Australian Institute of Health and Welfare (2022) Alcohol, tobacco & other drugs in Australia, AIHW, Australian Government, accessed 29 September 2022.
Australian Institute of Health and Welfare. (2022). Alcohol, tobacco & other drugs in Australia. Retrieved from https://www.aihw.gov.au/reports/alcohol/alcohol-tobacco-other-drugs-australia
Alcohol, tobacco & other drugs in Australia. Australian Institute of Health and Welfare, 24 August 2022, https://www.aihw.gov.au/reports/alcohol/alcohol-tobacco-other-drugs-australia
Australian Institute of Health and Welfare. Alcohol, tobacco & other drugs in Australia [Internet]. Canberra: Australian Institute of Health and Welfare, 2022 [cited 2022 Sep. 29]. Available from: https://www.aihw.gov.au/reports/alcohol/alcohol-tobacco-other-drugs-australia
Australian Institute of Health and Welfare (AIHW) 2022, Alcohol, tobacco & other drugs in Australia, viewed 29 September 2022, https://www.aihw.gov.au/reports/alcohol/alcohol-tobacco-other-drugs-australia
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In Australia, pharmaceutical drugs are available via a prescription from a registered healthcare professional or over-the-counter (OTC) from pharmacies and other retail outlets, 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 use other than prescribed use.
The non-medical use of pharmaceutical drugs is an ongoing public health problem in Australia and may be associated with a range of harms.
Opioid dispensing rates increased from 2012–13 to 2016–17, before declining into 2020–21.
In 2019, nearly 1 in 25 (4.2%) Australians aged 14 and over reported the non-medical use of pharmaceuticals in the previous 12 months.
Pharmaceutical pain-killers/pain-relievers and opioids (excluding over-the-counter) are the most common pharmaceuticals used for non-medical purposes.
Between 2015–16 and 2020–21, rates of hospitalisations decreased for both benzodiazepines and opioids.
Between 1997 and 2019, the rate of deaths where benzodiazepines were present rose from 1.9 per 100,000 population to 3.3 per 100,000 population
View the pharmaceuticalS fact sheet >
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). Pharmaceutical drugs may be consumed for non-medical use 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.
In Australia, pharmaceutical drugs that may be used for non-medical purposes include opioids (painkillers/analgesics) and sedatives (sleeping/anti-anxiety medications). In recent years, there has also been rising concern about non-medical use of gabapentinoids (particularly pregabalin).
Pharmaceutical opioids are used to treat pain, some respiratory illness, and opioid (including heroin) dependence. Examples include oxycodone, buprenorphine and codeine.
Sedatives are a group of drugs that cause calming and sedative effects due to their depressive activity on the central nervous system. Benzodiazepines comprise the largest group of drugs in this class and examples include diazepam, alprazolam and temazepam.
Gabapentinoids are a group of drugs that were originally prescribed to manage epilepsy. They are increasingly prescribed for neuropathic pain (nerve pain). Examples include pregabalin and gabapentin.
The non-medical use of pharmaceutical drugs is an ongoing concern internationally, with different pharmaceutical opioids being misused in different regions.
In Australia in 2019, past-year use of opioids (including the use of opiates and the use of pharmaceutical opioids for non-medical purposes), was 3.3% of the population aged 14 and over. This is higher than the global average (1.2% of the global population aged 15–64 years). In 2019, the majority of pharmaceutical misuse in Australia continued to be for codeine (UNODC 2021).
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 2019, 3.6% of the population aged 12 and older had misused pharmaceutical opioids at least once in the past year (UNODC 2021).
The Australian Criminal Intelligence Commission’s (ACIC) Illicit Drug Data Report (IDDR) includes data on prescription pharmaceutical detections at the Australian border (ACIC 2021). The importation of prescription pharmaceuticals is primarily undertaken by individuals for personal use and without criminal intent (ACIC 2021).
