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Australian Institute of Health and Welfare 2018. Opioid harm in Australia and comparisons between Australia and Canada. Cat. no. HSE 210. Canberra: AIHW.
Australian Institute of Health and Welfare Board Chair Mrs Louise Markus
Director Mr Barry Sandison
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Australian Institute of Health and Welfare GPO Box 570 Canberra ACT 2601 Tel: (02) 6244 1000 Email: info@aihw.gov.au
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Contents
ACKMOWICOBINGHES wands scan acuewiedian CPAs ee Clas RRR RAKE EOD eC ede ey akenneees vi ADDIS VIGUONS 44.94 cde cane ph ees arn en sab Geese Ose eae e pelle ae Kae Canes sown eesoreeds vii SVIMDOINS .iccndsia ie sienebxeyed tae SRs ae Rese ESSE akS REE RRA ESR ase eee Rese eTA vii
WitdibareOnigids) c:240 wees ee kenenee ech ve Ghee ee heed ee ee wee eee es eee peau oeree 2 ORIOIG USE, cchscee re kerp ines Gedo ener EES aed weSF AEST AA RS PASS HERS PERE aRSP aR 4 OIGIG Hanae casas d baba ac ecehs Sameera teehee anes ee laa baeoee ce bo ) Opioid use and harm internationally «. .os cicc cies i vaawind ide vaieevewuine eaeees 6 Whatis the pufpose of UNS FEDORT? eos ies cog oe eue cusyneheeces Hees eee Re Reeeee Fe 7.
& US@ OF OPlOMdS:.. 1255 Fake cia hewerdeceesh bho eiee ecb iid tebwd saw eshie sees cia de 2
Medicahise OF Otigls 4) cnvcyedcavencpigee tye dee ecaeods ae eee eens peemees 12 Illicit and non-medical use of OpiOidS... 6... ke eee cece te eee een e te enees 23 Wastewater consumption monitoring ....... 0. cece ect ene 28 & OPIGIG POISONING sc xs-scecns ive den ewe nce pad dees eee s es eebered deepen eeeny aes 30
ED arid hospital care tor Opioid POISONING; . 5.cvc0sedecvere ves eeous4 seer esse ee Sees 32 ORIOIO MESS 5 cee eee ae ehp cee Pee es ROY Y KOHy dee CAOPRCRY oe AE RRSP aCe eS 45
DIGIC GEDGNG ENCE io oice ob eke rece eos tree tant beeebnciece eed ewe ees eee es 56
7 ED and hospital care for opioid dependence ............... cece cc eee reece nets 58
Specialised treatment services for dependence............ cece cece eee e eet e tees 65
Opioid PRalMacoMerapy ccs cos face PES PAAL RO SHAEED EASE RRS TACs HERS ERR REESE 4 66
& Other mental and behavioural harms due to use of opioids................. eee 68 // ED and hospital care for other mental and behavioural disorders due to
IS OR Sis oo nae ord gree eet ate coco Gee aod Gate steatee Vee ae aeg toes 69
How comparable are ED and hospital admitted patient care data for
Australia and Canada? oiis sven ica S Sw ido bE Ade PERE Lee Rows ek ee rds 76
DISCUSSION §)6/-455.4:2 6244 $46 SS AGERE RD OE ESS ARREARS SEEATARIRA EDS EMI ADERTT SS 82
SuiimMaly Ot MNGINES: 35 iets cane cetianes kehpamee eee aay a Ste eases ss aayEetes 83
What can be learnt from the collaboration with Canada?........... 00. cece eee eee 87
What is being done to reduce opioid harm in Australia?... 0... 0... eee eee eee 87
What are Ihe data 2apst ie) s6epanee dckeay ride eens Meee ceby desea he eeepeeees 89
Appendix A: Data sources and Methods ... 5.064.066 ssccsccnpee tee rentceo reece newe ne een eate 90 Alcohol and Other Drug Treatment Services National Minimum Data Set..................00.. 90 National Drug Stratesy Household Suey. ccct. eden ee wereae dtu te eauitds Sieeewenenearedies 91 National Hospital Morbitity Database cco ciws oe ett caSenh shee Seth heehee eee ceeeel hes 92 National Mortality Database: «ic3cides ccdotds bende dded Cans iekga tens ieheucdaids i viasianan 94 National Non-admitted Patient Emergency Department Care Database (NNAPEDC)............ 