Alcohol, tobacco & other drugs in Australia

The health burden of alcohol and other drug use is considerable and includes hospitalisation from injury and other disease, mental illness, pregnancy complications, injection-related harms, overdose and mortality.

Drug-induced 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). Multiple drug types may have been reported on a single death record. As a result, the sum of each drug type may be more than the total number of deaths.

AIHW analysis of the AIHW National Mortality Database (Figure IMPACT1; Table S1.1) showed:

• In 2018, there were 1,740 drug-induced deaths (a rate of 7.0 per 100,000 population). Although the number of drug-induced deaths in 2018 was the same as the number recorded in 1999, the rate of drug-induced deaths in 2018 (7.0 deaths per 100,000 population) was 23% lower than in 1999 (9.1 deaths per 100,000 population).
• Opioids were the most common drug class identified in drug-induced deaths over the past 2 decades. Opioids include the use of a number of drug types, including heroin, opiate based analgesics (such as codeine and oxycodone) and synthetic opioid prescriptions (such as tramadol and fentanyl).
• In 2018, opioids were present in nearly two-thirds of drug-induced deaths (64.5% or 1,123 deaths) — a rate of 4.6 per 100,000 population. Analysis by the ABS found that in almost two-thirds (63.1% or 708 deaths) of opioid-induced deaths, benzodiazepines were also present (ABS 2019). The majority of opioid-induced deaths were accidental (80%). The rate of opioid-induced deaths involving synthetic opioids has increased over the past decade (ABS 2019).
• By single drug type, the most common substance present in drug-induced deaths in 2018 were benzodiazepines, identified in 883 deaths (51%). It is important to note that benzodiazepines may not have been recorded as the underlying cause of death (see also Non-medical use of pharmaceutical drugs: Harms: Deaths).
• Over the past decade, drug-induced deaths were more likely to be due to prescription drugs than illegal drugs, and there has been a substantial rise in the number of deaths with a prescription drug present. However, since 2014, there has been an increase in the proportion of deaths attributed to illegal drugs (from 17% in 2014 to 30% in 2018) and a decrease in the proportion attributed to prescription drugs only (from 75% in 2014 to 60% in 2018) (Man et al. 2019).
• The rate of drug-induced deaths in 2018 was higher in Regional and remote areas (7.2 per 100,000 population) compared with Major cities (6.8 per 100,000 population) (Table S2.71).
• The rate of drug-induced deaths has fluctuated over the past decade (2009–2018) in both Major cities and Regional and remote areas. However, when comparing the rates for 2009 and 2018, in Regional and remote areas the rate increased by 20% while the rate in Major cities in 2018 was equal to that in 2009 (Table S2.71).

Deaths due to harmful alcohol consumption

The harmful consumption of alcohol can contribute to mortality in a number of different ways, and deaths can be directly attributable or partially attributable to harmful alcohol consumption. In Australia, deaths that are certified as being directly attributable to alcohol are coded as the underlying cause of death (the condition which initiated the train of morbid events). Alcohol-induced deaths are defined as those that can be directly attributable to alcohol use, as determined by toxicology and pathology reports (ABS 2018).

Alcohol may also play a substantial role in a person’s death, yet not be recognised as the underlying cause of death. In such cases, the alcohol use would be referred to as an associated cause of death. Alcohol-related deaths are defined as deaths directly attributable to alcohol and together with deaths where alcohol was listed as an associated cause of death (ABS 2018).

Data from the ABS showed:

• There were 1,366 registered alcohol-induced deaths in 2017; the highest in 2 decades (1,156 deaths in 1997).
• In 2017, the alcohol-induced death rate was 5.1 per 100,000 population; this has remained stable since a low of 4.5 deaths per 100,000 in 2012.
• The rate of alcohol-induced deaths for males has been on average 3.5 times higher than that of females over the past 2 decades.
• There were an additional 2,820 deaths where alcohol was mentioned as a contributory cause of death in 2017. This highlights that people were twice as likely to have alcohol certified at death as a contributory factor than to have died from an alcohol-induced death (ABS 2018).

