Illicit opioids, including heroin

Opioids refer to a class of drugs that are naturally or synthetically derived from the opium poppy plant (ACIC 2019; NSW Ministry of Health 2017). Diacetylmorphine, commonly known as heroin, is a derivative of morphine, an alkaloid contained in raw opium (ACIC 2020).

This section focuses on the harms, availability and consumption of illicit opioids including heroin, as distinct from pharmaceutical opioids such as morphine, methadone and oxycodone. See the section on the non-medical use of pharmaceutical drugs for recent trends and data in relation to the use and harms for pharmaceutical opioids.

Availability

 The availability of heroin in Australia has fluctuated over time. In the early 2000s, there was a rapid and considerable reduction in the availability of heroin in Australia (commonly referred to as the heroin shortage or drought) and this was associated dramatic reductions in heroin-related overdoses (Degenhardt et al. 2004).

Since then, the availability of heroin has steadily increased. Prior to COVID-19 in 2020, the Illicit Drug Reporting System (IDRS) showed no significant changes in the perceived availability, pricing and purity of heroin in Australia, as reported by people who inject illicit drugs (Peacock et al. 2019). This suggests that the Australian heroin market was highly stable (Table S2.11). In 2020, the price of heroin remained relatively stable compared to other years. However, there were some changes in the perceived purity and availability of heroin. More specifically, in 2020:

  • there was a significant reduction in the proportion of people who believed heroin was ‘very easy’ to obtain (35%, compared to 54% in 2019)
  • a higher proportion of people perceived heroin as being ‘difficult’ to obtain (19%, compared to 9% in 2019)
  • over 2 in 5 (44%) participants believed the purity of heroin was ‘low’, an increase from 27% in 2019 (Peacock et al. 2021).

Notably, IDRS interviews were conducted from June–September 2020, after COVID-19 restrictions were introduced in Australia (Peacock et al. 2021). This should be taken into account when comparing these data with previous years.

The number of heroin detections at the Australian border has fluctuated over the past decade, with the long-term trend remaining relatively stable. The number of heroin detections at the Australian border has decreased 26% over the last decade, from 250 in 2009–10 to 184 in 2018–19. However, the weight of heroin detected has increased 141% over the same period, from 117.5 kilograms in 2009–10 to 283.4 kilograms in 2018–19. There has also been an increase in both the number and weight of national heroin seizures over the past decade. Between 2009–10 and 2018–19 the number of national heroin seizures increased 32% from 1,582 up to 2,080, while the weight of heroin seized increased 165% from 74.7 kilograms to 197.7 kilograms (ACIC 2020).

Consumption

The National Drug Strategy Household Survey (NDSHS) shows that heroin use among the general population has remained low in Australia between 2001 (0.2%) and 2019 (less than 0.1%) (Figure HEROIN1). However, between 2016 and 2019, more people reported heroin to be the drug of most concern to the community (7.5% compared with 8.5%) and thought it caused the most deaths (10.6% compared with 11.9%) (tables S2.37 and S2.70; AIHW 2020b).

Figure HEROIN1: Lifetime and recent use of heroin, people aged 14 and over, 2001 to 2019 (per cent).

The figure shows the proportion of lifetime and recent use of heroin for people aged 14 and over between 2001 and 2019. In 2019, only 0.1% of people aged 14 and over reported using heroin in the last 12 months and this has remained stable since 2001. Lifetime use of heroin has been decreasing since 2007, from 1.6% to 1.2% of people aged 14 and over.

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The National Wastewater Drug Monitoring Program (NWDMP) also indicates that heroin consumption in Australia is relatively low, although consumption increased throughout 2020. Estimated population-weighted average consumption of heroin reached its highest level since the program commenced in April 2020 for regional areas, and in August 2020 for capital city sites (ACIC 2021).

Geographic trends

NWDMP data show that heroin consumption varies by geographic area, with capital city average consumption continuing to exceed regional average consumption. From April to August 2020, the population-weighted average consumption of heroin increased in capital cities and decreased in regional sites. Consumption then decreased in capital cities in October 2020. The estimated weight of heroin consumed has increased from 830 kilograms in 2016–17 to 1,021 kilograms in 2019–20 (ACIC 2021).

