Alcohol, tobacco & other drugs in Australia

People who inject drugs (PWID) are among the most marginalised and disadvantaged drug users. They experience multiple negative health consequences including higher risk of fatal overdoses and are disproportionately affected by blood-borne infectious diseases (such as HIV and hepatitis C). There were over 11 million people who inject drugs globally in 2019, of whom 1.4 million were living with HIV and 5.6 million with hepatitis C. Almost 1.2 million people live with both (UNODC 2021).

Key findings

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Prevalence of drug injection

In Australia, a low proportion of the general population report injecting drugs. Information on data sources referred to in this section are in Box PWID1. The National Drug Strategy Household Survey (NDSHS) found that in 2019, 1.5% of the population aged 14 and over had injected a drug in their lifetime (Table S2.31), with 0.3% having injected a drug in the past year (both stable from 2016) (Table S2.32, Figure PWID1). Males who were aged 14 and over were more likely to have recently injected drugs (in the past year) than their female counterparts (2.2% compared to 0.9%) (AIHW 2020).

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Illicit drugs

Heroin and methamphetamine are the most commonly injected drugs in Australia and are often cited as preferred drugs among PWID (Heard et al. 2021; Sutherland et al. 2021).

Estimates from the Illicit Drug Reporting System (IDRS) show that methamphetamine was the most common drug of choice among PWID, surpassing heroin for the first time since monitoring began (Sutherland et al. 2021).

Drug most often injected

Estimates from the 2021 IDRS showed that, among PWID who responded:

• Methamphetamine (53% of PWID) and heroin (34%) were the most common drugs injected in the last month.
• The proportion of participants who said heroin was the drug they injected most often in the last month decreased from 46% in 2020 to 34% in 2021 whilst the proportion of participants who said methamphetamine was the drug they injected most increased significantly, from 41% in 2020 to 53% in 2021, making it the most commonly injected drug in 2021(Table S2.50).
• In the preceding 6 months, 78% of participants reported using crystal methamphetamine, with 97% of those participants reporting the main route of administration was injecting.
• Half (50%) of the IDRS participants reported using heroin in the preceding 6 months. This was a decrease from 63% in 2020, and represents an overall decline from 79% in 2000 (Table S2.54).
• Of those participants who had recently used heroin, 28%  reported using it daily (Sutherland et al. 2021).

Data collection for 2021 took place from June to July. Due to COVID-19 restrictions being imposed in various jurisdictions during data collection periods, interviews in 2020 and 2021 were delivered face-to-face as well as via telephone. This change in methodology should be considered when comparing data from the 2020 and 2021 samples relative to previous years.

Last drug injected

Injecting drug use among PWID is often assessed by asking people to report the drug that they most recently injected (last drug injected). Data from the Australian Needle Syringe Program Survey 2016–2020 showed that methamphetamine and heroin are the most common last drugs injected (Figure PWID2).

• In 2020, methamphetamine (47%) was the most commonly reported last drug injected nationally and across most jurisdictions (ranging from 35–68%). Nationally, this figure has increased from 43% in 2016.
• Heroin (22%) was the second most commonly reported last injected drug in 2020. The proportion of respondents who reported last injecting heroin decreased from 28% in 2016.
• Pharmaceutical opioids (including morphine, oxycodone and fentanyl) were the third most commonly reported class of drugs last injected, with the proportion remaining stable since 2016 (8% in 2016 and 2020) (Heard et al. 2021) (Table S3.61).

Other drugs that are often reported as the last drug injected include performance and image enhancing drugs (PIEDs; such as steroids, peptides or hormones) (Table S3.61). 

Figure PWID2: Percentage of respondents by last drug injected, 2012 to 2020

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Other frequently used drugs

Use of cannabis by PWID is also common. The 2021 IDRS showed that:

• Over two-thirds (67%) of PWID had used cannabis in the last 6 months, stable from 67% in 2020.
• Just over half (51%) of those who had recently used cannabis reported daily use (Sutherland et al. 2021).

