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 [1]. 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 a growing problem internationally, with reported increases in misuse in Canada, Europe, the United Kingdom (UK) and the United States (US) [2]. In 2016 in the US an estimated 6.2 million people aged 12 and older misused a pharmaceutical drug at least once in the past month, with pharmaceutical opioids (painkillers) the most commonly misused [3]. Dramatic increases in opioid-related deaths associated with rising use in the US have led to the problem being declared an 'epidemic' [4, 5].

Availability

Data from the Pharmaceutical Benefits Scheme (PBS) indicates that there has been an increase in the prescribing of pharmaceutical opioids in Australia [6].

• 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) [7] (Tables S2.9 and S2.10).

The most current PBS data from 2016–17 shows that the most commonly prescribed benzodiazepine continues to be diazepam with just under 1.7 million prescriptions in 2016–17 [8].

The ACIC’s Illicit Drug Data Repot includes data on prescription pharmaceuticals detections at the Australian border. The importation of prescription pharmaceuticals is primarily undertaken by individuals for personal use.

The number of pharmaceutical detections reported at the Australian border only reflect detections of benzodiazepines and opioids (including morphine, buprenorphine, methadone and oxycodone). In 2016–17 there were a total of 2,574 pharmaceutical detections, an increase of 563.4% since 2007–08 (388 detections) [9,10]. The vast majority (93.4%) of these detections were for benzodiazepines (2,404 in 2016–17). However, though they remain the minority of overall pharmaceutical detections, there has been a 1,316.7% increase in the number of pharmaceutical opioid detections over the past decade (170 in 2016-17, up from 12 in 2007–08) [9,10].

Consumption

Data from the 2016 NDSHS showed that:

• 1 in 20 (4.8%) Australians aged 14 and over had used a pharmaceutical for non-medical purposes in the previous 12 months (Table S2.32).
• 1 in 8 (12.8%) had used a pharmaceutical for non-medical purposes in their lifetime (Table S2.31).
• 1 in 4 (26%) used pharmaceutical drugs daily or weekly for non-medical purposes.
• Pharmaceutical opioids/painkillers are the most commonly pharmaceutical used for non-medical purposes (3.6%), followed by tranquilisers/sleeping pills (1.6%) (Table S2.31 and S2.32).

In 2013, before the break in time series (see Box PHARMS2), the recent use of a pharmaceutical for non-medical purposes was 4.7%, having steadily increased from 3.7% in 2007. Pharmaceutical opioids/painkillers (3.6%) were the most common pharmaceutical used for non-medical purposes in 2013; while there was no change in misuse of all other forms of pharmaceuticals between 2013 and 2016 [11].

The National Wastewater Drug Monitoring Program (NWDMP) data indicates that the average fentanyl and oxycodone consumption was substantially higher in regional sites than capital cities [12]. It is important to note that wastewater analysis cannot differentiate between prescribed and illicit use.

The 2016 NDSHS showed that people who use pharmaceutical drugs for non-medical purposes were older than illicit drug users; in 2016, their mean age was 45 compared with 34 for users of illicit drugs [11]. Non-medical use of pharmaceutical opioids was most common among those in their 40s (4.5%) and least common among those aged 14–19 (2.7%). Those aged 20–29 were most likely to use sedatives (2.1%) for non-medical purposes with those aged 14–19 least likely (1.1%) to use this category of pharmaceuticals for non-medical purposes (Figure PHARMS2).

Data from the 2016 NDSHS showed that more than one-quarter (28%) of Australians aged 14 and over perceive the non-medical use of pharmaceuticals to be acceptable, an increase from 23% in 2013. To put this in perspective, nearly twice the number of people approved the use of pharmaceutical drugs compared with the use of tobacco (15.7%) and cannabis (14.5%) [11].

Geographic trends

In 2016, among people aged 14 and over [11]:

• South Australians were more likely to have recently used pain-killers/opiates (4.3%) for non-medical purposes than people in any other state or territory.
• People living in Tasmania were more than 1.5 times more likely to have recently used tranquillisers/sleeping pills (2.9%) for non-medical purposes than people in other jurisdictions
• Tasmania (5.6%) and South Australia (5.5%) had the highest rates of non-medical pharmaceutical use.