Harms

Heroin is a central nervous system depressant. Like other opioids, it binds to receptors in the brain, sending signals to block pain and slow breathing.

Heroin may be snorted, swallowed or smoked, but is most commonly melted from a powder or rock form and injected. Injection comes with a range of additional harms associated with the unsanitary sharing of injecting equipment, such as the transmission of blood borne viruses like Hepatitis C and HIV (Table HEROIN1).

Table HEROIN1: Short and long-term effects of heroin use

Short-term effects

Long-term effects

  • Analgesia
  • Cough suppressant
  • Euphoria
  • Dry mouth
  • Heavy feeling in hands and feet
  • Nausea and vomiting
  • Severe itch
  • Drowsiness
  • Respiratory depression resulting in fatal and non-fatal overdose, especially when used in conjunction with other sedative substances including benzodiazepines and alcohol
  • Severe constipation
  • Tooth decay (from lack of saliva)
  • Irregular menstrual periods in females
  • Impotence in males
  • Loss of appetite and weight
  • Neurochemical changes in the brain
  • Memory impairment
  • Mental health issues including depression
  • Physical dependence and associated withdrawal, which manifest as flu-like symptoms

Source: Adapted from ACIC 2019a; Nielsen & Gisev 2017; NSW Ministry of Health 2017.

Hospitalisations

Opioid poisoning can result in significant harm, including respiratory failure, aspiration, hypothermia and death. In
2016–17, hospitalisations with a principal diagnosis of opioid poisoning were more likely to involve pharmaceutical opioids than heroin or opium (AIHW 2018).

The number of hospitalisations for opioid poisoning continues to increase over time. Between 2007–08 and 2016–17 there was a 25% increase in the number of hospitalisations with a principal diagnosis of opioid poisoning (from 14.1 to 17.6 per 100,000 population, after adjusting for age) (AIHW 2018).

Burden of disease and injury

Opioid use was responsible for 1.0% of the total burden of disease and injuries in Australia in 2015 and 37% of the total burden due to illicit drug use (Table S2.69). 

Most of the burden due to opioid use was due to 2 linked diseases: poisoning and drug use disorders (excluding alcohol). Poisoning contributed to 20%, and drug use disorders (excluding alcohol) to 31%, of the total burden due to opioid use. A further 2.9% of the burden due to opioid use was attributable to suicide and self-inflicted injuries (AIHW 2019a).

Ambulance attendances

Data on alcohol and other drug-related ambulance attendances are sourced from the National Surveillance System for Alcohol and Other Drug Misuse and Overdose report. Data for heroin-related attendances for 2019 are available for New South Wales, Victoria and the Australian Capital Territory. Data are not presented for Tasmania due to low numbers of attendances. Data are presented for 4 snapshot months per year, specifically March, June, September and December. Please see the data quality statement for further information.

The rate of heroin-related attendances ranged from 8.4 per 100,000 population in New South Wales to 18.0 in the Australian Capital Territory and 18.1 in Victoria.

Across the 3 reporting jurisdictions, the majority of heroin-related attendances were for males. The median age of attendances were similar across jurisdictions—39 years in the Australian Capital Territory and 40 years in both New South Wales and Victoria.

Higher rates for heroin-related ambulance attendances were reported in metropolitan areas for New South Wales (10.1 per 100,000 population compared with 4.8 for regional areas) and Victoria (21.3 per 100,000 population compared with 8.1 for regional areas).

In New South Wales, a higher proportion of heroin-related attendances were transported to hospital in metropolitan areas than in regional areas (67% and 60%, respectively). In Victoria, 50% of heroin-related attendances in metropolitan areas were transported to hospital compared with 62% in regional areas. In the Australian Capital Territory, 38% of attendances were transported to hospital (Table S2.81) (Moayeri et al. 2020).

Deaths

The risk of overdose in heroin users is high, especially when used in conjunction with other drugs like benzodiazepines (e.g. alprazolam, diazepam) and alcohol.

