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.

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). Common pharmaceuticals used for non-medical purposes in Australia include opioids and benzodiazepines (see Box PHARMS1 for more information). 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.

Key findings

View the Non-medical use of pharmaceutical drugs in Australia fact sheet >

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

Opioids

Data from the Pharmaceutical Benefits Scheme (PBS) indicate that approximately 15.2 million opioid prescriptions were dispensed to 3.1 million patients in 2019–20 (Figure PHARMS1; Tables S2.7a and S2.8a). Oxycodone was the most commonly dispensed opioid (5.2 million prescriptions dispensed), but more patients were dispensed codeine (1.7 million patients) than oxycodone (1.2 million). This suggests that there was a higher number of PBS prescriptions dispensed per patient for oxycodone than codeine.

Between 2012–13 and 2015–16, there was an increase in the age-standardised rate of opioid prescriptions dispensed (from 53,801 per 100,000 to 58,485) and the rate of patients who received a PBS supply of an opioid (from 12,126 per 100,000 to 12,686). This trend then reversed, decreasing to 53,427 scripts dispensed per 100,000 and 11,480 patients per 100,000 in 2019–20.

• Oxycodone and codeine had the highest rate of prescriptions dispensed and patients per 100,000 across the period.
• The rate of prescriptions dispensed was lower in 2019–20 than 2012–13 for all opioids, with some exceptions:
  • The rate of oxycodone prescriptions dispensed declined from 21,325 per 100,000 population in 2016–17 to 18,132 in 2019–20, but remained higher than in 2012–13 (16,364 per 100,000).
  • The rate of tapentadol prescriptions dispensed has steadily risen from 8 per 100,000 population in 2013–14 to 3,730 per 100,000 in 2019–20.
  • The rate of patients who were dispensed tapentadol also increased, from 6 per 100,000 in 2013–14 to 839 in 2019–20 (Figure PHARMS1; Tables S2.7b and S2.8b).

Dispensing of prescription opioids may have been affected by recent policy changes. Please refer to the Policy context section for more information.

Benzodiazepines

PBS data indicate that dispensing of prescription benzodiazepines is also common. In 2019–20, approximately 5.5 million benzodiazepine prescriptions were dispensed to 1.5 million patients (Figure PHARMS1; Tables S2.7a and S2.8a). Diazepam was the most common benzodiazepine dispensed in 2019–20 (2.5 million prescriptions dispensed), and there were also more patients who received a PBS supply of diazepam than for other benzodiazepines (787,000 patients).

Between 2012–13 and 2019–20, there was a steady decrease in the age-standardised rate of benzodiazepine prescriptions dispensed (from 26,496 per 100,000 in 2012–13 to 19,533 in 2019–20) and the rate of patients who were dispensed a benzodiazepine (from 6,480 per 100,000 in 2012–13 to 5,573 in 2019–20). However, dispensing varied across benzodiazepine drugs over time.

• Diazepam and temazepam had the highest rate of prescriptions dispensed and patients per 100,000 across the period.
• The rate of benzodiazepine prescriptions dispensed decreased from 2012–13 to 2019–20 across all benzodiazepine drugs.
• However, for diazepam, the rate of patients increased from 2,767 per 100,000 population in 2012–13 to 3,013 per 100,000 in 2019–20 (Figure PHARMS1; Tables S2.7b and S2.8b).

Dispensing of prescription benzodiazepines may have been affected by recent policy changes. Please refer to the Policy context section for more information.

Figure PHARMS1: PBS prescriptions dispensed or patients who received a PBS supply of selected opioids or benzodiazepines, 2012–13 to 2019–20 (number or rate per 100,000)

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

The number of pharmaceutical detections reported at the Australian border only reflect detections of benzodiazepines and opioids (including morphine, buprenorphine, methadone and oxycodone) (ACIC 2020). In 2018–19 there were a total of 1,156 pharmaceutical detections, an increase of 98% since 2009–10 (585 detections) (ACIC 2020). 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 2020).

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 2020).

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 2020). 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 2020).

Figure PHARMS2: Recentᵃ use of pharmaceuticals, by age, sex and drug used, 2019 (per cent)

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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 2020).

Geographic trends

Findings from the 2019 NDSHS (AIHW 2020) 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 2020)
• 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 2020)
• 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 2020).

Figure PHARMS3: Recentᵃ use of painkillers, pain-relievers and opioidsᵇ, by remoteness area or socioeconomic area, people aged 14 and over, 2016 and 2019 (per cent)

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The National Wastewater Drug Monitoring Program (NWDMP) measures the presence of substances in sewerage treatment plants across Australia. This includes estimated population-weighted average consumption of fentanyl and oxycodone, although wastewater analysis cannot differentiate between prescribed and illicit use (ACIC 2021).