97 National Opioid Pharmacotherapy Statistics Annual Data collection ............ 0. eee eee eee 100 National Wastewater Drug Monitoring Program. ......... cee cece eee eee nee eee ee 100 Pharmaceutical Benetits Scheme data. cic. cc cies ce verde eSedn sans ves Ba eave Ge ee ead eee ebes 101 MetnOdS sc cictctded cdeb icc decd edeee bens ida bee tdbacntdudaee eeoieeeiedadeseeiaskdes 104 Comparability of Australian and Canadian ED and hospital presentation data................ 105 GIOSSAIY :craaonsn canes vie leases nee ewaGe Mrs CAs eRe EHE Ree ON TEehE eens Wem ere ie 106 RGlGrenCes, « deta-as Guise one eeae shawn s Pherae else see nee ees eilewes tesees pele Saxan ene 108 LiSC Of tables ¢j.6isexi xia be8GSe or cena eden aed NKSEA TER RS Oe Re NIE REECE ORE SEA DEER Oe 113 LISCOMTIPUNGS ioc aatiedindoediesesww ened eGineeavotes deeds bes veateds eiecnanvatesdeautses 114
RElated PUDNCATIONS 5 64c5ds Sutras er ee heey eee ee eeG a ete Rete eee SORT eee eee heees 116
vi
Acknowledgments
Jennifer Kerrigan, Ruby Brooks and Lizzie Gorrell of the Population Health Unit of the Australian Institute of Health and Welfare (AIHW) wrote this report, under the guidance of Claire Sparke, Moira Hewitt and Lynelle Moon.
The comparisons with Canada were written in collaboration with Jennifer Frood and Tracy Johnson from the Canadian Institute for Health Information (CIHI).
Geoff Neideck and Matthew James from the AIHW reviewed this report, and Cathy Claydon, David Whitelaw, Dian Xu, Fiona Elliot, James Katte, Josh Sweeney, Karen Bishop, Kevin Monahan, Kristina Da Silva, Lachlan Facchini, Marissa Veld, Micaella Watson and Steve Glaznieks from the AIHW provided input and advice.
Suzanne Nielsen, Louisa Degenhardt, Chris Killick-Moran and staff from CIHI reviewed the report and provided valuable feedback.
Abbreviations
ABS ACIC AIHW AOD
AODTS NMDS
ATC
CIHI DDD
ED
NCIS NDS NDSHS NHMD NMD NNAPEDC NOPSAD NWDMP OECD OME PBS
TGA WHO
Australian Bureau of Statistics
Australian Criminal Intelligence Commission
Australian Institute of Health and Welfare
alcohol and other drug
Alcohol and Other Drug Treatment Services National Minimum Data Set Anatomical Therapeutic Chemical
Canadian Institute for Health Information
defined daily dose
emergency department
National Coronial Information System
National Drug Strategy
National Drug Strategy Household Survey
National Hospital Morbidity Database
National Mortality Database
National Non-admitted Patient Emergency Department Care National Opioid Pharmacotherapy Statistics Annual Data National Wastewater Drug Monitoring Program Organisation for Economic Co-operation and Development oral morphine equivalent
Pharmaceutical Benefits Scheme
Therapeutic Goods Administration
World Health Organization
Symbols
n.p.
not publishable because of small numbers, confidentiality or other concerns about the quality of the data
no change
Vii
viii
Summary
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.
ay 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).
&y Higher rates of OME for opioids dispensed in /nner 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 /nner 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 /nner 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.
ay 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.
Introduction
Opioid use and its associated harms is an issue of great public health interest, within Australia and internationally. Increasing opioid harm, related to both pharmaceutical and illegal opioids, has been reported in several countries, including the United States of America and Canada (CDC 2017; CIHI 2017b).
