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How to reduce opioid overdose deaths in Australia

Once again, overdose deaths from opioids are increasing in Australia. And once again, we are in danger of ignoring effective, evidence-based interventions. According to the National Drug and Alcohol Research…

Most overdose deaths are due to heroin but an increasing number are due to pain relieving prescription opioid drugs. Thomas Marthinsen

Once again, overdose deaths from opioids are increasing in Australia. And once again, we are in danger of ignoring effective, evidence-based interventions.

According to the National Drug and Alcohol Research Centre, there were 360 opioid overdose deaths in 2007 but 500 in 2008 – a 40% increase. These overdose figures have been carefully checked.

Preliminary figures suggest that there were 612 such deaths in 2009, a 22% increase from 2008, and 705 in 2010, a 15% increase from the year before. Increases in overdose deaths occurred in all of the major states but were most marked in Victoria where such deaths increased 133% from 73 in 2001, to 170 in 2008.

Most of these deaths are due to heroin but an increasing number have recently been due to pain relieving prescription opioid drugs. Most involve men in their early 30s.

And for every fatal overdose, there are many more non-fatal overdoses. Non-fatal overdoses can result in severe physical and mental damage, expensive ambulance call outs and admissions to hospital emergency departments and intensive care units. So the health and financial costs of non-fatal overdoses to individual young Australians and the community are anything but trivial.

Recent trends

Heroin is produced from opium and most of the heroin reaching Australia originates from Burma. The last time opium production peaked in Burma was in the mid-1990s. That increase resulted in a glut of heroin in Australia and annual opioid overdose deaths peaked at 1,116 in 1999.

Opium production in Burma decreased 82% from 1,760 metric tonnes in 1996 to 312 metric tonnes in 2005. Annual opioid overdose deaths in Australia fell to 938 in 2000 and then to 386 in 2001. Opioid overdose deaths then remained below 400 until 2008.

In recent years, Burma’s opium production has increased 88% from 312 metric tonnes in 2005 to 586 metric tonnes in 2010. If this trend continues, Australia could once again experience the extremely high levels of overdose deaths that occurred in the 1990s.

The shortage of heroin in Australia that began in 2000 (and also affected some other countries) coincided with the sharp decline in opium production in Burma between 1996 and 2005. This decline was probably due to a combination of factors including the retirement of a major Burmese opium warlord (Khun Sa), a shift from outdoor opium cultivation (easily detected by aerial and satellite surveillance) to indoor amphetamine production, increasing consumption of heroin in China en route to Australia and local climatic changes.

Inevitably, some Australian politicians claimed at the time the shortage was due to the then new “tough on drugs” policy; they were less enthusiastic about accepting responsibility for the increase in amphetamine use that followed the heroin shortage.

Treatment options

There are several things we can do to address this looming problem. First, we could expand and improve our drug treatment system and reduce the barriers to entering and remaining in treatment. There’s copious high-quality evidence that methadone and buprenorphine treatments are effective and safe. For every $1 spent on these treatments, there’s a community saving of $4 to $7.

Methadone and buprenorphine reduce the excess risk of death among people who inject heroin by about 80%. And a recent study suggests that these treatments reduce the risk of HIV by over 50%. They also reduce property crime substantially.

But most people who enrol in methadone or buprenorphine programs have to pay at least $50 per week from what is usually a very low income. And there’s far more demand than supply of such treatments in most parts of Australia.

What’s more, the treatments are very stigmatised, especially methadone. Many patients enrolled in methadone and buprenorphine treatment complain that staff don’t treat them with respect. Many don’t even bother trying to enter treatment and others leave far too early.

Stigma is one of the nasty side effects of our punitive approach to illicit drugs. The experimental and unapproved drug naltrexone is also advocated by some as something of a panacea but a recent NHMRC review concluded that there was insufficient evidence that this drug is effective or safe.

Safer injecting

Safe injecting facilities (like the Kings Cross Medically Supervised Injecting Facility) also reduce the risk of fatal and non-fatal opioid overdoses. They mainly cater for the most disadvantaged subset of an already very disadvantaged population of people who inject drugs.

Many of the people who attend the 90 safe injecting facilities around the world have severe physical and mental illnesses, are homeless and very isolated. Many have had little or no previous contact with health or social agencies, including those providing drug treatment.

Safe injecting facilities are only needed near or within large drug markets (where most overdose death occurs) that spill over into surrounding neighbourhoods. Australia only needs a few such facilities in half a dozen major cities in the country.

New South Wales accounts for almost half of Australia’s drug overdose deaths and a fifth of these deaths occur within two kilometres of Kings Cross. Safe injecting facilities also improve neighbourhood amenity so they’re usually very popular with local residents.