People living in Remote and Very Remote areas were twice as likely as those from Major Cities to have recently used pain-killers/opiates for non-medical purposes (6.6% compared with 3.3%). Overall, they were 1.7 times more likely than those from Major Cities to have used pharmaceuticals for non-medical purposes (8.0% compared with 4.6%) (Figure PHARMS3).

Similarly, people living in the most disadvantaged socioeconomic areas were 1.8 times more likely than those from the most advantaged socioeconomic areas to have the highest level of non-medical pain-killers/opiates use (4.8% compared with 2.6%). They were also more likely to have used pharmaceuticals for non-medical use in the past 12 months than people living in the most advantaged socioeconomic areas (6.0% compared with 4.2%) (Table S2.13).

Harms

There are a range of short and long-term health, social and economic harms associated with the misuse of pharmaceutical drugs (Table PHARMS1).

Table PHARMS1: Short and long term effects associated with pharmaceutical misuse

Drug type	Short-term effects	Longer-term effects
Pharmaceutical opioids	Constipation Nausea Sedation Vomiting Dizziness Itching Dry mouth Overdose (fatal and non-fatal)	Dependence Decreased cognitive function Psychiatric co-morbidity Occlusion of blood vessels Gastro-intestinal bleeding Mental health problems including depression
Benzodiazepines	Relaxation, sleepiness and lack of energy Dizziness Euphoria Confusion Visual distortions Moodiness Short-term memory loss	Anxiety, irritability, paranoia, aggression and depression Muscle weakness, rashes, nausea and weight gain Sexual problems Menstrual irregularities Memory loss, cognitive impairment, dementia and falls Confusion, lethargy and sleep problems

Source: Adapted from [13,14,15,16].

Mental health

In the 2016 NDSHS, adults aged 18 and over who had recently misused a pharmaceutical were more likely than those who had not to:

• Assess their health status as good, fair or poor (53%) compared with 44% who had not recently misused a pharmaceutical.
• Self-report higher rates of health conditions, particularly for the conditions of mental illness (29% compared with 15.2%) and chronic pain (15.9% compared with 10.3%).
• Have experienced ‘high or very high’ levels of psychological distress (24% compared with 11%) (Table S2.75).

There were also differences in mental health status depending on the type of pharmaceutical drug used. Specifically:

• Adults misusing benzodiazepines were more likely to report a mental illness, including anxiety disorders and depression, than people misusing opioid analgesics (35% compared with 29%).
• Adults who misused benzodiazepines were slightly more likely than those who misused opioid analgesics to experience ‘high or very high’ levels of psychological distress (28% compared with 24%) (Figure PHARMS4).

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 2016–17 of all separations with a drug-related principal diagnosis:

• sedatives and hypnotics (including alcohol) accounted for the highest proportion (59%)
• in 87% of separations involving sedatives, alcohol was also involved
• 13% were for opioids, with heroin, opium, morphine and methadone accounting for half of this group (6.6% of all drug-related separations) [17].

Deaths

Of the 1,808 drug induced deaths in 2016 (rate of 7.5 per 100,000 population) reported by the ABS, the most common substance present was a benzodiazepine (37%) followed by other opioids such as oxycodone, morphine and codeine (30%) (Figure PHARMS5) [20]. In over 96% of drug-induced deaths where benzodiazepines were present, they were taken in conjunction with other drugs including alcohol (Table S2.70).

The National Drug and Alcohol Research Centre (NDARC) reported that in 2016, among people aged 15–64 years there were 679 deaths attributed to pharmaceutical opioids only and 111 deaths to pharmaceutical opioids and heroin [18]. Specifically for synthetic opioid analgesics (including fentanyl and tramadol), the rate of attributable deaths among people aged 15–64 years has increased from 0.11 per 100,000 in 2007 (n=15) to 1.34 per 100,000 in 2016 (n=214) [18].

