanyl and tramadol) in particular, the rate has increased from 0.1 per 100,000 (32 deaths) in 2009 to 1.0 per 100,000 (241 deaths) in 2018 (Table S1.1).

NDARC reported that in 2018, there were 655 (60%) deaths attributed to pharmaceutical opioids only, 322 (30%) to illicit opioids only (such as heroin and opium) and 108 (10%) deaths to both pharmaceutical opioids and illicit opioids (Man et al. 2019). This is consistent with the findings from the ABS that indicated that pharmaceutical opioids and prescription opioids were present in over 70% of opioid-induced deaths in 2018 (ABS 2019a). Pharmaceutical opioids were also the most common opioid present in suicide overdose (ABS 2019a).

The rate of drug-induced deaths involving benzodiazepines was similar in Major cities and Regional and remote areas in 2018 (Table S2.71). However, the rate of drug-induced deaths involving prescription opioids was higher in Regional and remote areas than in Major cities for natural and semi-synthetic opioids (2.3 deaths per 100,000 population compared with 1.8 per 100,000 population) and synthetic opioids (1.3 deaths per 100,000 population in Regional and remote areas, compared with 0.9 deaths per 100,000 population in Major cities) (Table S2.71).

Treatment

Data collected as part of the 2018–19 Alcohol and Other Drug Treatment Services National Minimum Data Set (AODTS NMDS) showed that:

• Pharmaceuticals were the principal drug of concern for a client’s own drug use in 4.7% of closed treatment episodes (Table S2.76; Figure PHARMS5).
• Client demographics where pharmaceuticals were the principal drug of concern:
  • Almost two-thirds (61%) of clients were male (Table S2.77) and around 1 in 10 were Indigenous (12.6%) (Table S2.78).
  • In 2018–19, a higher proportion of female clients (55%) reported codeine as their principal drug of concern, males were more likely than females to report other sedatives and hypnotics as their principal drug of concern (59%) (Table S2.77).
• Source of referral for treatment:
  • Almost half of the referrals for treatment where pharmaceuticals were the principal drug of concern were for self/family (44% of treatment episodes), followed by a health service (41%) (Table S2.79).
• Treatment type:
  • The most common main treatment type where pharmaceuticals were the principal drug of concern was counselling (27% of episodes) followed by assessment only (21%) (AIHW 2020a) (Table S2.80).

At-risk groups

The available evidence indicates that the misuse of pharmaceuticals among vulnerable populations is at substantially higher levels than in the general population.

The non-medical use of pharmaceuticals was higher for Aboriginal and Torres Strait Islander people than for non-Indigenous Australians. For further information, see Illicit drugs in the Aboriginal and Torres Strait Islander people section.

People with a mental health condition were twice as likely to report the non-medical use of pharmaceuticals than people who had not been diagnosed or treated for a mental health condition. See also: Illicit drugs in the People with mental health conditions section.

People who inject drugs consume pharmaceutical drugs, particularly prescription opioids, at higher rates than the general population and may substitute illicit drugs for pharmaceutical drugs depending on availability. See also: Illicit drugs in the People who inject drugs section.

Policy context

Real-time prescription monitoring

In July 2017, the Australian Government announced $16 million in funding to implement a national real-time monitoring system of prescription drugs. The system will provide an instant alert to pharmacists and doctors if patients are receiving multiple supplies of prescription only medicines (also referred to as ‘doctor or pharmacy shopping’). The program will initially include the monitoring of controlled medicines that are particularly susceptible to misuse including morphine, oxycodone, dexamphetamine and alprazolam. The system aims to assist doctors and pharmacists to identify patients who are at risk of harm due to dependency, misuse or abuse of pharmaceutical drugs and patients that are diverting these medicines.

Restricting access to codeine

As of 1 February 2018, medicines containing codeine were reclassified to schedule 4 drugs, meaning they could no longer be sold over-the-counter in pharmacies and were available by prescription only. This decision was made by the Therapeutic Goods Administration (TGA) following substantial evidence of harm from the abuse and misuse of low dose codeine-containing medicines including analgesic preparations combined with other pain relief medicines such as aspirin, paracetamol and ibuprofen (TGA 2018). The scheduling change may account for some of the reductions observed in the 2019 NDSHS in the non-medical use of pain-killers and opioids since 2016 (AIHW 2020b).

Resources and further information

• National Drug Strategy Household Survey 2019, Australian Institute of Health and Welfare.
• Opioid harm in Australia: and comparisons between Australia and Canada, Australian Institute of Health and Welfare.
• Non-medical use of pharmaceuticals: trends, harms and treatment, Australian Institute of Health and Welfare.
• National Real Time Prescription Monitoring (RTPM).
• Up-scheduling of codeine.