Opioid harm in Australia and comparisons between Australia and Canada
What are opioids?
Opioids are a group of pain-relieving drugs that work by interacting with the brain's opioid receptors and changing how they respond to pain stimuli. As well as relieving pain, opioids can produce euphoria (a sense of profound wellbeing).
Opioids can be grouped in several different ways. ‘Strong’ and ‘weak’ opioids are defined based on how much is needed to produce the desired pain-relieving effect, often in comparison with morphine. ‘Strong’ opioids are more potent, so a smaller amount is required to relieve pain compared with a ‘weak’ opioid. Hydromorphone and oxycodone are more potent than morphine, as is fentanyl, which is considered to be up to 100 times as potent as morphine (Chodoff & Domino 1965). More potent opioids are typically prescribed in smaller doses than morphine.
Opioids can also be grouped into pharmaceutical opioids and illegal opioids. It is important to note that pharmaceutical opioids can be misused or used illicitly (see ‘Opioid use’ later in this chapter).
Opioids include (Table 1.1):
* naturally derived opioids, which can be directly derived from—or synthesised using—opium poppies.
These include: Terms used - the illegal opioids heroin and opium in this report - the weak pharmaceutical opioid codeine Opioid: a type of pain-relieving
- the strong pharmaceutical opioids oxycodone, cl
buprenorphine and morphine date] a nat-(a-16)8( ¢-] me) o)(e)(e ome) ellel(ese- eli tele) (=
; ae ; with a prescription for medical purposes. * synthetic opioids, which may be
synthesised in a laboratory using NK=t=¥-) Me) o) fe) Le K-yaxe) oC ear lalemal-1ge)1 08 chemicals not derived from the opium Illicit opioid use: includes use of illegal poppy. These include: fo) o}fe)(e-yar- Tale maal mani emo) s
- the weak pharmaceutical opioid tramadol non-medical use of pharmaceutical
- the strong pharmaceutical opioids pethidine, opioids.
methadone, and fentanyl.
Box 1.1 at the end of this chapter outlines how opioids have been classified in this report, which differs between data sources.
Opioid harm in Australia and comparisons between Australia and Canada
Table 1.1: Opioids, by strength relative to oral morphine, by type
Strength Strength relative to oral morphine
Codeine Weak 0.13 Naturally derived opioids Tramadol Weak 0.20-0.24 Synthetic opioids Pethidine® Strong 0.4 Synthetic opioids Tapentadol Strong 0.4 Synthetic opioids Morphine Strong 1.0-3.0 Naturally derived opioids Oxycodone Strong 1.5-3.0 Naturally derived opioids Methadone Strong 4.7-13.5 Synthetic opioids
(often reported separately) Hydromorphone Strong 5-15 Naturally derived opioids Buprenorphine Strong 38.8-85.0 Naturally derived opioids Fentanyl Strong 100 Synthetic opioids
‘Mlegal opioids
Opium Weak 0.1-0.2 Naturally derived opioids
(often reported separately)
Heroin Strong 10-15 Naturally derived opioids (often reported separately)
(a) Pethidine ceased being subsidised by the Pharmaceutical Benefits Scheme (PBS) in 2012 so use is not included in the results of this report.
Notes 1. Based on milligrams of each opioid equivalent to 1 milligram of oral morphine. 2. Different preparations of each drug may equate to a different oral morphine equivalent; these are represented by a range.
Source: Gisev et al. 2018; Carnwath & Merrill 2002; UNODC 1953.
Pharmaceutical opioids
Pharmaceutical opioids can be obtained with a prescription from a health practitioner or used under their guidance in health-care settings. Before February 2018, it was also possible to obtain medicines containing low doses of codeine over the counter at pharmacies (that is, without a prescription). Pharmaceutical opioids may also be obtained through illicit means.
Pharmaceutical opioids can be effective for treating acute pain or cancer pain, though evidence to support their long-term use for chronic non-cancer pain is lacking (Currow et al. 2016).