Treatment

Data collected as part of the AIHW’s 2016–17 Alcohol and Other Drug Treatment Services National Minimum Dataset (AODTS NMDS) showed that:

• Pharmaceuticals were the drug of concern (principal or additional) in 17% of closed treatment episodes. In treatment episodes, pharmaceuticals was more likely to be identified as an additional drug of concern (11%) than a principal drug of concern (5%) (Figure PHARMS6).
• Over the 11-years from 2006–07, the proportion of treatment episodes with a pharmaceutical drug as the principal drug of concern rose from 6% in 2006–07 to 8% in 2011–12, and then fell to 5% in 2016–17 (Table S2.76).
  • The proportions of treatment episodes for morphine and benzodiazepines have been decreasing over the 10-year period, while the proportions for codeine, methadone, oxycodone, and buprenorphine have been increasing (Table S2.76).
• Client demographics:
  • Where pharmaceuticals were the principal drug of concern, over half (58%) the clients were male, and around 1 in 10 were Indigenous (12%) (Table S2.79).
  • In 2016–17, a higher proportion of female clients (53%) reported codeine as their principal drug of concern, and women were slightly more likely than males to report other sedatives and hypnotics as their principal drug of concern (53%) (Table S2.79).
• Source of referral:
  • Almost half of the referrals for treatment episodes where pharmaceuticals were the principal drug of concern were for self/family (47%), followed by a health service (38%) (Table S2.80).
• Treatment type:
  • The most common main treatment type for episodes where pharmaceuticals were the principal drug of concern was counselling (28%) followed by assessment only (21%) [19] (Table S2.81).

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.

Aboriginal and Torres Strait Islander persons

Data from the 2016 NDSHS showed that Aboriginal and Torres Strait Islander persons about one in 10 (10.6%) had used a pharmaceutical for non-medical purposes. This was about 2.3 times higher than the rate for non-Indigenous Australians (4.6%) [11]. The ABS 2014–15 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) found that the non-medical use of pharmaceuticals among Indigenous Australians was higher than reported in the NDSHS, with 12.6% of Indigenous Australians aged 15 and over having recently used a pharmaceutical for non-medical purposes [21].

People engaged in the criminal justice system

Data from the 2016 Drug Use Monitoring in Australia (DUMA) program indicated that 40% of police detainees self-reported non-medical prescription drug use in the previous 12 months [21]. Data from the 2016—17 DUMA program is unable to specify the proportions of non-medical use of pharmaceuticals, yet showed a high proportion of detainees tested positive to benzodiazepines (21.3%). There were also 12.8% of police detainees that tested positive to at least one opiate (including heroin) [9].

People in remote and disadvantaged socioeconomic areas

Data from the 2016 NDSHS showed that people living in Remote and very remote areas were 1.7 times as likely as those living in Major cities to have recently misused a pharmaceutical (8.0% compared with 4.6%). In particular, use of opioid analgesics in these areas was twice as high as in Major cities (6.6% compared with 3.3%). Whereas the levels of recent benzodiazepine misuse in these areas was similar, 1.7% compared with 1.8% [11].

This is consistent with data from the National Wastewater Drug Monitoring Program that found the pharmaceutical opioids oxycodone and fentanyl, were detected at higher levels in regional areas than capital city areas [12].

People living with chronic pain

People who use opioids for chronic pain are more likely than the general population to misuse pharmaceutical drugs [13,23]. 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.

People who inject drugs

People who inject drugs may substitute illicit drugs, such as heroin, for pharmaceutical drugs depending on availability. It is well known that people who inject drugs consume pharmaceutical drugs, particularly prescription opioids, at far higher rates than the general population [24].

Data from the 2018 IDRS showed that respondents commonly reported the non-prescribed use of the following drugs in the preceding 6 months [25]:

• Morphine (22%)
• Oxycodone (14%)
• Buprenorphine (7%) and buprenorphine-naloxone film (10%)
• Fentanyl (7%).

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 no longer 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 [26].

Resources and further information

• National Drug Strategy Household Survey 2016 detailed findings, Australian Institute of Health and Welfare.
• Non-medical use of pharmaceuticals: trends, harms and treatment, Australian Institute of Health and Welfare.
• Real-time prescription monitoring in Victoria.
• Up-scheduling of codeine.