• Average consumption of both fentanyl and oxycodone continues to be higher in regional areas than capital cities.
• In 2020, average fentanyl consumption decreased to the lowest levels recorded by the program in both regional areas (August 2020) and capital city sites (October 2020) (ACIC 2021).
• By contrast, average oxycodone consumption increased from April to August 2020 in both regional areas and capital cities. In capital cities, consumption further increased from August to October 2020.
• In August 2020, per capita consumption of oxycodone exceeded that of methamphetamine in one jurisdiction for the first time since the program began.
• Despite the recent increase in oxycodone consumption, estimated average consumption of both fentanyl and oxycodone has declined overall since 2016.
  • Consumption of fentanyl and oxycodone increased from August 2016 to August 2018, but has fallen each year since 2018. Consumption of both drugs was lower in August 2020 than in August 2016 in both capital city sites and regional areas (ACIC 2021).

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

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.

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).

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).

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). Drug-induced deaths are more likely to be due to pharmaceutical drugs than illegal drugs, with benzodiazepines being the most commonly-involved single drug type in drug-induced deaths (811 deaths in 2019). The rate of deaths where benzodiazepines were present rose from 1.9 per 100,000 population in 1997 to 3.3 deaths per population in 2019.

Over the past decade, there has been a rise in deaths with a prescription drug present. For synthetic opioids (including fentanyl and tramadol) in particular, the rate has increased from 0.3 per 100,000 (57 deaths) in 2010 to 0.9 per 100,000 (231 deaths) in 2019 (Figure PHARMS4; Table S1.1a).

Figure PHARMS4: Number or age-standardised rate (per 100,000 population) of drug-induced deathsᵃ for benzodiazepines, pharmaceutical opioids and heroin, 1997 to 2019

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The National Drug and Alcohol Research Centre (NDARC) reported that over half (56% or 632 deaths) of all opioid-induced deaths in 2019 were attributed to pharmaceutical opioids only. This is compared to 32% (356 deaths) for illicit opioids only (that is, heroin and opium) and a further 11% (118 deaths) that were attributed to both pharmaceutical and illicit opioids (Chrzanowska et al. 2021). This is consistent with findings from the ABS that indicated that pharmaceutical 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 intentional overdose deaths (suicide) (ABS 2019a).

Involvement of other drugs in pharmaceutical drug-induced deaths is common. For example, preliminary estimates from NDARC show that benzodiazepines were involved in 55% (614 deaths) of opioid-induced deaths in 2019 (Chrzanowska et al. 2021). In 2019, 97% of drug-induced deaths where benzodiazepines were present involved other drugs, including alcohol (AIHW unpublished).

Geographic trends

The rate of drug-induced deaths involving benzodiazepines in 2019 was higher in Major cities (3.3 per 100,000 population) compared with Regional and remote areas (3.0 per 100,000 population). However, the rate of drug-induced deaths involving prescription opioids was slightly higher in Regional and remote areas than in Major cities for natural and semi-synthetic opioids (1.9 deaths per 100,000 population compared with 1.8 per 100,000 population) and synthetic opioids (1.2 deaths per 100,000 population compared with 0.8 deaths per 100,000 population) (Table 8).

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 2019–20 AODTS NMDS showed that pharmaceuticals were the principal drug of concern in 5% of closed treatment episodes for clients’ own drug use—a similar proportion to 2018–19 (Table S2.76; Figure PHARMS5).

In 2019–20, where pharmaceuticals were the principal drug of concern:

• Over 3 in 5 (62%) clients were male and around 1 in 7 (14%) were Indigenous Australians (tables S2.77 and S2.78).
• Almost 3 in 10 (29%) clients were aged 30–39, 24% were aged 20–29 and 22% were aged 40–49. Half (50%) of clients who sought treatment for benzodiazepines were aged 30 and over (AIHW 2021).
• The most common sources of referral were self or family and health services, accounting for 42% of closed treatment episodes each (Table S2.79).
• Counselling was the most common main treatment type (24% of closed treatment episodes), followed by assessment only (19%) (Table S2.80).

Figure PHARMS5: Treatment provided for own non-medical use of pharmaceuticals, 2019–20 (per cent)

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

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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.
• 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.
• 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.

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).

Many over-the-counter combination medicines containing codeine were not listed on the PBS prior to February 2018 and are now only able to be obtained with a private prescription. As a result, these medicines are not represented in PBS claim data. However, 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 2020).