General practitioners, specialist medical professionals, other doctors working in hospitals, and dental practitioners can prescribe pharmaceutical opioids. Some doctors are able to prescribe specialised pharmacotherapy opioids—including methadone or buprenorphine—which may be used to treat opioid dependence and manage the symptoms of withdrawal. Since 2010, some nurse practitioners have been able to prescribe pharmaceutical opioids (Department of Health 2017b; Department of Health 2010). Paramedics in ambulances can administer morphine—and in some states, fentanyl—to pre-hospital patients (ACT Ambulance Service 2010; Bendall et al. 2011).
Opioid harm in Australia and comparisons between Australia and Canada
The Therapeutic Goods Administration (TGA) must approve new drugs before they can be introduced into Australia. There are also clinical practice guidelines (RACGP 2017) and learning resources
(NPS MedicineWise 2018) for how and when pharmaceutical opioids should be used. Additionally, each manufacturer provides the TGA with descriptions for the approved indications listed in the Australian Register of Therapeutic Goods. These indications vary by brand; are vague; and are not always consistent with current clinical guidelines (TGA 2018a). The TGA is currently reviewing a number of regulatory response options to combat prescription opioid misuse and harms
(TGA 2018a, 2018b).
Illegal opioids
In Australia, it is illegal to manufacture, sell or possess opium and heroin.
Opium is derived from the white Indian poppy. It contains the chemicals morphine, codeine and thebaine and can be consumed in its raw form or processed to produce heroin or pharmaceutical
opioids. Opium poppies are grown in Australia and other parts of the world for use in pharmaceutical opioids, but the sale and unregulated use of the raw form is illegal in Australia.
Heroin was used as a legally prescribed medical treatment in Australia throughout the 19th century, but was prohibited in Australia in 1953 (Gibson et al. 2003) and is restricted (a Schedule 9 substance) with no approved therapeutic use. The effects of heroin include drowsiness, shallow breathing, slow heart rate and slurred speech (Drug and Alcohol Services South Australia 2017).
In the 1990s, the price of high-purity heroin dropped, making the drug more readily available in Australia. In 2001, this increased availability was curtailed by a number of factors including lower profits, increased Australian law enforcement efforts and lower production in source countries (Degenhardt et al. 2004). This change in supply led to a reduction in heroin-related fatal and non-fatal overdoses (Roxburgh et al. 2013a; The Royal Australasian College of Physicians 2009).
Opioid use
Opioid use includes:
* legal use of pharmaceutical opioids
+ illicit use, which includes use of illegal opioids, as well as misuse of pharmaceutical opioids. Misuse of pharmaceutical drugs, including opioids, refers to:
* non-medical use (for example, taking over-the-counter or prescription-only drugs for non-therapeutic purposes) (Barrett et al. 2008)
* use for therapeutic purposes (including extra-medical use): - without a valid prescription - ina greater quantity or frequency than prescribed
- in the context of iatrogenic dependence, which is a drug dependence that has developed following medical treatment.
Opioid harm in Australia and comparisons between Australia and Canada
There has been a growing trend of non-medical use of pharmaceutical drugs, broadly, in Australia (AIHW 2017d). In 2016, around 1 million Australians over the age of 14 had used a pharmaceutical drug for a non-medical purpose within the past year.
Opioids may be used for non-medical purposes to help manage withdrawal from illegal opioids, or to counter or enhance the effects of other illicit drugs (ACIC 2017).
Opioid harm Opioid use can result in a number of different social- and health-related harms, ranging in severity.
Opioids can cause constipation; nausea and vomiting; sedation; and dizziness. These effects can occur with therapeutic use of pharmaceutical opioids, as well as with misuse of pharmaceutical opioids or the use of illegal opioids.
Opioid poisoning can be caused by a range of circumstances, including taking more than prescribed (or in a larger amount); combining opioids with other sedative substances; loss of tolerance;
or a change in health status. Three key signs of opioid poisoning are unconsciousness; respiratory depression; and pinpoint pupils. Poisoning can result in ED treatment or hospitalisation and can lead to death.