The most common cause of alcohol-induced death was alcoholic liver disease; while mental and behavioural conditions due to alcohol use, including alcohol addiction, is the most common contributor to alcohol-related deaths. Mental and behavioural disorders due to alcohol abuse also made up about 20% of alcohol-induced deaths in 2017 (ABS 2018).

Burden of disease

Burden of disease analysis is used to compare the impact of different diseases, conditions or injuries on a population (AIHW 2019b). It combines the burden of living with ill health (non-fatal burden) with the burden of dying prematurely (fatal burden). This is measured through the calculation of disability-adjusted life years (DALY) – one DALY is one year of 'healthy life' lost due to illness and/or death.

Tobacco, alcohol and illicit drug use contribute to increased chronic disease, injury, poisoning and premature death and are among the leading risk factors contributing to disease burden in Australia (AIHW 2019b) (Figure IMPACT2). Analysis of data from the Australian Burden of Disease Study 2015 including revised analysis of estimates for tobacco, alcohol and illicit drug use based on the latest evidence of linked diseases indicated the following:

• Tobacco, alcohol and illicit drug use collectively accounted for 16.5% of the total burden of disease in Australia in 2015 (AIHW 2019c).
• Tobacco use contributed to 9.3% of the total burden of disease in Australia in 2015. It was responsible for 41% of the burden of respiratory diseases, 22% of cancers, 11.5% of cardiovascular diseases, and 6.8% of infections (AIHW 2019b).
• Alcohol use contributed to 4.5% of the total burden of disease in Australia in 2015 and was the leading risk factor for males aged 25–44 (11.9% compared to females 3.4%) (AIHW 2019b). Males experienced a greater proportion of disease burden attributable to alcohol use than females. Alcohol use was responsible for 100% of the burden due to alcohol use disorders, 40% of liver cancer burden, 28% of chronic liver disease burden, 22% of road traffic injuries—motor vehicle occupant burden and 14% of suicide burden (Table S2.63) (AIHW 2019b).  
• Illicit drug use contributed to 2.7% of the total burden of disease in Australia in 2015, most of which was experienced by males and females aged 25–44 (AIHW 2019b). Males aged 25–44 experienced a greater proportion of total disease burden attributable to illicit drug use than females (10% compared to 4.4%) (AIHW 2019b). Illicit drug use was responsible for 100% of the burden of drug use disorders (excluding alcohol) and 27% of the poisoning burden. It was also responsible for 75% of the acute Hepatitis C burden, 37% of the acute Hepatitis B burden, and 7.9% of the HIV/AIDS burden (AIHW 2019b).
• Opioid use accounted for the largest proportion (37%) of the illicit drug use burden, followed by amphetamine use (21%), cocaine (11.4%) and cannabis (8.3%). In addition, 18.2% of the burden was from diseases contracted through unsafe injecting practices (Table S2.69) (AIHW 2019b).

Injury and hospitalisation

Recent consumers of alcohol (past 12 months)

• According to the 2019 National Drug Strategy Household Survey (NDSHS):
  •  1.2% of consumers aged 14 years or older had been injured while under the influence of alcohol and required medical attention and 0.4% required admission to hospital for their injuries. 
  • less than 1% of consumers aged 14 years or older required medical attention (0.3%) or hospitalisation (0.2%) because they were so intoxicated (Table S1.4).
• People who consumed alcohol in risky quantities (lifetime or single occasion risk) were far more likely to require medical attention or admission to hospital due to injuries sustained while drinking or due to intoxication. This was even higher among people aged 14 years or older who consumed 11 or more standard drinks at least monthly with 4.9% requiring medical attention for their injuries (AIHW 2020b) (Table S1.5).
• According to information drawn from the National Hospital Morbidity Database on drug-related principal diagnosis, alcohol was the drug with the highest number of hospital separations across the 5-year period from 2013–14 to 2017–18, accounting for about half of those separations (53%).