PWID also use pharmaceutical drugs, particularly prescription opioids, at higher rates than the general population (Sutherland et al. 2021). This likely reflects the practice of substituting pharmaceutical drugs for illicit drugs, such as heroin. Data from the 2021 IDRS showed that, in the last 6 months:

• 16% of participants reported non-prescribed use of morphine.
• 9% reported non-prescribed use of oxycodone, down from 11% in 2020.
• 9% reported non-prescribed use of buprenorphine-naloxone film, stable from 9% in 2020.
• 6% reported non-prescribed use of buprenorphine.
• 6% reported non-prescribed use of fentanyl (Sutherland et al. 2021).

Use of cocaine is also common among PWID, with 15% of participants in the 2021 IDRS reporting using cocaine in the last 6 months, stable from 17% in 2020 (Sutherland et al. 2021).

Health and harms

Injecting drug use is a major risk factor for transmitting blood-borne viruses, including HIV, hepatitis B and hepatitis C. Needle and syringe sharing among people who inject drugs is partly responsible for transmitting infection, although unsafe sexual behaviours also play a role (AIHW 2012).

Burden of disease and injury

The Australian Burden of Disease study, 2018, found that unsafe injecting practices were responsible for 0.9% of the total burden of disease and injuries in 2018 (AIHW 2021).

Unsafe injecting practices are linked to Hepatitis B, Hepatitis C, HIV/AIDS, liver cancer and chronic liver disease. Liver cancer and chronic liver disease are the long-term consequences of contracting hepatitis B and hepatitis C infection. Acute hepatitis C and B were responsible for 74% and 33% of burden (respectively) (AIHW 2021). Chronic liver disease and liver cancer were each responsible for 27% of the burden due to unsafe injecting practices (AIHW 2021).

The IDRS report on trends in self-reported past year non-fatal overdose and responses to overdose found that, between 2009 and 2020, the proportion of participants who reported receiving no treatment on the occasion of their overdose fluctuated, but remained above 10% (Thomas et al. 2021).

Injecting risk behaviours

Data from the Australian Needle Syringe Program Survey (ANSPS) provides some evidence of the risk of harms related to injecting drug use in persons who regularly inject drugs in Australia:

• The proportion of respondents reporting recent reuse of needles and syringes (including the reuse of one’s own syringes) decreased over the past 5 years (from 27% in 2016 to 23% in 2020).
• The proportion of respondents reporting receptive sharing of needles and syringes in the last month also decreased over the past 5 years (from 19% in 2016 to 16% in 2020) (Heard et al. 2021).

Data from the 2021 IDRS provide additional evidence of risks for harms, including:

• 1 in 10 (10%) participants reported lending a needle to someone after they had used it, and 6% reported borrowing a needle after someone else had used it (consistent with 5% in 2020).
• Almost 2 in 5 (38%) participants reporting re-using their own needle in the last month.
• Almost 2 in 5 (18%) participants reporting sharing other injecting equipment (for example, spoons) in the last month. This is a decrease from 25% in 2020 and a high of 51% in 2000 (Peacock et al. 2021) (Table S3.63; Figure PWID3).

Figure PWID3: Injecting risk behaviours in the last month among people who inject illicit drugs, 2000 to 2021 (per cent)

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Injection-related health problems

In 2021, 26% of IDRS participants reported experiencing an injection-related health problem in the last month. This represents a decline from 29% in 2020. Of those who commented (n=885), in the last month:

• 11% experienced nerve damage, similar to 2020 (12%).
• 7% reported that they had experienced a ‘dirty hit’ (that is, a hit that made them feel sick), similar to 2020 (8%).
• 8% experienced an infection or abscess, similar to 2020 (8%) (Sutherland et al. 2021) (Table S3.64).

Although national HIV antibody prevalence is low, the ANSPS found that among survey participants, there was an increase in prevalence from 1.4% in 2016 to 2.5% in 2020 (Table S3.65). Some populations of PWID are at greater risk of HIV than others.

• Nationally, across all survey years, HIV antibody prevalence was consistently higher among male respondents than among female respondents (Figure PWID4). HIV antibody prevalence has also been consistently higher among homosexual male respondents than among bisexual and heterosexual male respondents.
• Between 2016 and 2020, HIV prevalence was also higher among those who reported methamphetamine as the last drug injected (4% in 2020) compared to those who reported last injecting other drugs (1.1% for heroin as the last drug injected and 0.8% for those with other opioids as the last drug injected).
• HIV prevalence was higher among those aged 45 years and over (3.5% in 2020) compared with 2.4% of people aged under 25 and 2.2% of people aged 25–34 (Heard et al. 2021).