Opioid dependence refers to a cluster of behavioural, cognitive and physical phenomena that can develop after repeated use of opioids (Australian Consortium for Classification Development 2017). These typically include a strong craving to use the substance; difficulties in controlling the use of opioid substances; continuing to use the substance despite the potential for harmful consequences; increased tolerance to the substance; physical withdrawal symptoms on cessation of use of the substance; and giving a higher priority to using the substance than to other obligations, such as work or study. Opioid dependence can relate to both pharmaceutical or illegal opioids: for example, iatrogenic dependence refers to the development of symptoms of dependence after the legitimate use of opioids prescribed by a medical professional (Hartman 2015).
Other opioid-related harms include injuries and deaths arising from violence to, or by, someone on opioids; negligent driving by someone on opioids; bloodborne viral infections (such as HIV and hepatitis C) from unsafe injecting practices; and social harms such as antisocial behaviour.
Burden from opioid use
Some of the health-related harms of opioid use can be quantified by burden of disease analysis, which measures the impact of different diseases or injuries on a population. It combines the burden of living with ill health (non-fatal burden) with the burden of dying prematurely (fatal burden).
In 2011, opioid use was responsible for 0.9% of the total burden of disease and injuries in Australia (AIHW 2018e). Most of the burden due to opioid use was due to Accidental poisoning, which accounted for 63% of the burden due to opioid use, and Opioid dependence, which accounted for 30%. A further 7.8% of the burden due to opioid use was from Suicide and self-inflicted injuries (AIHW 2018e).
Opioid use was responsible for just over half (51%) of all Accidental poisoning burden, all Opioid dependence burden and 3% of Suicide and self-inflicted injuries burden (AIHW 2018e).
Opioid harm in Australia and comparisons between Australia and Canada
Opioid use and harm internationally
Issues related to opioid use and harm have been reported in several countries. Although complicated by underlying differences in health systems, data definitions, social context, populations and
data availability, international comparisons of data are important. Such comparisons can aid in understanding how Australia performs compared with other countries, and effective approaches used by other countries that could be considered in Australia.
Licit opioid consumption can be measured using the defined daily dose (DDD) per capita, per day. This is a measure, per capita, of the assumed average doses of opioids for an adult, per day (see Box 2.1 for further information). Based on data from the International Narcotics Control Board, Australia has the 8th highest opioid consumption in DDDs per capita, per day, of 167 countries and territories (International Narcotics Control Board 2017). The United States ranks 1st, with around 46,100 DDDs per 1,000,000 population, followed by Canada, with around 30,600. Australia has around 15,700, which is more than either the United Kingdom (14,600) or New Zealand (11,500) (Figure 1.1).
Figure 1.1: Licit opioid consumption, defined daily doses per 1,000,000 population, countries and territories with highest consumption, 2014-16
United States
Canada
Germany Austria Denmark Switzerland Belgium
Australia
5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 50,000
oO
Defined daily doses per million inhabitants per day Note: Does not include buprenorphine.
Source: International Narcotics Control Board 2017.
The Global Burden of Disease Study compared mortality from opioid use disorders between 1997 and 2016 across 195 countries (Global Burden of Disease Collaborative Network 2017) (Figure 1.2). The study provides a useful tool for country comparisons using consistent or comparable methods for country estimates. It is important to note, however, that the Global Burden of Disease Study methods differ from those used in the Australian Burden of Disease Study and from Australian methods for identifying drug-induced deaths.
Opioid harm in Australia and comparisons between Australia and Canada
Among the countries shown in Figure 1.1, and based on data from the Global Burden of Disease Study, the age-standardised rate of deaths in 2016 was highest for the United States, which was around twice as high as the rates for Canada or Australia.