Recent users of illicit drugs (past 12 months):

2019 NDSHS data on injury and hospitalisation for recent users of illicit drugs have a high relative standard error and should be interpreted with caution (AIHW 2020b).

• Data from the 2019 NDSHS, shows that 1.2% of recent illicit drug users aged 14 and over reported that they had injured themselves while under the influence of illicit drugs and required medical attention and 0.5% said their injury was serious enough to require hospitalisation (Table S1.6).
• Less than 1% of recent illicit drug users reported that they had overdosed and required medical attention (0.9%) or hospitalisation (0.4%) (Table S1.6). This was higher among people who had used meth/amphetamines in the previous 12 months (2.0% had overdosed and required medical attention and 0.8% required hospitalisation) (AIHW 2020b) (Table S1.7).

Information on drug-related hospitalisations is drawn from the National Hospital Morbidity Database.

• In 2017–18, there were 11.3 million separations in Australia’s public and private hospitals (AIHW 2019a), and drug-related principal diagnoses (considered to be responsible for an episode of admitted patient care to hospital) accounted for 136,156 (1.2%) of these separations (Table S1.8a).
• The total number of drug-related hospital separations increased from 116,778 in 2013–14 to 137,733 in 2016–17, but decreased to 136,156 in 2017–18. At the same time, total hospital separations have increased, with drug-related hospital separations consistently making up about 1% of all hospital separations across this 5-year period (Table S1.8b).
• Sedatives and hypnotics continued to account for the highest proportion of hospital separations with a drug-related principal diagnosis (60% of all such separations), with alcohol making up 88% of separations for sedatives and hypnotics (Figure IMPACT3).
• Stimulants and hallucinogens, which includes cannabis, cocaine and methamphetamines, accounted for 17% of all separations where the principal diagnosis was drug-related (Table S1.8a).
• Overnight separations continued to be more common for drug-related treatment than same-day separations, accounting for 60% of all drug-related separations (Table S1.8a).
• There was a notable increase in methamphetamine drug-related principal diagnoses, rising from 3.1% of all drug-related principal diagnoses in 2013–14 to 7.6% of all drug-related principal diagnoses in 2017–18 (Table S1.8b).

Analysis of the National Hospital Morbidity Database by the National Drug and Alcohol Research Centre (NDARC) identified a lower number of drug-related hospital separations in 2017–18 (60,627) (Chrzanowska et al. 2019) than the AIHW analysis (tables S1.8a-c). This is primarily due to the exclusion of alcohol-related hospital separations from the NDARC analysis (see Box IMPACT2).

According to the NDARC analysis:

• the 5 drugs responsible for the highest proportion of drug-related hospital separations in 2017–18 were: amphetamines and other stimulants (23%); antiepileptic, sedative-hypnotic and antiparkinsonism drugs (16%); opioids (14%); non-opioid analgesics (13%); and cannabinoids (10%). The AIHW analysis, excluding alcohol, provides similar findings.
• the age-standardised rate of drug-related hospital separations in 2017–18 (250 per 100,000 population) was lower than that for 2015–16 and 2016–17 (both 272 per 100,000 population). However, the rate remains higher than rates reported for previous years (Chrzanowska et al. 2019).

Mental health conditions

There is a strong association between illicit drug use and mental health issues. According to the 2019 NDSHS:

• between 2016 and 2019 there was an increase in the proportion of people who had recently used an illicit drug (in the past 12 months) experiencing high or very high levels of psychological distress (from 22% to 26%)
• the proportion of recent drug users who had been diagnosed with or treated for a mental health condition in the previous 12 months remained stable at around 26% (Table S1.9). 

Increases in mental health issues were reported by participants of the 2019 Ecstasy and Related Drugs Reporting System (EDRS), where the primary issue of concern reported among this population of regular ecstasy and other stimulant users was anxiety (76%) and depression (68%) (Peacock et al. 2019a) (refer to Box HARM1 for more information).