Figure PWID4: HIV antibody prevalence by sex, 1995 to 2020 (per cent)

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According to the ANSPS, Hepatitis C (HCV) is more common than HIV among PWID. Almost 2 in 5 (39%) of respondents were HCV antibody positive in 2020, a decline from 51% in 2016 (Table S3.66).

• HCV antibody prevalence was higher among older respondents and those with longer injection histories.
• Prevalence of HCV continues to be higher among respondents reporting heroin or other opioids as the last drug injected (59% and 50%, respectively) compared to respondents who last injected methamphetamine (29%). 
• HCV RNA prevalence (active infection) was consistently higher among respondents who reported imprisonment in the year preceding survey completion compared to those who had not been incarcerated.
• HCV RNA prevalence was also consistently higher among respondents who reported receptive needle and syringe sharing in the last month compared to respondents who did not report receptive sharing (Heard et al. 2021).
• HCV Direct Acting Antiviral (DAA) therapy was included on the Australian Government Pharmaceutical Benefits Scheme (PBS) from March 2016. This inclusion resulted in an increase in the uptake of treatment. Of respondents who were eligible for treatment, the proportion reporting recent HCV treatment (in the last 12 months) increased from 22% in 2016 to 32% in 2020 (Heard et al. 2021).

Data collection for the 2020 ANSPS was impacted by COVID-19 restrictions. The survey took place in several phases from September to December 2020, instead of the usual October timeframe. South Australia required participants complete the survey offsite due to a snap lockdown and Victoria were unable to participate due to public health restrictions (Heard et al. 2021). This should be taken into account when comparing data from 2020 with previous years.

Treatment

Data from the 2021 IDRS found that:

• Nearly 2 in 5 (37%) participants reported receiving treatment for substance use in 2021, a significant decrease from 48% in 2020.
• Of those participants not currently receiving treatment, 13% reported difficulties accessing treatment in the past six months. Among these same participants, methamphetamine (60%) and heroin (27%) were the main substances for which participants intended to seek treatment (Sutherland et al. 2021).

Policy context

Policy support

The 2019 NDSHS showed that most people support measures to reduce problems associated with injecting drugs. About two-thirds of the population aged 14 and over supported rapid detoxification therapy (69%), methadone/buprenorphine maintenance programs (67%), needle and syringe programs (64%), treatment with drugs other than methadone (66%) and the use of naltrexone (65%), which is a medication that blocks the effect of opioids such as heroin. In addition:

• a trial of prescribed heroin received the least support (33%)
• apart from a trial of prescribed heroin, use of naltrexone, and availability of take-home naloxone, higher proportions of females than males supported measures aimed at reducing problems associated with injecting drug use
• support for needle and syringe programs (90%), use of naltrexone (83%), availability of take-home naloxone (83%), and a trial of prescribed heroin (60%) was particularly high among recent injecting drug users compared with the general population (Table S3.67)
• in 2019, there were declines in the support for needle and syringe programs (from 67% in 2016 to 64%) and a trial of prescribed heroin (from 35% to 33%) (Table S3.68).

Needle and syringe programs

All Australian states and territories operate needle syringe programs (NSPs), providing a range of services to PWID (Heard et al. 2021).

According to the IDRS, in 2017, NSPs were by far the most common source of needles and syringes in the preceding 6 months (94%), followed by NSP vending machines (19%). Chemists were used by 16% of participants nationally (Karlsson & Burns 2018) (Table S3.69). This is supported by the findings of the 2019 NDSHS that NSPs were the most commonly reported source (39%), followed by chemists (34%) (AIHW 2020) (Table S3.70). This is likely to reflect the different sampling of the 2 surveys whereby the NDSHS is targeted at the general population, while the IDRS accesses PWID.

Medically supervised injecting centres

Medically supervised injecting centres (MSIC) are places where people can use and inject drugs under the supervision of registered nurses, counsellors and health education professionals. This service aims to prevent injury and death by being present when someone injects in order to provide immediate medical assistance as required. Kings Cross in Sydney has been home to an MSIC since 2001 (Uniting 2017), and a second opened in Richmond, Victoria in July 2018.