Figure 1.2: Age-standardised rates of deaths due to opioid-use disorders, selected countries, 1997 to 2016
7 he
Age-standardised rate (per 100,000 population)
0 1 nN 00 (en) j=) = N Mm tT wn \o ny ee) (on) oO = N ~m Tt wy oO oO (ep) oO oO oO oO oO oO oO oO je) oO [o) 7 - - - -_ - _ oO [op) (o>) j=) je) j=) je) j=) j=) jo) jo) je) je) j=) je) je) j=) oO oO oO —_ _ = N N N N N N N N N N N N N N N N N
Year eee Australia eee Austria eeeee Belgium Canada eweee Denmark ememe Germany eee Switzerland eee United States
Source: Global Burden of Disease Collaborative Network 2017.
What is the purpose of this report?
This report aims to bring together data from a range of sources to present a comprehensive description of opioid harm in Australia. It is the first time such a report has been produced by the AIHW and, although there are still data gaps, the report adds to the evidence base on opioid use and harms in Australia. It presents current national data and trends on prescription, non-medical and illicit use of opioids; opioid poisoning; and opioid dependence. This report also presents findings from a collaboration between the AIHW and the Canadian Institute for Health Information (CIHI), including high-level comparisons of prescription opioids; ED presentations and hospitalisations from opioid harms; and some of the issues explored and overcome in order to compare opioid harm in the 2 countries.
The classification of opioids varies between the data sources used in this report (Box 1.1), which should be borne in mind when comparing data from different sources.
Opioid harm in Australia and comparisons between Australia and Canada
Box 1.1: Classifications of opioids used in this report
In this report, data from the Pharmaceutical Benefits Scheme (PBS), used to report on dispensed prescriptions, are reported by active ingredients, such as oxycodone, codeine, fentanyl and so on.
Self-reported illicit and non-medical opioid-use data from the National Drug Strategy Household Survey (NDSHS) are reported in the following categories: * Heroin
* Pain-killers/analgesics and pharmaceutical opioids, which includes over-the-counter codeine products; prescription codeine products; oxycodone; tramadol; morphine; fentanyl; gabapentinoids; and other prescription pain-killers/pain relievers and opioids
* Methadone or buprenorphine * All opioids, which includes all of the above.
In 2016, there was a change in the survey to better capture non-medical use of opioids, which means the data for 2016 cannot be compared with data from previous years.
Data from the National Mortality Database (used to report on opioid deaths) are classified using the International Classification of Diseases, while data from the National Hospital Morbidity Database (used to report on opioid hospitalisations) are classified using the International Statistical Classification of Diseases and Related Health Problems, 10th revision, Australian modification. Data from both data sources are reported using the following categories in this report:
* Opium
* Heroin
* Naturally derived opioids, which includes codeine, morphine and oxycodone * Methadone
* Synthetic opioids, which includes pethidine, fentanyl and tramadol
* Other and unspecified opioids.
Currently, the quality of Australian emergency department data does not enable analysis of which opioids are involved in Opioid poisoning presentations.
Data from the specialist Alcohol and Other Drug Treatment Services National Minimum Data
Set (AODTS NMDS) and the National Opioid Pharmacotherapy Statistics Annual Data (NOPSAD) collection, which are used to report on treatment for opioid dependence, are classified using the Australian Standard Classification of Drugs of Concern, 2nd edition. Data from both data sources are reporting using variations of the following categories:
* Codeine
* Morphine
* Buprenorphine * Heroin
* Methadone
* Oxycodone
Other opioids, which includes fentanyl, pethidine and tramadol
Not stated/not reported.
Opioid harm in Australia and comparisons between Australia and Canada
se of opioids
Opioid harm in Australia and comparisons between Australia and Canada 9
Key findings
Opioid prescriptions dispensed
In 2016-17, 15.4 million opioid prescriptions were dispensed under the Pharmaceutical Benefits Scheme (PBS) to 3.1 million people.
Strong opioids (for example, morphine, oxycodone and fentanyl) accounted for 59% of all opioid prescriptions dispensed in 2016-17, of which oxycodone was the most commonly dispensed opioid prescription (37% of all opioid prescriptions dispensed).
