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 use other than prescribed use.

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). 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.

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.

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).

Availability

Opioids

In 2019–20, data from the Pharmaceutical Benefits Scheme (PBS) indicate that approximately 15.2 million opioid prescriptions were dispensed to 3.1 million patients for pain relief (that is, excluding prescriptions for the treatment of opioid dependence) (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 rates 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 rates 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 (IDDR) includes data on prescription pharmaceutical detections at the Australian border (ACIC 2021a). The importation of prescription pharmaceuticals is primarily undertaken by individuals for personal use and without criminal intent (ACIC 2021a).

The number of pharmaceutical detections reported at the Australian border only reflect detections of benzodiazepines and opioids (including morphine, buprenorphine, methadone and oxycodone) (ACIC 2021a). In 2019–20 there were a total of 1,112 pharmaceutical detections, a decrease of 8% since 2010–11 (1,211 detections) (ACIC 2021a). 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 2021a).

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: 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).

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: Codeine rescheduling).
• 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: Codeine rescheduling).
• 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 2022).

Data from Report 15 of the NWDMP indicate that nationally:

• In August 2021, oxycodone consumption continued to be higher in regional areas than capital cities.
• Oxycodone consumption increased steadily after early 2017 and reached a peak in December 2018 but has declined since then.
• Since December 2018, oxycodone consumption in both capital city and regional locations has declined and reached a record low in the current reporting period (ACIC 2022).

Estimated average consumption of oxycodone and fentanyl consumption was higher in regional parts of the country in August 2021, nearly double the consumption in capital cities. Average oxycodone consumption remains at historically low levels and has stabilised since April 2021. Similarly, the average consumption of fentanyl has been decreasing for several years, with the rate of decrease slowing since June 2021 (ACIC 2022).

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

Poly drug use

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%) (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, 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.

In 2020, multiple drugs were consumed in at least half of ambulance attendances related to benzodiazepines and opioid analgesics. For benzodiazepines, this ranged from 52% of attendances in New South Wales and Queensland to 67% of attendances in Tasmania; for opioid analgesics the range was from 50% in Tasmania to 62% in the Australian Capital Territory (Table S2.81).

Harms

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.

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.

Benzodiazepines

In 2020, for benzodiazepine-related ambulance attendances:

• Rates of attendances ranged from 14.1 per 100,000 population in Tasmania to 30.1 per 100,000 population in Queensland.
• The majority of attendances were for females in Victoria (54% of attendances), Queensland (55%), Tasmania (61%) and the Australian Capital Territory (53%), while in New South Wales a slightly higher proportion of attendances were for males (51% of attendances).
• The median age of patients for benzodiazepine-related attendances was similar across jurisdictions (33 to 37 years).
• Benzodiazepine-related attendances where multiple drugs (excluding alcohol) were present ranged from 52% in New South Wales and Queensland to 67% in Tasmania (Table S2.81).

Characteristics of benzodiazepine-related ambulance attendances varied by region in 2020:

• Higher rates for attendances were reported in metropolitan areas for New South Wales, Victoria, and Tasmania. Queensland reported similar rates for metropolitan (30.3 per 100,000 population) and regional areas (29.8 per 100,000 population).
• Similar proportions of benzodiazepine-related attendances were transported to hospital in metropolitan and regional areas for all reporting jurisdictions, ranging from 85% in the Australian Capital Territory (metropolitan only) to 94% in regional Queensland (Table S2.81).

Opioid analgesics

In 2020, for opioid analgesic-related ambulance attendances:

• The rate of attendances ranged from 5.0 per 100,000 in New South Wales to 9.6 per 100,000 in Queensland.
• The median age of patients ranged from 40 years in Queensland to 47 years in Tasmania.
• The majority of opioid analgesic-related attendances in New South Wales were for males (52%). Higher proportions were reported for females in Victoria (53%), Queensland (51%), Tasmania (60%) and the Australian Capital Territory (53%).
• Attendances where multiple drugs (excluding alcohol) were present ranged from 50% in Tasmania to 62% in the Australian Capital Territory (Table S2.81).

Characteristics of opioid analgesic-related ambulance attendances varied by region in 2020:

• Higher rates of attendances were reported in regional areas for New South Wales, Victoria and Queensland, whereas Tasmania reported higher rates in metropolitan areas.
• Similar proportions of opioid analgesic-related attendances were transported to hospital in metropolitan and regional areas for Victoria (90% and 88%, respectively), Queensland (89% and 93%, respectively) and Tasmania (92% and 94%, respectively)
• In New South Wales, the proportion of attendances transported to hospital was higher in metropolitan areas (91% metropolitan and 82% for regional).
• In the Australian Capital Territory (metropolitan only), 88% of attendances were transported to hospital (Table S2.81).

Hospitalisations

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 in 2019–20, of all drug-related hospitalisations:

• Around 1 in 13 (7.6%) were for antiepileptic, sedative-hypnotic and antiparkinsonism drugs (excluding alcohol). Within this category, almost half (47%) of hospitalisations were for benzodiazepines.
• Around 1 in 20 were for opioids (5.4%) or non-opioid analgesics (4.8%) (Table S1.8a).

There was a decrease in the number of hospitalisations related to benzodiazepines and opioids between 2015–16 and 2019–20.

• Benzodiazepine-related hospitalisations decreased from 6,253 (26.1 per 100,00 population) in 2015–16 to 5,001 (19.6 per 100,000) in 2019–20.
• Opioid-related hospitalisations decreased from 9,194 (38.3 per 100,000 population) in 2015–16 to 7,597 (29.7 per 100,000) in 2019–20 (Table S1.8b).

In 2019–20, almost 3 in 4 hospitalisations for both benzodiazepines (72%) and opioids (73%) occurred in Major cities. In Australia, the rate of hospitalisations for benzodiazepines and opioids is typically higher in Major cities and Regional areas than in Remote and very remote areas (Man et al. 2021). In 2019–20:

• The rate of benzodiazepine-related hospitalisations in Major cities was 19.7 per 100,000 population (3,616 hospitalisations).
• The rate of opioid-related hospitalisations in Major cities was 30.4 per 100,000 population (5,576 hospitalisations) (Table S1.8c).

Deaths

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 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 2020

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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 2020, 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 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).

Treatment

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 non-medical use 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 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.

Codeine rescheduling

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).

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.