References

1. Larance B, Degenhardt L, Lintzeris N, Winstock A & Mattick R 2011. Definitions related to the use of pharmaceutical opioids: extramedical use, diversion, non-adherence and aberrant medication-related behaviours. Drug and Alcohol Review 30(3):236–245.
2. UNODC (United Nations Office on Drugs and Crime) 2017. World Drug Report 2017. Vienna: UNODC. Viewed 14 December 2017.
3. SAMHSA (Substance Abuse and Mental Health Services Administration) 2017. Key substance use and mental health indicators in the United States: results from the 2016 national survey on drug use and health. Publication no. SMA 17-5044, NSDUH Series H-52. Rockville: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Viewed 30 November 2017.
4. Centres for Disease Control and Prevention 2017. Prescription opioid overdose data. Viewed 30 November 2017.
5. U.S. Department of Health & Human Services 2017. Opioids: the prescription drug and heroin overdose epidemic. Washington, D.C: DHHS. Viewed 7 December 2017.
6. AIHW (Australian Institute of Health and Welfare) 2018a. Opioid harm in Australian and comparisons between Australia and Canada. Cat. no. HSE 210. Canberra: AIHW.
7. AIHW 2017a. Non-medical use of pharmaceuticals: trends, harms and treatment 2006–07 and 2015–16. Cat. no. HSE 195. Canberra: AIHW. Viewed 19 January 2018.
8. DoH (Department of Health) 2017. Expenditure and prescriptions twelve months to June 2017. Canberra: DoH. Viewed 5 June 2018.
9. ACIC (Australian Criminal Intelligence Commission) 2018. Illicit drug data report 2016–17. Canberra: ACIC. Viewed 21 September 2018.
10. ACC (Australian Crime Commission) 2009. Illicit drug data report 2007–08. Canberra: ACIC. Viewed 5 October 2018.
11. AIHW 2017b. National drug strategy household survey 2016: detailed findings. Drug statistics series no. 31. Cat. no. PHE 214. Canberra: AIHW. Viewed 14 December 2017.
12. ACIC 2019. National wastewater drug monitoring program, report 6. Canberra: ACIC. Viewed 20 February 2019.
13. Currow DC, Phillips J & Clark K 2016. Using opioids in general practice for chronic non-cancer pain: an overview of current evidence. The Medical Journal of Australia. 204(8):305–209.
14. DCPC (Drugs and Crime Prevention Committee) 2007. Inquiry into the misuse/abuse of benzodiazepines and other forms of pharmaceutical drugs in Victoria: final report. Melbourne: Drugs and Crime Prevention Committee. Viewed 5 October 2017.
15. Nicholas R, Lee N & Roche A 2011. Pharmaceutical drug misuse in Australia: complex problems, balanced responses. Adelaide: National Centre for Education and Training on Addiction.
16. NSW Ministry of Health 2017. A quick guide to drugs and alcohol, 3^rd edn. Sydney: National Drug and Alcohol Research Centre.
17. AIHW 2018b. Drug related hospitalisations. Canberra: AIHW. Viewed 30 November 2018. 
18. Roxburgh A, Dobbins T, Degenhardt L & Peacock A 2018. Opioid, Amphetamine, and Cocaine-Induced Deaths in Australia: August 2018. Sydney: National Drug and Alcohol Research Centre, University of New South Wales.
19. AIHW 2018c. Alcohol and other drug treatment services in Australia 2016–17. Drug treatment services no. 31. Cat. no. HSE 207. Canberra: AIHW.
20. Australian Bureau of Statistics 2017. Causes of death, Australia, 2016. ABS cat no. 3303.0. Canberra: ABS.
21. ABS 2016. National Aboriginal and Torres Strait Islander social survey, 2014–15. Cat. no. 4714.0. Canberra: ABS.
22. Patterson, E, Sullivan, T & Ticehurst, A 2018. Use and misuse of prescription drugs amongst police detainees. Trends & Issues in Crime and Criminal Justice no. 541. Canberra: AIC.
22. Vowels KE, McEntee ML, Julnes PS, Frohe T, Ney JP & van der Goes, DN 2015. Rates of opioid misuse, abuse and addiction in chronic pain: a systematic review and data synthesis. PAIN (156):569–576.
23. Degendhardt L, Gilmour S, Shand F, Bruno R, Campbell G, Mattick RP et al. 2013. Estimating the proportion of prescription opioids that is consumed by people who inject drugs in Australia. Drug and Alcohol Review 32(5):468–74.
24. Peacock A, Gibbs D, Sutherland R, Uporova J, Karlsson A, Bruno R et al. 2018. Australian Drug Trends 2018. Key findings from the National Illicit Drug Reporting System Interviews. Sydney: National Drug and Alcohol Research Centre, UNSW Australia.
25. TGA (Therapeutic Goods Administration) 2017. Codeine information hub: changes to patient access for medicines containing codeine. Canberra: Department of Health. Viewed 5 October 2017.