Pregnancy complications

Tobacco smoking in pregnancy is the most common preventable risk factor for pregnancy complications, and is associated with poorer perinatal outcomes, including low birthweight, being small for gestational age, pre-term birth and perinatal death.

Data from the National Perinatal Data Collection showed, in 2018, that babies of mothers who smoked during pregnancy were more likely than babies of mothers who did not smoke to be:

• low birthweight (12.7% compared with 6.0% of liveborn babies)
• small for gestational age (16.1% compared with 8.7% of liveborn singleton babies)
• born pre-term (14.0% compared with 8.1%) (AIHW 2020a).

Alcohol consumption during pregnancy is also associated with adverse impacts for development of the fetal brain. Fetal alcohol spectrum disorder (FASD) is the term used to describe the effects of prenatal alcohol exposure including fetal alcohol syndrome (FAS). There are currently no data available indicating the prevalence of FASD in Australia, however there have been some jurisdictional based studies which reported birth prevalence of FAS of between 0.01 and 0.68 per 1000 live births. Higher prevalence of FAS is commonly found among Indigenous communities, likely reflecting socioeconomic factors and patterns of alcohol use (Burns et al. 2013).

The 2009 Australian Guidelines to reduce Health risks from Drinking Alcohol from the National Health and Medical Research Council state, that for women who are pregnant or planning a pregnancy or breastfeeding, not drinking is the safest option (NHMRC 2009).

The 2019 NDSHS showed that 65% of pregnant women abstained from drinking alcohol during their pregnancy; this is an increase from 40% in 2007 and 56% in 2016. The remaining women reported that they reduced their drinking during pregnancy (35%) compared with when they were not pregnant, and less than 1% reported drinking the same (AIHW 2020b).

Injection-related harms

The 2019 NDSHS estimates that a very low proportion of the Australian general population aged 14 and over have injected drugs, either in their lifetime (1.5%) or in the past 12 months (0.3%) (AIHW 2020b) (tables S2.31 & S2.32).

The Australian Burden of Disease Study 2015 showed that 0.5% of the total burden of disease and injuries were related to unsafe injecting practices (AIHW 2019b). This was specifically linked to acute Hepatitis C (75% of the attributable burden), acute Hepatitis B (37%), chronic liver disease (24%), liver cancer (24%) and HIV/AIDs (8%).

Data from the Australian NSP survey provides some evidence of the harms related to injecting drug use in persons who regularly inject drugs in Australia:

• the proportion of respondents reporting recent reuse of needles and syringes (including the reuse of one’s own syringes) increased from 21% in 2014 to 26% in 2018
• the proportion of respondents reporting receptive sharing of needles and syringes in the last month increased from 16% in 2014 to 18% in 2018
• nationally, HIV antibody prevalence has remained low and stable from 2014 to 2018 (between 1.4% and 2.1%), with some populations at greater risk than others (Heard et al. 2019).

Data from the Illicit Drug Reporting System (IDRS) provides additional evidence of risk of harms and actual experience of harms, including (Peacock et al. 2019b):

• 11% of participants of the 2019 IDRS reporting lending a needle to someone after they had used it, and 8% reported borrowing a needle after someone else had used it. Re-use of their own needle was reported by 44% of IDRS participants (Table S3.65)
• 45% of the IDRS sample experienced an injection-related health problem in the month preceding interview. The most common health problems were a dirty hit (22%), nerve damage (20%) and an artery injection (15%) (Table S3.66). 

Overdose

People who use illicit drugs or pharmaceutical drugs for non-medical purposes can place themselves at high risk of fatal and non-fatal overdose.