The number of pharmaceutical detections reported at the Australian border only reflect detections of benzodiazepines and opioids (including morphine, buprenorphine, methadone and oxycodone) (ACIC 2021). In 2019–20 there were a total of 1,112 pharmaceutical detections, a decrease of 8% since 2010–11 (1,211 detections) (ACIC 2021). The majority (73%) of these detections were for benzodiazepines (810 in 2019–20). However, though they remain the minority of overall pharmaceutical detections, there has been a 695% increase in the number of pharmaceutical opioid detections over the past decade (38 in 2010-11, increasing to a record high of 302 in 2019–20 (ACIC 2021).
AIHW analysis of recent data from the Pharmaceutical Benefits Scheme (PBS) provides information on dispensing of prescription opioids, benzodiazepines and gabapentinoids in Australia (Box PHARMS2). These numbers largely represent medicines being prescribed for and used for their intended purposes. However, drug-related harms are often associated with drug prescribing rates (such as described for opioids in Roxburgh et al. (2017)) so it is important to monitor prescription rates in the context of harm reduction.
Recent data indicate that opioids continue to be dispensed at higher rates than benzodiazepines or gabapentinoids, but rates of dispensing have fallen or remained stable for all 3 drug classes over the past 5 years. Detailed information on specific drug classes and patient characteristics is outlined below.
The Pharmaceutical Benefits Scheme (PBS) was introduced by the Australian Government in 1948 to improve access to necessary medicines. Under the PBS, Australian residents can access a range of medicines at a cheaper price, subsidised by the Government. Most PBS-listed medicines can only be dispensed at a pharmacy (PBS 2022).
Data from the PBS provide information on the number of prescriptions (scripts) dispensed and the number of patients supplied at least one script within a given financial year. The PBS database includes information on a range of medicines that may be used for non-medical purposes or carry a risk of potential for harm (including opioids, benzodiazepines and gabapentinoids). Monitoring dispensing of these medicines under the PBS can provide information on the availability of these drugs among the general Australian population. The PBS also includes data on medicines that are used to help people stop or reduce their tobacco or alcohol consumption.
AIHW analysis of PBS data includes opioids, benzodiazepines, gabapentinoids, smoking cessation medicines and alcohol cessation medicines. See the Technical notes for a full list of item codes.
Data from the PBS indicate that in 2020–21:
Rates of dispensing across all drug classes were typically highest in Inner regional and Outer regional areas. See Data by region for information on PBS dispensing by remoteness area and state/territory.
This figure shows that the age-standardised rate of opioid scripts dispensed increased from 53,801 per 100,000 population in 2012–13 to 58,485 per 100,000 in 2015–16, before declining to 48,198 per 100,000 in 2020–21. The rate of benzodiazepine scripts dispensed steadily decreased from 26,496 per 100,000 population in 2012–13 to 18,133 per 100,000 in 2020–21.
Between 2012–13 and 2020–21:
For information on concomitant dispensing of opioids and benzodiazepines, see Poly drug use. Dispensing of prescription opioids, benzodiazepines and gabapentinoids may have been affected by recent policy changes. Refer to the Policy context section for more information.
Opioid, benzodiazepine and gabapentinoid dispensing varied by the age and sex of patients. Across all drug categories:
This figure shows the number of prescriptions dispensed for opioids in 2020-21. by sex. The largest group was females aged 80 and over with 1,827,700 scripts dispensed, this is followed by females aged 70–79 1,372,356 with scripts dispensed. There is a filter to select year, drug, measure (prescriptions dispensed or patients) and number or crude rate.
Box PHARMS3: What are defined daily doses?
Opioid use can be examined using defined daily doses (also known as statistical defined daily doses or S-DDDs). A defined daily dose is a measure used for statistical purposes that represents the dose of a particular drug that is assumed to be the ‘average amount per day’ when used by adults (WHOCC 2018). S-DDDs account for variations between medicines (for example, pack size and drug strength) and are useful for examining changes in dispensing over time or comparing data between regions or populations (WHOCC 2018).
S-DDDs may not match the recommended or prescribed dose and may underestimate or overestimate ‘true’ use. See the Technical notes for more information on how S-DDDs are calculated in this report.