Trying to repair the severe and multiple problems that have developed over the many years of injecting drugs takes a lot of time and a lot of effort. People who use drugs, their families and communities often look for a magical quick-fix solution that will instantaneously sort everything out perfectly. So too do our politicians.

Unfortunately, there are no quick fixes. But there are effective and pragmatic interventions that will save hundreds of lives and millions of dollars. What we need to do is ask ourselves if we are ready to think about these interventions for people who are someone’s son or daughter, sister or brother, father or mother.

Join the conversation

21 Comments sorted by

  1. Mark King

    Senior Lecturer, Psychology and Counselling and Researcher, CARRSQ at Queensland University of Technology

    Thanks Alex for putting the figures together to make the case yet again. It's a shame that you and other experts in the field had to keep pushing the same line for so many years with limited progress to show for it. There seems to be fundamental disconnect at the political and popular level when it comes to relating policies like War on Drugs to outcomes in terms of the limited actual benefits and the greater overall harm (there's a few other issues like this as well).

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    1. Alex Wodak

      Emeritus Consultant at St Vincent's Hospital, Darlinghurst

      In reply to Mark King

      Dear Mark,

      So little to show? Ban Ki-Moon supported the decriminalisation of drugs (7 May 2009). The Global Commission on Drug Policy which includes former Presidents of 4 countries, the then PM of Greece, former US Secretary of State, former UN Sec Gen, former Chair US Federal Reserve, Sir Richard Branson etc etc supports major reform. In the 2011 US Gallup poll, 50% supported and 46% opposed 'the legalisation of marijuana'. And in Australia > 2/3 now support needle syringe programmes, methadone…

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  2. John Davidson

    Retired engineer

    Safe injecting rooms in their present form may have prevented some overdose deaths in the short term but, in the longer term they offer the worst of worlds. They offer the worst of worlds because they only work if the police allow drug users to bring their own drugs to to the injecting room and don't use injecting room users to track down their drug dealers.
    I suspect that most new addicts are recruited by users with drugs in their pockets rather than by the deliberate efforts of dealers and…

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    1. Joe Gartner

      Eating Cake

      In reply to John Davidson

      That's a great point, John. It seems odd to offer a safe injection area to prevent disease transmission and overdosing when the drugs themselves are of dubious purity and the antecedent to the client's presentation is purchase of a drug which benefits organised crime.
      We cut cut out organised crime by prescribing opiates sourced and manufactured within Australia, also helping out Tasmania's stressed economy (as this is where the opium poppy is legally grown).
      We might even reduce the appalling overdose rate and the historic shift to amphetamine abuse....

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    2. alexander j watt

      logged in via Twitter

      In reply to Joe Gartner

      back in the early years of the 20th century opium & cannabis containing remedies were available over the counter from the chemist. I'm sure there were plenty of 'addicts' but it wasn't the social scourge it is now, because at least it was a safe supply, and at least you weren't a social misfit /criminal for indulging or supplying.

      if we can rediscover our cultures long and complex association with opiates then we can move on from all the hysteria which is anyway just an imported American moral position.

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    3. Alex Wodak

      Emeritus Consultant at St Vincent's Hospital, Darlinghurst

      In reply to John Davidson

      Dear Sam,

      It's quite simple - and it's a good question. Many years experience in the alcohol and drug field has taught me to profoundly respect policy and practice based on sound evidence and fear policy and practice not based on sound evidence. The evidence for the effectiveness and safety of peer based naloxone is based on many observational studies plus a strong rationale. Observational studies have a low ranking in evidence based medicine and are generally not considered adequate evidence…

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    4. Alex Wodak

      Emeritus Consultant at St Vincent's Hospital, Darlinghurst

      In reply to John Davidson

      Dear John,

      They don't offer the worst of worlds to the many people who want to inject drugs but don't want to die from an overdose. Or theloved ones who care about their family member who injects drugs. They don't offer the worst of worlds to taxpayers who save a lot of money. Or the person waiting for a hospital bed for a hip replacement. Safer injecting facilities are not a silver bullet for drug law reform but part of a more pragmatic and more effective and cost effective approach to drugs which are currently illicit. There is a lot of research which backs up the value of safer injecting facilities. This evidence is more important than speculation

      best wishes,

      Alex

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  3. Chris Borthwick

    Writer

    The problem, Alex, is that you're a rational person in an irrational world. The public don't want to reduce opiate deaths nearly as much as they want to conceptualise themselves as superior -- tough, uncompromising, moral, strong, hardworking, clean, normal - to the soft, demanding, self-indulgent, weak, lazy, dirty hippies. The more deaths the better, in that frame.