For all opioid prescriptions dispensed, and oxycodone in particular, while the rates of prescriptions dispensed increased, on average the prescriptions dispensed were for lower doses and/or quantities in 2016-17 compared with 2012-13, after adjusting for differences in the age structure of the population.
Females were more likely to be prescribed an opioid than males, with 58% of all opioid prescriptions dispensed to females, and females accounting for 55% of individuals receiving 1 or more prescriptions in 2016-17.
Opioid prescriptions were most common among those aged 65 and over, with 44% of prescriptions dispensed to people in this age group.
After adjusting for age, the rate of OME was highest for /nner 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). It was lowest for Very remote areas (645 OME mg per 1,000 population, per day).
Hospitalisations involving side effects of pharmaceutical opioid use
The rate of hospitalisations per 100,000 population almost doubled in the 10 years to 2016-17, after adjusting for age.
Rates were higher for females than for males, for all age groups, in 2016-17.
Illicit and non-medical use of opioids
In 2016:
for both lifetime and recent use, Pain-killers/analgesics and pharmaceutical opioids were the most common type of opioid used for illicit or non-medical purposes
people in the lowest socioeconomic group were 1.8 times as likely to have recently used opioids for illicit or non-medical purposes as those in the highest.
Between 2001 and 2013 there was:
a 21% increase in the proportion of people using opioids for illicit or non-medical purposes over their lifetime, but no change in recent users
a decline in the lifetime and recent use of Heroin (by 25% and 50%, respectively).
Opioid harm in Australia and comparisons between Australia and Canada
All opioids—including codeine—can lead to dependence, accidental overdose, hospitalisation or death. There have been recent rises in opioid prescriptions dispensed, and in the proportion of people using opioids for illicit or non-medical purposes (AIHW 20174).
In Australia in 2016-17, 3.1 million people were dispensed a prescription opioid, and an estimated 735,000 people were using opioids for illicit or non-medical purposes—including approximately 715,000 people using pharmaceutical opioids and 39,700 using heroin. The extent of overlap between prescription opioid use and illicit and non-medical use is unknown, and all the data are missing for over-the-counter codeine supply and private prescriptions (Figure 2.1).
Figure 2.1: Number of people using opioids in Australia over 12 months, 2016
Data not captured?
Non-medical
use of | pharmaceutical opioids‘
715,000
(a) Number of opioid prescriptions dispensed under the 2016-17 PBS.
(b) Illegal opioid use estimated from the 2016 National Drug Strategy Household Survey (NDSHS), based on self-reported use of heroin in the last 12 months (which may be an underestimate) (see Box 2.2).
(c) Non-medical opioid use estimated from the 2016 NDSHS, based on self-reported use of pain-killers/analgesics and pharmaceutical opioids in the last 12 months.
(d) ‘Data not captured’ include medical use of over-the-counter codeine; private prescription opioids; opioids from doctor bags; and opioids provided during a hospital admission in public hospitals and on discharge to patients in New South Wales and the Australian Capital Territory.
Information about the availability and use of opioids in Australia is captured in a number of ways,
including in:
* Pharmaceutical Benefits Scheme (PBS) data, which record all prescriptions dispensed under the PBS
* the National Drug Strategy Household Survey (NDSHS), which collects self-reported information about the misuse of pharmaceuticals and other drugs
* the National Wastewater Drug Monitoring Program (NWDMP), which monitors consumption related to all types of drug use (legal, illicit and non-medical use).
This chapter discusses opioid use in Australia, drawing mainly on these 3 data sources. It also discusses side effects of pharmaceutical opioid use, as captured in the National Hospital Morbidity Database (NHMD).
11
Medical use of opioids
Prescription opioids
PBS data record all prescriptions dispensed under the PBS (Box 2.1). The PBS subsidises an estimated 80% of all prescription drugs dispensed in Australia (Monheit et al. 2016), so PBS data are a good indicator of the available supply of prescription pharmaceuticals. Data on over-the-counter medicines, such as some codeine-containing medicines which were available over the counter until February 2018, are not captured, as they are not part of the PBS (Department of Health 2016a).
