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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.