opioid use in Australia

Trends in Opioid Use in Australia

General Trends

• Worldwide opioid use has significantly increased, with opioid analgesic prescriptions doubling between 2001-03 and 2011-13.
• Australia’s opioid consumption is about one-third that of the United States but is comparable to many European countries.
• Nearly three million Australians received at least one Pharmaceutical Benefit Scheme (PBS)-listed opioid analgesic between April 2013 and March 2014.
• Around 150,000 people (5%) accounted for 61% of opioid use in terms of opioid defined daily doses (DDDs) supplied.

Increasing Use and Prescription Patterns

• The rolling annual average of DDDs/1000 population/day supplied increased from 15.73 to 17.06 over a 10-year period.
• Paracetamol with codeine and tramadol were the most commonly supplied opioids for most of this period.
• The use of tramadol and morphine is decreasing, while the use of fentanyl, buprenorphine, oxycodone with naloxone, and hydromorphone is increasing.
• Oxycodone prescribing has notably increased since 2013, becoming the second most commonly used opioid, especially among older Australians.

Over-the-Counter Opioid Trends

• The most commonly sold opioid is over-the-counter (OTC) codeine, which is also the most accessible in the community setting.
• Despite concerns over effectiveness and adverse events, codeine is still used in high volumes.
• There is a decision to up-schedule codeine to Schedule 4 (S4), effective in 2018.

Non-Medical Use of Opioids

• The prevalence of non-medical use of pharmaceutical opioids remains relatively low among the general Australian population.
• However, significant increases have been reported, with prevalence doubling from 0.2% to 0.4% between 2007 and 2010.

Reasons for Opioid Prescription

• Approximately half (52%) of PBS-listed opioids are used for the treatment of acutely painful conditions.
• The remaining prescriptions are divided almost equally between episodic (25%) and long-term treatment (23%).
• People prescribed opioids generally have poorer health, functioning, and higher levels of distress compared to those not receiving opioid analgesics.

Demographics and Opioid Prescribing

• Patients with higher socioeconomic status indicators are less likely to be on longer-term opioid analgesic treatment.
• Older patients and those who do not speak English at home are more likely to be prescribed opioids long-term.

Geography and Opioid Prescribing

• Higher rates of opioid use are seen in areas outside major cities, less populated regions, areas with more men and older people, and regions with more low-income households and jobs requiring physical labor.

Implications of Prescribing Variation

• Longer-term opioid prescribing is more common in patient groups at higher risk of poor health, based on a range of health and non-health factors.
• Programs targeting inappropriate opioid prescribing need to focus on these high-risk groups and areas outside major cities.

Problematic Use of Opioids

Prevalence and Incidence

• The prevalence of non-medical use/misuse of pharmaceutical opioids remains relatively low, but rates of misuse and addiction are significant.
• Problematic use is dose-dependent, with higher doses associated with higher rates of dependence or abuse.

Sources and Treatment Seeking

• Medical practitioners are an important source of misused pharmaceuticals, but most misused opioids are obtained from dealers and through on-selling of prescribed opioids.
• Treatment seeking for pharmaceutical opioids increased significantly during the reporting period 2001/02 – 2011/12.

Overdose and Mortality

Hospitalisation due to opioids: Hospitalisation for pharmaceutical opioid poisoning is not common. Rates peaked in 2006/07 (83 per million persons) and have declined more recently (65 per million persons)

Overall Trend in Overdose and Age Most Affected

• The number of deaths due to opioid overdose in Australia is growing.
• Between 2004 and 2014, deaths due to accidental overdose increased by 61% (from 705 deaths in 2004 to 1137 in 2014).
• In 2014, 78% of the people who died from opioid overdose were aged between 30 and 59 years.

Geographical Trend in Overdose

• The overall increase in overdose deaths is driven by those occurring in rural and regional areas.
• Between 2008 and 2014, overdose deaths in rural and regional areas increased by 83% (from 3.1 deaths per 100,000 to 5.7 per 100,000).
• In the same period, the rate in metropolitan areas changed from 4.2 per 100,000 to 4.4 per 100,000.

Overdose Trend in Aboriginal and Torres Strait Islander Peoples

• Accidental deaths due to opioid overdose per capita for Aboriginal and Torres Strait Islander peoples have increased substantially.
• Between 2004 and 2014, there was a 141% increase (from 3.9 deaths per 100,000 in 2004 to 9.4 per 100,000 in 2014).

Relationship Between Patient Factors, Opioid Characteristics, and Overdose

• Higher opioid dosages are associated with an increased risk of fatal overdose.
• There is a three-fold increase in mortality when comparing high-dose opioid (>200 mg oral morphine equivalent daily dose [OMEDD]) to low-dose opioids (<20 mg OMEDD).

Risk Factors for Fatal Overdose

• Slow-release and long-duration opioids
• Co-prescription of opioids and benzodiazepines
• Sleep-disordered breathing
• Reduced renal or hepatic function
• Older age
• Pregnancy
• Mental health disorders including SUDs

Overdose Statistics in Victoria

• In Victoria, 80% of all drug overdoses from 2001 to 2013 involved prescription medications.
• Pharmaceutical opioids contributed to half of all drug-overdose deaths during that time.
• Fatal overdosing with pharmaceutical opioids is related to dose and duration of action.

Strategies to Improve Appropriateness of Opioid Use

• The RACGP supports standardised regulatory definitions and laws regarding drugs of dependence, an effective national real-time prescription monitoring (RTPM) system, and improved analysis of PBS prescriptions.
• The RACGP also supports programs targeting inappropriate opioid prescribing, improved collaboration with pharmacies, and education of consumers and health professionals.
• In 2020, changes to opioid indications were made to help address misuse and harms in Australia, with PBS restrictions and authority requirements updated accordingly.

Real-Time Prescription Monitoring

• The RACGP supports the introduction of RTPM to improve monitoring of opioids nationally.
• RTPM is not a sole solution to curbing opioid misuse but plays a key role in supporting high-quality use of drugs of dependence.