Box 2.1: The Pharmaceutical Benefits Scheme and measures of opioid use
In Australia, most prescription pharmaceuticals are subsidised for all Australian Medicare cardholders under the PBS. Prescriptions that cost more than the co-payment threshold
($6.40 for concessional patients and $39.50 for general patients as of 1 January 2018) are subsidised, costing the patient only that threshold amount, while the government pays for the rest.
Trend data presented here for 2012-13 onwards include prescriptions that were priced under the PBS co-payment thresholds. Prior to 2012, prescriptions priced under the co-payment threshold were not captured in the PBS data (for example, codeine preparations supplied to general patients).
There are a number of different measures that can be used to understand patterns of opioid use, each of which has limitations.
The number of opioid prescriptions dispensed simply measures how many opioid prescriptions were supplied. It does not include prescriptions that were not dispensed or medications obtained without a prescription. It does not provide information about dosage or duration of treatment or about the number of people treated. Rates of opioid prescriptions dispensed (for example, the rate per 100,000 population) can be age-standardised to adjust for differences in the age structure of the population over time, or between population subgroups.
The number of people dispensed opioids refers to how many people in a given time period had 1 or more prescription opioids dispensed. This is useful for determining how many people are using opioids across a time period. It does not provide information about dosage or duration of treatment. The rate of people prescriptions dispensed (for example, per 100,000 population) can be age-standardised to adjust for differences in the age structure of the population over time, or between population subgroups.
The defined daily dose (DDD) is the dose of a particular drug that is assumed to be the average per day when used for its main indication in adults. The DDD can be used with data on the number of prescriptions dispensed and the mass of active drug in each prescription to calculate the rate of DDD dispensed (for example, per 1,000 population per day). For example,
10 DDDs per 1,000 population per day means that there were 10 DDDs of the drug dispensed per 1,000 population per day. However, the DDD for a drug may not match the recommended or prescribed dose. This may occur, for example, due to changes in the primary indication
the drug is used for, or due to individualised dosing based on patient response. Because the DDD may differ from the recommended or prescribed dose, the rate of DDD dispensed may underestimate or overestimate true use.
continued
Opioid harm in Australia and comparisons between Australia and Canada
Box 2.1 (continued): The Pharmaceutical Benefits Scheme and measures of opioid use
The rate of oral morphine equivalent (OME) (for example, per 1,000 population per day) is a measure of opioid use that adjusts for the difference in potency between different opioids. Using data on the number of prescriptions dispensed, the mass of active drug in each prescription, and OME conversion factors, 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.
For more information on the PBS data see Appendix A. <Pharmaceutical Benefits Scheme data>.
How many opioids and what type of opioids are dispensed? In 2016-17, 15.4 million opioid prescriptions were dispensed under the PBS (Table S2.1).
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) (Table $2.1; Figure 2.2).
The 15.4 million opioid prescriptions dispensed in 2016-17 were dispensed to 3.1 million people. While oxycodone was the most commonly dispensed opioid, based on the number of prescriptions dispensed, more people were dispensed codeine (1.7 million people) than oxycodone (1.3 million people) (Table S2.2).
Oxycodone is considered a ‘strong’ opioid, while codeine and tramadol are ‘weak’ opioids (Table 1.1). Based on the number of prescriptions dispensed, strong opioids accounted for 59% of all opioid prescriptions dispensed in 2016-17. These data are for prescription opioids only, and do not include over-the-counter codeine, which was available when these data were collected and has been estimated to account for more than half of all codeine pack sales (Gisev et al. 2016).
For all opioids combined, there were 1,082 OME mg per 1,000 population, per day, dispensed in 2016-17. The most-used opioids, as measured by the rate of OME, were oxycodone (34% of all opioid OME), tramadol (17%) and fentanyl (11%) (Figure 2.2).
Strong opioids accounted for 75% of opioid use, as measured by the rate of OME. This is similar to the recent analysis of PBS data by Karanges et al. (2018), which found that, in 2015, strong opioids accounted for 78% of opioid use as measured by OME.