National data on drug-related ambulance attendances are currently not available, but Victorian data show that the level of harm is considerable. In 2017–18, in Victoria, the rate of ambulance attendances involving any illicit drug was 206.6 per 100,000 population (12,768 attendances). The rate of ambulance attendances involving the licit or illicit use of pharmaceuticals was 178.2 per 100,000 (11,013 attendances) (Turning Point 2018). 

Data from the 2019 IDRS and EDRS shows rates of self-reported overdose:

• Of participants of the 2019 IDRS, 12% reported a heroin overdose in the past 12 months (Peacock et al. 2019b).
• Of regular ecstasy and other stimulant users who participated in the 2019 EDRS, 22% reported experiencing a non-fatal stimulant overdose in the past 12 months (Peacock et al. 2019a).

References

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ABS 2018. Causes of Death, Australia, 2017. ABS cat. no. 3303.0. Canberra: ABS. Viewed 12 October 2018.

ABS 2019. Causes of Death, Australia, 2018. ABS cat. no. 3303.0. Canberra: ABS. Viewed 15 October 2019.

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AIHW 2019b. Australian burden of disease study: Impact and causes of illness and death in Australia 2015. Series no.19. BOD 22. Canberra: AIHW. Viewed 13 June 2019.

AIHW 2019c. Burden of tobacco use in Australia: Australian Burden of Disease Study 2015. Australian Burden of Disease series no. 21. Cat. no. BOD 20. Canberra: AIHW.

AIHW 2020a. Australia’s mothers and babies 2018 – in brief. Perinatal statistics series no. 36. Cat. no. PER 108. Canberra: AIHW. Viewed 29 May 2020.

AIHW 2020b. National Drug Strategy Household Survey 2019. Drug statistics series no. 32. Cat. no. PHE 270. Canberra: AIHW. Viewed 16 July 2020.

Burns L, Breen C, Bower C, O’Leary C & Elliott E 2013. Counting fetal alcohol spectrum disorder in Australia: the evidence and the challenges. Drug and alcohol review. 32(5): 461-467.

Chrzanowska A, Man N, Degenhardt L, Dobbins T & Peacock A 2019. Trends in drug-related hospitalisations in Australia, 1999-2018. Drug Trends Bulletin Series. Sydney: National Drug and Alcohol Research Centre, UNSW Sydney. Viewed 8 January 2020.

Heard S, Iversen J, Geddes L & Maher L 2019. Australian Needle Syringe Program Survey National Data Report 2014-2018: Prevalence of HIV, HCV and injecting and sexual behaviour among NSP attendees. Sydney: Kirby Institute, UNSW.

Man N, Chrzanowska A, Dobbins T, Degenhardt L & Peacock A 2019. Trends in drug-induced deaths in Australia, 1997-2018. Drug Trends Bulletin Series. Sydney: National Drug and Alcohol Research Centre, UNSW Sydney. Viewed 8 January 2020.

NHMRC (National Health and Medical Research Council) 2009. Australian guidelines to reduce health risks from drinking alcohol. Canberra: NHMRC. Viewed 12 October 2017.

Peacock A, Karlsson A, Uporova J, Gibbs D,  Swanton R, Kelly G, Price O, Bruno R, Dietze P, Lenton S,  Salom C, Degenhardt L & Farrell M 2019a. Australian Drug Trends 2019: Key findings from the National Ecstasy and Related Drugs Reporting System (EDRS) Interviews. Sydney, National Drug and Alcohol Research Centre, UNSW Australia.

Peacock A, Uporova J, Karlsson A Gibbs D, Swanton R, Kelly G, Price O, Bruno R, Dietze P, Lenton S, Salom C, Degenhardt L & Farrell M 2019b. Australian Drug Trends 2019: Key findings from the National Illicit Drug Reporting System Interviews. Sydney, National Drug and Alcohol Research Centre, UNSW Australia.

Penington Institute 2020. Australia’s annual overdose report 2020. Melbourne: Penington Institute. Viewed 31 August 2020.

Turning point 2018. Ambo-AODstats. Melbourne: Victoria. Viewed 6 June 2018.