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 derived from the sap extracted from the seedpod of the opium poppy (ACIC 2019).

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. The Illicit Drug Reporting System (IDRS) has shown no significant changes in the perceived availability, pricing and purity of heroin in Australia in recent years, as reported by people who inject drugs (Peacock et al. 2019). This suggests that the Australian heroin market is now highly stable (Table S2.11).

The number of heroin detections at the Australian border has increased 6% over the past decade, from 250 in 2008–09 to 265 in 2017–18. However, the weight of heroin detected has increased 26% over the same period, from 150.6 kilograms in 2008–09 to 190 kilograms in 2017–18. There has also been an increase in both the number and weight of national heroin seizures over the past decade. Between 2008–09 and 2017–18 the number of national seizures increased 17% from 1,691 up to 1,977, while the total weight of heroin seized increased 57% from 145.6 kilograms to 229 kilograms (ACIC 2019; ACC 2010).

Consumption

The National Drug Strategy Household Survey (NDSHS) shows that heroin use among the general population is low in Australia.

  • In 2016, only 0.2% of Australians aged 14 and over reported using heroin in the last 12 months and this has remained stable since 2001 (Figure HEROIN1).
  • Although use of heroin is low, frequency of use is much higher than other drugs, with 49% of users using heroin as often as weekly.
  • Compared with other drugs, people using heroin had the highest proportion saying they tried to stop or cut down but could not (44%) (AIHW 2017) (Table S2.35).

The National Wastewater Drug Monitoring Program also shows that heroin consumption in Australia is relatively low, with the capital city average consumption higher than the regional average. The average consumption of heroin increased between April 2019 and August 2019 in both capital city and regional sites (ACIC 2020).

The use of opioids such as heroin or morphine is very uncommon (less than 1%) among secondary school students aged 12–17 in Australia. Of the very small proportion that reported using heroin, the majority did so only once or twice (Guerin & White 2018) (Table S2.53).

In 2019, heroin (45%) was one of the top 2 most commonly nominated drugs of choice among people who inject drugs, along with methamphetamine (33%) (Peacock et al. 2019).

Harms

Heroin is a central nervous system depressant. Like other opioids, it attaches receptors to 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).

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 1,740 drug-induced deaths in Australia in 2018, 438 or 25% were due to heroin—the highest number of deaths attributed to heroin since 1999 (Figure HEROIN2; ABS 2019).

Overall, the rate of death attributed to heroin in Australia has increased from 1.0 per 100,000 people in 2009 to 1.8 per 100,000 in 2018 (Table S1.1). The rate of opioid-induced deaths involving heroin have increased in the past 5 years (ABS 2019).

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).

Data from the ABS reported a higher rate of opioid-induced deaths for people living outside capital cities compared with those living in capital cities, whereas deaths where heroin was identified were more likely to occur in a capital city (ABS 2019). This is consistent with AIHW analysis which showed that the rate of drug-induced deaths where heroin was identified was higher in Major cities than in Regional and remote areas in 2018 (2.1 deaths per 100,000 population compared with 1.1 deaths per 100,000 population) (Table S2.71).

Although 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), overdose deaths involving heroin have significantly increased in recent years (ABS 2017). 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).

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Treatment

Data collected as part of the AIHW’s 2018–19 Alcohol and Other Drug Treatment Services National Minimum Data Set (AODTS NMDS) showed that: 

  • Heroin was a principal drug of concern for a client’s own drug use in 5.2% of closed treatment episodes (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).

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 2019, 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%), the Australian Capital Territory (39%) and Victoria (34%) (AIHW 2020b).

Further information on pharmacotherapy in Australia.

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At-risk groups

Aboriginal and Torres Strait Islander people

Indigenous Australians are overrepresented in treatment services for heroin as the principal drug of concern (AIHW 2019a).

People who inject drugs

Heroin is commonly injected and so its use is overrepresented among people who inject drugs. In 2019, 55% of the IDRS sample reported using heroin in the preceding 6 months (Table S2.54), and 36% of recent consumers reported using heroin daily (Peacock et al. 2019).

People engaged with the criminal justice system

In 2017–18 there were 3,029 national arrests relating to heroin and other opioids (a 2% increase from 2016–17). Most of the arrests related to consumers (89.5%) rather than providers of the drug (ACIC 2019).