PBS data indicate that 88.3 million defined daily doses were dispensed in 2020–21 for all opioids, a rate of 9.4 S-DDDs/1,000 population/day. Oxycodone (2.3 S-DDDs/1,000/day), codeine and tramadol (each 2.0 S-DDDs/1,000/day) had the highest rates of dispensing (tables PBS17–18).
Between 2012–13 and 2020–21, the total rate of S-DDDs dispensed for opioids fell from around 13 S-DDDs/1,000 population/day in 2012–13 (Table PBS18). Trends in dispensing varied by opioid drugs:
Decreased rates of opioid dispensing measured in terms of S-DDDs may be related to several recent policy changes, including the de-listing of some medicines, increased restrictions on prescribing some opioids, and the introduction of smaller pack sizes for some PBS-listed immediate-release opioid formulations in June 2020. Refer to the Policy context section for more information.
Opioids are effective for managing strong cancer pain and in the context of end-of-life (palliative) care. However, there is limited evidence that opioid medicines are beneficial for the long-term treatment of non-cancer pain conditions (for example, back pain). Long-term opioid use is also linked to increased risk of harm such as overdose (RACGP 2020). Australian clinical guidelines recommend that opioids only be used for chronic non-cancer pain if a patient is experiencing moderate/severe pain that is not adequately managed with other treatments (RACGP 2020).
PBS data indicate that most opioid dispensing in Australia is not related to cancer or palliative care. In 2020–21, around 2.1 million scripts were dispensed in relation to palliative care (8,100 scripts per 100,000 population) and 782,000 scripts were dispensed in relation to cancer treatment (3,000 scripts per 100,000). By comparison, 11.2 million scripts were dispensed not in relation to palliative care or cancer treatment (43,600 scripts per 100,000) (tables PBS19–20). Note that the number of opioid prescriptions related to palliative care and cancer may be underestimated, as some palliative care patients may not have received any PBS items from the Palliative Care Schedule, and some patients receiving treatment for cancer may not have received cancer treatment-related drugs through the PBS.
The rate of opioid dispensing for palliative care has declined since 2018–19, while rates of dispensing for the other 2 categories (cancer treatment and neither palliative care nor cancer treatment) have declined between 2017–18 and 2020–21 (Table PBS20).
Data from the 2019 NDSHS showed that:
Between 2016 and 2019, there was a significant decrease in the use of pharmaceuticals for non-medical purposes (from 4.8% to 4.2%) (AIHW 2020, Table 4.6). 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: Codeine rescheduling).
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).
In 2016, the way the NDSHS captured non-medical use of painkillers/analgesics and opioids changed to better reflect how these substances are used and understood in the community.
There were no changes to the tranquillisers/sleeping pills, steroids, or methadone/buprenorphine sections of the questionnaire.
These changes to the 2016 survey has resulted in a break in the time-series for painkillers and opiates and for the overall misuse of pharmaceuticals.
This figure shows the proportion of persons who reported recent use of pharmaceuticals for non-medical purposes by age group in 2019. In 2019, recent non-medical use of pharmaceuticals in the last 12 months was common for people aged 20–29 (6.4%) and 40–49 (4.9%). It was least common for people aged 14–19 (2.3%). There is a filter to select other drug types: Pain-killers/pain relievers and opioids and tranquillisers/sleeping pills.
View data tables >
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).
Findings from the 2019 NDSHS (AIHW 2020) showed:
This figure shows the proportion of recent non-medical use of pharmaceuticals by people aged 14 and over and socioeconomic area in 2016 and 2019. In 2019, the proportion of people aged 14 and over living in the most disadvantaged socioeconomic areas who used pain-killers/pain relievers for non-medical purposes was higher than those from the most advantaged socioeconomic areas (3.0% compared 1.8%).
