Locally and internationally, the rising use of opioids is a cause of concern. All opioids—including codeine—can be addictive and their use can result in dependence, accidental overdose, hospitalisation or death.
This report brings together information from a range of data sources to tell the national story of opioid use and its harmful effects. It is the first time that the AIHW has produced such a comprehensive report that presents current national data and trends on opioid use and harms in Australia. The report also presents findings from a collaboration between the AIHW and the Canadian Institute for Health Information (CIHI). This includes comparisons between ED presentations and hospitalisations in Australia and Canada, where possible, and discussion of the benefits and challenges of international collaboration.
In Australia in 2016–17, 3.1 million people had 1 or more prescriptions dispensed for opioids (most commonly for oxycodone); about 40,000 people used Heroin; and about 715,000 people used Pain-killers/analgesics and pharmaceutical opioids for illicit or non-medical purposes.
Opioid deaths and poisoning hospitalisations have increased in the last 10 years
Legal or pharmaceutical opioids (including codeine and oxycodone) are responsible for far more deaths and poisoning hospitalisations than illegal opioids (such as heroin). Every day in Australia, nearly 150 hospitalisations and 14 emergency department (ED) presentations involve opioid harm, and 3 people die from drug-induced deaths involving opioid use.
In 2016, the number of opioid deaths (1,119) was the highest number since the peak in 1999 (1,245 deaths). After 1999, the number of deaths fell to a low of 439 in 2006, then began to climb again.
In 2016, opioid deaths accounted for 62% of all drug-induced deaths. From 2007 to 2016, after adjusting for differences in the age structure of the population, the rate of opioid deaths increased by 62%, from 2.9 to 4.7 deaths per 100,000 population. The increase was driven by an increase in accidental opioid deaths and in pharmaceutical opioid deaths.
Similarly, from 2007–08 to 2016–17, after adjusting for age, the rate of hospitalisations per 100,000 population with a principal diagnosis (main reason for hospitalisation) of opioid poisoning increased by 25%, while the rate of hospitalisations with any diagnosis (all reasons for hospitalisation) of opioid poisoning increased by 38%.
Pharmaceutical opioids are responsible for more opioid deaths and poisoning hospitalisations than heroin
In 2016, the most commonly mentioned opioid in opioid deaths was Naturally derived opioids (for example, oxycodone, codeine and morphine), which was mentioned in 49% of opioid deaths.
Similarly, in 2016–17, hospitalisations with a principal diagnosis of opioid poisoning were more likely to involve pharmaceutical opioids than heroin or opium. The rate per 100,000 for those by Naturally derived opioids was more than twice as high as for those by Heroin.
More opioid prescriptions were dispensed but on average prescriptions were for lower doses and/or quantities
In 2016–17, 15.4 million opioid prescriptions were dispensed under the Pharmaceutical Benefits Scheme (PBS) to 3.1 million people.
The oral morphine equivalent (OME) is a measure of opioid use that adjusts for the difference in potency between different opioids. It converts the amount of each opioid dispensed to the amount of oral morphine that would be required to produce the same pain-relieving effect. After adjusting for differences in the age structure of the population, from 2012–13 to 2016–17, although there was a rise in the rate of prescriptions dispensed per 100,000 population and the number of people per 100,000 population receiving them (9% and 4% respectively), the OME stayed the same over the same period (989 to 987 OME mg per 1,000 population per day)—on average, the prescriptions dispensed were for lower doses and/or quantities.
Oxycodone and codeine most commonly dispensed opioids
Oxycodone was the most commonly dispensed prescription opioid in 2016–17, with 5.7 million prescriptions dispensed to 1.3 million people, followed by codeine (3.7 million prescriptions to 1.7 million people) and tramadol (2.7 million prescriptions to 600,000 people).
Similar to the results for all opioid prescriptions dispensed, on average prescriptions dispensed for oxycodone were for lower doses and/or quantities. After adjusting for differences in the age structure of the population over time, from 2012–13 to 2016–17 there was approximately a 30% rise in both the number of oxycodone prescriptions dispensed per 100,000 population and the number of people receiving them per 100,000 population, but the OME over the same period remained the same (338 to 340 OME mg for oxycodone per 1,000 population per day).
Higher rates of OME for opioids dispensed in Inner regional and Outer regional areas
After adjusting for differences in the age structure of the population, the total number of prescriptions dispensed per 100,000 population was highest for Inner regional areas (74,000 per 100,000 population) and lowest for Very remote areas (38,000 per 100,000 population). The rate of OME was also highest for Inner regional areas (1,374 OME mg per 1,000 population per day), followed closely by Outer regional areas (1,362 OME mg per 1,000 population per day). These rates of OMEs are 2 times higher than in Very remote areas, which at 645 OME mg per 1,000 population per day was the lowest of all areas.
1 in 10 Australians have ever used any type of opioid for illicit or non-medical purposes
In 2016, around 1 in 10 (11%) of Australians aged 14 and over had ever used at least 1 type of opioid for illicit or non-medical purposes; recent use (that is, use in the last 12 months) was much lower, at 3.7%. Most had used pharmaceutical opioids rather than illegal opioids, with 9.7% having ever used Pain-killers/analgesics and pharmaceutical opioids, compared with 1.3% who had ever used Heroin.
Of people who reported non-medical use of Pain-killers/analgesics and pharmaceutical opioids, 75% had used Over-the-counter codeine products, 40% had used Prescription codeine products and 17% had used Oxycodone.
Opioid use varies between Australia and Canada
Both Australia and Canada have government-funded pharmaceuticals. Overall, there was a downward trend in both countries in the total average opioid dosage (the defined daily dose or DDD) per 1,000 people, per day prescribed in the 5 years to 2016–17. However there were slight differences in the types of opioids prescribed, with the DDD rate for hydromorphone substantially higher in Canada, and the DDD rate for tramadol and buprenorphine higher in Australia. Both countries had a similar DDD rate for fentanyl.
Illicit use of fentanyl is more common in Canada than it is in Australia, while heroin use is comparatively higher in Australia than in Canada. The impact of this difference is that people using these different drugs—while they are all opioids—have different trajectories and contact with the acute care system. Fentanyl is more potent than heroin and has a greater potential to be lethal, meaning many users die before they can receive acute care.
Side effects from opioid use are responsible for the greatest number of hospitalisations in both Canada and Australia
Despite differences in the rates of hospital care in Australia and Canada for opioid harms—due in part to differences in systems and infrastructure for health services—there are similarities in the profiles of people most likely to receive hospital care for opioid harm.
In both Australia and Canada, the greatest volume of harm treated in hospitals came from side effects from opioid use. The age distribution for people hospitalised for this reason was similar in Australia and Canada, with rates of hospitalisation increasing with increasing age, reflecting the rates of prescription opioids in both countries.