The Drug Use Monitoring in Australia (DUMA) program showed the proportion of detainees testing positive to heroin decreased from 6% in 2017 (Patterson et al. 2019) to 5% in 2018 (Voce & Sullivan 2019). The proportion of prison entrants who had used heroin in the last 12 months was slightly higher (7%) (AIHW 2019b).

References

ABS (Australian Bureau of Statistics) 2017. Causes of Death, Australia, 2016. ABS cat. no. 3303.0. Canberra: ABS. Viewed 4 January 2018.

ABS 2019. Causes of Death, Australia, 2018. ABS cat. no. 3303.0. Canberra: ABS. Viewed 15 October 2019.

ACC (Australian Crime Commission) 2010. Illicit Drug Data Report 2008–09. Canberra: ACIC. Viewed 7 August 2019.

ACIC (Australian Criminal Intelligence Commission) 2019. Illicit Drug Data Report 2017–18. Canberra: ACIC. Viewed 7 August 2019.

ACIC 2020. National Wastewater Drug Monitoring Program Report 9, 2020 . Canberra: ACIC. Viewed 3 April 2020.

AIHW (Australian Institute of Health and Welfare) 2017. National Drug Strategy Household Survey 2016: detailed findings. Drug statistics series no. 31. Cat. no. PHE 214. Canberra: AIHW. Viewed 14 December 2017.

AIHW 2018. Opioid harm in Australia and comparisons between Australia and Canada. Cat. no. HSE 210. Canberra: AIHW. Viewed 9 November 2018.

AIHW 2019a. Australian burden of disease study: Impact and causes of illness and death in Australia 2015. Series no.19. BOD 22. Canberra: AIHW. Viewed 13 June 2019.

AIHW 2019b. The health of Australia’s prisoners 2018. Cat. no. PHE 246. Canberra: AIHW. Viewed 30 May 2018.

AIHW 2020a. Alcohol and other drug treatment services in Australia 2018–19. Cat no. HSE 243. Canberra: AIHW. Viewed 26 June 2020.

AIHW 2020b. National Opioid Pharmacotherapy Statistics Annual Data Collection (NOPSAD) 2019. Cat. no. 266. Canberra: AIHW. Viewed 31 March 2020.

Degenhardt L, Day C & Hall W 2004. The causes, course and consequences of the heroin shortage in Australia. Canberra: National Drug Law Enforcement Research Fund.

Degenhardt L, Reuter P, Collins L & Hall W 2004. ‘Chapter 5: Evaluating factors responsible for the heroin shortage’ in The causes, courses and consequences of the heroin shortage in Australia. Degenhardt L, Day C & Hall W (eds). Monograph no. 3. Canberra: National Drug and Law Enforcement Research Fund. Viewed 14 December 2017.

Guerin N & White V 2018. Australian secondary school students’ use of tobacco, alcohol, and over-the-counter and illicit substances in 2017. Victoria: Centre for Behavioural Research in Cancer. Viewed 11 March 2019.

Man N, Chrzanowska A, Dobbins T, Degenhardt L & Peacock A 2019. Trends in drug-induced deaths in Australia, 1997-2018. Drug Trends Bulletin Series. Sydney: National Drug and Alcohol Research Centre, UNSW Sydney. Viewed 8 January 2020.

Nielsen S & Gisev N 2017. Drug pharmacology and pharmacotherapy treatments. In: Ritter, King and Lee (eds). Drug use in Australian society. 2nd edn. Oxford University Press.

NSW Ministry of Health 2017. A quick guide to drugs and alcohol, 3rd edn. Sydney: National Drug and Alcohol Research Centre.

Patterson E, Sullivan T & Bricknell S 2019. Drug use monitoring in Australia: Drug use among police detainees, 2017, Statistical Reports Number 14. Canberra: Australian Institute of Criminology. Viewed 8 January 2020.

Peacock A, Uporova J, Karlsson A, Gibbs D, Swanton R, Kelly G, Price O, Bruno R, Dietze P, Lenton S, Salom C, Degenhardt L & Farrell M 2019. Australian Drug Trends 2019: Key findings from the National Illicit Drug Reporting System Interviews. Sydney: National Drug and Alcohol Research Centre, UNSW Australia.

UNODC (United Nations Office on Drugs and Crime) 2019. World Drug Report 2018. Vienna: UNODC. Viewed 19 February 2019.

Voce A & Sullivan T 2019. Drug use monitoring in Australia: Drug use among police detainees, 2018. Statistical Reports no. 18. Canberra: Australian Institute of Criminology. Viewed 8 January 2020.