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 oxycodone and fentanyl. It should be noted that wastewater analysis cannot differentiate between prescribed and illicit use (ACIC 2022). Data from Report 16 of the NWDMP indicate that nationally:
Nationally, estimated population-weighted average consumption of fentanyl remains low, data from Report 16 of the NWDMP indicate:
For state and territory data, see the National Wastewater Drug Monitoring Program reports.
Poly drug use is defined as the use of more than 1 illicit drug or licit drug in the previous 12 months. In 2019, the NDSHS showed that just over half (52%) of people who reported the non-medical use of pharmaceuticals in the last 12 months said they did not use any other illicit drug. The most common other drugs concurrently used were alcohol (50% exceeded the single occasion risk guideline at least monthly), cannabis (40%) and cocaine (27%) (AIHW 2020, Table 1.3).
Data on alcohol and other drug-related ambulance attendances are sourced from the National Ambulance Surveillance System (NASS). Monthly data for 2021are currently available for New South Wales, Victoria, Queensland, Tasmania and the Australian Capital Territory It should be noted that some data for Tasmania and the Australian Capital Territory have been suppressed due to low numbers. Please see the data quality statement for further information.
In 2021, multiple drugs (excluding alcohol) were involved in at least half of ambulance attendances related to benzodiazepines and opioid analgesics. For benzodiazepines, this ranged from 68% of attendances in New South Wales to 75% of attendances in Tasmania; for opioid analgesics the range was from 73% in New South Wales to 81% in Victoria (Table S1.10).
For related content on multiple drug involvement see Impacts: Ambulance attendances.
Due to the compounding effects of respiratory depression, patients using opioids and benzodiazepines at the same time may be at higher risk of harm (Boon et al. 2020; RACGP 2022). Data from the Pharmaceutical Benefits Scheme (PBS) indicate that most opioid scripts are dispensed to patients who have not received a recent supply of a benzodiazepine, and vice versa. However, concomitant dispensing is not uncommon (that is, dispensing multiple medicines at the same time or almost the same time). In 2020–21:
Rates of concomitant dispensing of opioids and benzodiazepines declined overall between 2013–14 and 2020–21 but fluctuated over time (tables PBS37–44). For more information on dispensing of prescription drugs under the PBS, see Prescription drug dispensing.
For related content on non-medical use of pharmaceutical drugs impacts and harms, see also:
There are a range of short and long-term health, social and economic harms associated with the non-medical use 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.
Data on alcohol and other drug-related ambulance attendances are sourced from the National Ambulance Surveillance System (NASS). Monthly data are presented in 2021 for people aged 15 years and over for New South Wales, Victoria, Queensland, Tasmania and the Australian Capital Territory.
Any pharmaceutical drug
In New South Wales, Victoria, Queensland, Tasmania and the Australian Capital Territory, in 2021, for ambulance attendances where any pharmaceutical drug was reported:
Figure PHARMS5: Ambulance attendances for pharmaceuticals, by age, sex and selected states and territories, 2021
This figure shows pharmaceutical-related ambulance attendances in NSW. The highest number of attendances were for females aged 55+. There is a filter to select state/territory, drug and measure (number of attendances or rate per 100,000 population).
In 2021, for benzodiazepine-related ambulance attendances in these jurisdictions:
In 2021, for opioid analgesic-related ambulance attendances in New South Wales, Victoria, Queensland, Tasmania and the Australian Capital Territory:
Drug-related hospitalisations are defined as hospitalisations with a principal diagnosis relating to a substance use disorder or direct harm relating to use of selected substances (AIHW 2018).
AIHW analysis of the National Hospital Morbidity Database (NHMD) showed that, among all drug-related hospitalisations in 2020–21:
This represents a rate of 18.2 hospitalisations per 100,000 population for benzodiazepines and 26.0 per 100,000 for opioids (Table S1.13). Around 2 in 3 hospitalisations for benzodiazepines (67% or 3,100 hospitalisations) or opioids (63% or 4,200) involved an overnight stay (Table S1.12).