Opioids, including both licit and illicit substances, have been the leading class of drug present in drug-induced deaths in Australia for the last 2 decades. Of the 1,865 drug-induced deaths in Australia in 2019, 474 or 25% were due to heroin—the highest number of deaths attributed to heroin since 1997 (Figure HEROIN2). Overall, the rate of death attributed to heroin in Australia has increased from 1.0 per 100,000 people in 2010 to 1.9 per 100,000 in 2019 (Table S1.1). However, the rate has remained steady at 1.9 per 100,000 population between 2017 and 2019. The rate of drug-induced deaths where heroin was identified was higher in Major cities than in Regional and remote areas in 2019 (2.1 deaths per 100,000 population compared with 1.2 deaths per 100,000 population) (Table S2.71).

Figure HEROIN2: Number of drug-induced deaths for all opioids and heroin only, 1997 to 2019

The figure shows that the number of drug-induced deaths due to all opioids and heroin only steadily increased from 2006 to 2017. The number of deaths due to all opioids has decreased from 1,373 in 2017 to 1,129 in 2019, while the number of deaths due to heroin has increased from 444 to 474 in the same period.

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In 2018, deaths with heroin identified had a lower median age at death compared with pharmaceutical opioids (41.2 years for deaths with heroin identified, compared with 46.6 years for pharmaceutical opioids) (ABS 2019).

Although the rate of deaths involving heroin are not as high as they were in the late 1990s when heroin consumption was at its peak in Australia (Degenhardt, Day & Hall 2004), deaths involving heroin have significantly increased in recent years (Table S1.1). However, there are some challenges in interpreting the numbers of heroin deaths, as heroin can be difficult to identify at toxicology because it is rapidly metabolised by the body and resultant morphine metabolites cannot be distinguished from other morphine sources.

The increase in deaths due to heroin in Australia is consistent with international trends. These increases have been attributed to increases in heroin purity and availability, and also because the ageing cohort of heroin users have a range of medical conditions resulting from long-term drug use, making them particularly vulnerable (UNODC 2019).

Treatment

Data collected for the AODTS NMDS are released twice each year—a key findings report in April and a detailed report in June. Detailed information about closed treatment episodes for heroin will be updated in June 2021.

Data from the 2018–19 AODTS NMDS showed that heroin was the principal drug of concern in 5.2% of closed treatment episodes provided for client’s own drug use (Table S2.76).

  • Injecting was the most common method of use in most episodes where the principal drug of concern was heroin (79%) (AIHW 2020a).
  • Client demographics where heroin was the principal drug of concern:
    • Around 68% of clients were male (Table S2.77) and 1 in 6 (16.1%) clients were Indigenous (Table S2.78).
  • Source of referral for treatment:
    • The most common source of referral for treatment where heroin was the principal drug of concern was self/family (45% of treatment episodes), followed by a health service (29%) and diversion (6.9%) (Table S2.79).
  • Type of treatment:
    • The most common main treatment types were counselling (26% of treatment episodes), followed by assessment only (19.2%) and withdrawal management (13.0%) (Figure HEROIN3; Table S2.80).

Figure HEROIN3: Snapshot of closed treatment episodes for own heroin use, 2018–19 (per cent)

The figure shows that heroin was a principal drug of concern for clients’ own drug use in 5.2% of closed treatment episodes in 2018–19. The most common main treatment type provided to clients for their own heroin use was counselling (26%). Around 1 in 6 clients (16.1%) who sort treatment for their own heroin use were Indigenous Australians.

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Treatment agencies whose sole function is prescribing or providing dosing services for opioid pharmacotherapy are excluded from the AODTS NMDS. Due to the multi-faceted nature of service delivery in this sector, these data are captured in the National Opioid Pharmacotherapy Statistics Annual Data (NOPSAD) collection.

NOPSAD data showed that nationally in 2020, 37% of clients reported heroin as their opioid drug of dependence. However, this data should be used with caution due to the high proportion of clients with ‘not stated/not reported’ as their drug of dependence in New South Wales (64%), Victoria (33%) and Tasmania (19%) (AIHW 2021b).

Further information on pharmacotherapy in Australia.

At-risk groups

Indigenous Australians are overrepresented in treatment services for heroin as the principal drug of concern. See also: Illicit drugs in the Aboriginal and Torres Strait Islander people section.

Heroin is commonly injected and so its use is overrepresented among people who inject drugs. See also: Illicit drugs in the People who inject drugs section.