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    1. Alex Wodak

      Emeritus Consultant at St Vincent's Hospital, Darlinghurst

      In reply to Chris Borthwick

      Dear Chris,

      There is a lot of truth in your comment that logic and rationality only play a small part in decisions about drug policy (or other policy for that matter). But as Herb Stein said 'things that can't go on forever, don't'. And global drug prohibition is now under relentless attack from all sides. If Washington state in the USA votes to tax and regulate cannabis on 6 November - and the 'yes' vote is now 6-10% ahead in the polls, then the US President will have to chose between respecting…

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    2. Chris Borthwick

      Writer

      In reply to Chris Borthwick

      Let's hope, but, as FPA said 80 years back -

      Prohibition is an awful flop.
      We like it.
      It can't stop what it's meant to stop.
      We like it.
      It's left a trail of graft and slime,
      It don't prohibit worth a dime,
      It's filled our land with vice and crime.
      Nevertheless, we're for it.

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  4. Sam Liebelt

    logged in via Facebook

    While this is a well written article and makes some great point, I was shocked that someone of Alex's intellect and well standing position in the Drug and Alcohol sector failed to make even a passing mention of Naloxone as an inexpensive and lifesaving method for preventing overdose deaths from opioids. What was the article titled - "How to reduce Opioid overdose deaths in Australia". This is a proven and widely used drug for reversing overdose deaths, that's being used the world over. The ACT have…

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  5. Gerhard Steiniger

    Drug & Alcohol Worker - Registered Nurse

    Thanks for this informative and interesting article. I just want to remark that you write (quote): Most of these deaths are due to heroin but an increasing number have recently been due to pain relieving prescription opioid drugs.
    The "Accidental opioid-induced deaths in Australia 2008" report by Amanda Roxburgh and Lucy Burns published by the NDARC comes to the opposite conclusion, namely that (quote):In 2008, 152 (30%) of the opioid deaths among Australians aged 15 to 54 years were due to heroin…

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    1. Alex Wodak

      Emeritus Consultant at St Vincent's Hospital, Darlinghurst

      In reply to Gerhard Steiniger

      Dear Gerhard,

      I started writing this before the NDARC report came out and used the NDARC report extensively. You are right about that quote in the NDARC report - but I also felt the report did not go on to say unambiguously that '30% of ODDs were due to heroin and the other 70% were all due to prescription opioids'. The rapid increase in Opioid Overdose Death (OOD) incidence in WA and Tasmania is also in keeping with a more rapid increase in prescription opioid deaths. Data from the USA should make us very wary about a rapid increase in prescription opioid deaths but increasing opium production in Burma should make us worried about increasing heroin ODs.

      Speculating about these things is important. But the focus should be on actions to prevent these tragic deaths.

      best wishes,

      Alex

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  6. Johannes Holleritter

    logged in via Facebook

    Suboxone (as a form of addiction maintenance), is not the answer to opiate addiction. It may have some use as a detox drug in furtherance of abstinence. This is an important distinction. This is a complicated subject. To understand my views on this please look at www.SuboxoneAbuse.Wordpress.com .

    J

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    1. Alex Wodak

      Emeritus Consultant at St Vincent's Hospital, Darlinghurst

      In reply to Johannes Holleritter

      Dear Johannes,

      I have no tie with any pharmaceutical company including companies involved in buprenorphine manufacture or sales. But buprenorphine (together with methadone) have been endorsed by WHO, UNODC and UNAIDS and WHO included buprenorphine and methadone on its Essential Drugs List. Despite your strongly held views on this subject, there is good evidence that buprenorphine is an effective and safe treatment for opioid dependence.

      best wishes,

      Alex

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  7. Dave Phillips

    logged in via Facebook

    Regardless of how people came to be using and/or abusing drugs legal or otherwise, education is the key to prevention, head off the problem before it becomes a problem. As to what sort of education and implementation, I am not qualified to comment, but as a former ambulance officer some shock therapy in the form of attending either fatal overdoses or non fatal overdoses would be good up to a point without desensitising students and young people. The effects on the body are horrendous and the family dysfunction heart breaking to see and hear.

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    1. Alex Wodak

      Emeritus Consultant at St Vincent's Hospital, Darlinghurst

      In reply to Dave Phillips

      Dear Dave, education is intuitively attractive. We would all expect increasing education to increase knowledge, increasing knowledge to change attitudes, and better attitudes to improve behaviour. The problem is that the evidence for this is unimpressive. The size of the benefit is usually small and often also delayed and temporary. So sadly, the expectations that the community (and therefore our politicians) have for education are unrealistic. Aggressive advertising has helped to reduce smoking…

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    2. Dave Phillips

      logged in via Facebook

      In reply to Dave Phillips

      Thank you Alex, do you have the link for that documentary? I found myself moving away from drinking after being an ambulance officer, and more so after becoming a security officer where I have on occasions had to work at licensed premises and deal in many ways with intoxicated and substance effected patrons, I hate it and avoid those jobs like the plague. I found trying to speak to people when i was sober and they were under the influence an exercise in futility and replayed some footage of them…

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