In 2020–21, around 3 in 4 hospitalisations occurred in Major cities for both benzodiazepines (73% or 3,400 hospitalisations) and opioids (76% or 5,100) (Table S1.14). Accounting for differences in population size:
In the 6 years to 2020–21:
Drug-induced deaths are determined by toxicology and pathology reports and are defined as those deaths that can be directly attributable to drug use. This includes deaths due to acute toxicity (for example, drug overdose) and chronic use (for example, drug-induced cardiac conditions) (ABS 2021).
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 (817 deaths in 2020). The rate of deaths where benzodiazepines were present rose from 1.9 per 100,000 population in 1997 to 3.2 deaths per 100,000 population in 2020.
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 (75 deaths) in 2011 to 0.9 per 100,000 (218 deaths) in 2020 (Figure PHARMS6; Table S1.1).
This figure shows that drug-induced deaths decreased for all drug types from 1998 to 2020. Since 2018, deaths have been decreasing for all drug types. In 2020, the most common substance present in drug-induced deaths was benzodiazepines (817 deaths), followed by all opioids excluding heroin (731) and heroin (462).
The National Drug and Alcohol Research Centre (NDARC) reported that over half (56% or 606 deaths) of all opioid-induced deaths in 2020 were attributed to pharmaceutical opioids only. This is compared to 34% (360 deaths) for illicit opioids only (that is, heroin and opium) and a further 9% (101 deaths) that were attributed to both pharmaceutical and illicit opioids (Chrzanowska et al. 2022). This is consistent with previous 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 58% (624 deaths) of opioid-induced deaths in 2020 (Chrzanowska et al. 2022). In 2020, 97% of drug-induced deaths where benzodiazepines were present involved other drugs, including alcohol (AIHW unpublished).
The rate of drug-induced deaths involving benzodiazepines in 2020 was higher in Major cities (3.3 per 100,000 population) compared with Regional and remote areas (2.6 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 (1.7 deaths per 100,000 population compared with 1.6 per 100,000 population) and synthetic opioids (1.1 deaths per 100,000 population compared with 0.8 deaths per 100,000 population) (Table 8).
The 2020–21 Alcohol and Other Drug Treatment Services in Australia annual report shows that pharmaceuticals were the principal drug of concern in 4.8% of treatment episodes provided for clients’ own drug use (AIHW 2022).
This is a similar proportion to 2019–20 (4.5% of closed treatment episodes) (AIHW 2021).
Data collected for the AODTS NMDS are released twice each year—an Early Insights report in April and a detailed report mid-year.
The AODTS NMDS classification of ‘pharmaceuticals’ includes 10 drug types: codeine, morphine, buprenorphine, oxycodone, methadone, benzodiazepines, steroids, other opioids, other analgesics, and other sedatives and hypnotics. The most common drug types within this classification are benzodiazepines and opioids (AIHW 2021).
In 2020–21, where pharmaceuticals were the principal drug of concern:
Source: AIHW 2022, tables Drg.87, SC.32 and Drg.91.
For related content on at-risk groups, see:
The available evidence indicates that the non-medical use of pharmaceuticals among vulnerable populations is at substantially higher levels than in the general population.
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 non-medical use 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 or non-medical use of pharmaceutical drugs and patients that are diverting these medicines.
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 use 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).
Pharmaceutical opioid regulatory changes
Regulatory changes are being implemented in Australia to reduce harm from opioid prescription medicines. These include smaller pack sizes for immediate-release prescription opioid products; the inclusion of boxed warnings and class statements in the Product Information documents regarding their potential for harmful and hazardous use; and reinforcing the indications, or appropriate circumstances for the use of, immediate release and modified release products and for fentanyl patches. Smaller pack sizes and fentanyl indication changes came into effect in the first half of 2020. Other changes will be phased in subsequently.
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Chrzanowska, A, Man, N, Sutherland, R, Degenhardt, L & Peacock, A (2022). Trends in overdose and other drug-induced deaths in Australia, 1997-2020. Sydney: National Drug and Alcohol Research Centre, UNSW Sydney. DOI: 10.26190/ke9y-4731, accessed 30 June 2022.
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