Alcohol, tobacco & other drugs in Australia

Key findings

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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).

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 (AIHW, Table 4.2), with 0.3% having injected a drug in the past year (both stable from 2016) (AIHW 2020, Table 4.6; 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).

Figure PWID1: Lifetime^a and recent^b injecting drug use, people aged 14 and over, 2001 to 2019 (percent)

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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. 2023; Sutherland et al. 2022).

Estimates from the Illicit Drug Reporting System (IDRS) show that methamphetamine continues to be the most common drug of choice among PWID, after surpassing heroin, in 2021, for the first time since monitoring began (Sutherland et al. 2022).

Drug most often injected

Estimates from the 2022 IDRS showed that, among PWID who responded:

• Methamphetamine (54% of PWID) and heroin (35%) 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 remained stable, 35% in 2022 and 34% in 2021. The proportion of participants who said methamphetamine was the drug they injected also remained  stable, 54% in 2022 to 53% in 2021 (Sutherland et al. 2021, Figure 2).
• In the preceding 6 months, 80% of participants reported using crystal methamphetamine, with 98% of those participants reporting the main route of administration was injecting.
• Over half (53%) of the IDRS participants reported using heroin in the preceding 6 months, remaining stable relative to 2022, and represents an overall decline from 79% in 2000 (Sutherland et al. 2022, Figure 4).
• Of those participants who had recently used heroin, 35% reported using it daily (Sutherland et al. 2022).

Data collection for 2022 took place from May to July. Due to COVID-19 restrictions being imposed in various jurisdictions during data collection periods, interviews in 2020, 2021 and 2022 were delivered face-to-face as well as via telephone. This change in methodology should be considered when comparing data from the 2020, 2021 and 2022 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 2018–2022 showed that methamphetamine and heroin are the most common last drugs injected (Figure PWID2). 

• In 2022, methamphetamine (47%) was the most commonly reported last drug injected nationally and across most jurisdictions (ranging from 29–67%). Nationally, this figure has decreased from 48% in 2018.
• Heroin (25%) was the second most commonly reported last injected drug in 2022. The proportion of respondents who reported last injecting heroin decreased from 26% in 2018. 
• Performance and image enhancing drugs (PIEDs) was the third most commonly reported class of drugs last injected, with the proportion in 2022 (7%) higher than in 2018 (4%). 

Other drugs that are often reported as the last drug injected include: 

• Pharmaceutical opioids (including morphine, oxycodone, and fentanyl), (5% in 2022; 7% in 2018).
• Methadone (6% in 2022; 4% in 2018) (Heard et.al. 2023). 

Figure PWID2: Percentage of respondents by last drug injected, 2012 to 2022

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Other frequently used drugs

Use of cannabis by PWID is also common. The 2022 IDRS showed that:

• Nearly three-quarters (72%) of PWID had used cannabis in the last 6 months, an increase from 67% in 2021.
• Just over half (51%) of those who had recently used cannabis reported daily use, stable from 2021 (51%) (Sutherland et al. 2022).

PWID also use pharmaceutical drugs, particularly prescription opioids, at higher rates than the general population (Sutherland et al. 2022). This likely reflects the practice of substituting pharmaceutical drugs for illicit drugs, such as heroin. Data from the 2022 IDRS showed that, in the last 6 months:

• 14% of participants reported non-prescribed use of morphine.
• 10% reported non-prescribed use of oxycodone, up from 9% in 2021.
• 9% reported non-prescribed use of buprenorphine-naloxone film, stable from 9% in 2021.
• 5% reported non-prescribed use of buprenorphine
• 5% reported non-prescribed use of fentanyl (Sutherland et al. 2022).

Use of cocaine is also common among PWID, with 15% of participants in the 2022 IDRS reporting using cocaine in the last 6 months, stable from 15% in 2021 (Sutherland et al. 2022).

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 people 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) was stable over the past 5 years (from 23% in 2018 to 26% in 2022).
• The proportion of respondents reporting receptive sharing of needles and syringes in the last month was stable over the past 5 years (from 16% in 2018 to 19% in 2022) (Heard et al. 2023).

Data from the 2022 IDRS provide additional evidence of risks for harms, including:

• 8% of participants reported lending a needle to someone after they had used it, and 4% reported borrowing a needle after someone else had used it.
• About 1 in 3 (35%) participants reporting re-using their own needle in the last month.
• 1 in 5 (20%) participants reporting sharing other injecting equipment (for example, spoons) in the last month, stable relative to 2021 (18%) and down from a high of 51% in 2000 (Sutherland et al. 2022, Figure 35; Figure PWID3).

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

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Injection-related health problems

In 2022, 26% of IDRS participants reported experiencing an injection-related health problem in the last month stable from 2021 (26%). Of those who responded (n=879), in the last month:

• 11% experienced nerve damage, similar to 2021 (11%).
• 7% reported that they had experienced a ‘dirty hit’ (that is, a hit that made them feel sick), similar to 2021 (7%).
• 12% experienced an infection or abscess, an increase from 2021 (8%) (Sutherland et al. 2022, Table 20).

National HIV antibody prevalence is low. The ANSPS found that among survey participants, there was a slight increase in prevalence from 1.7% in 2018 to 2.1% in 2022 (Heard et al. 2023; Table 1.2.1). 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 female respondents (Figure PWID4). HIV antibody prevalence has also been consistently higher among homosexual male respondents (37.9%) than among bisexual (2.8%) and heterosexual (0.3%) male respondents (Heard et al 2023; Table 1.2.2).
• Between 2018 and 2022, HIV prevalence was also higher among those who reported methamphetamine as the last drug injected (3.1% in 2022) compared to those who reported last injecting other drugs (0.9% for heroin as the last drug injected and 0.5% for those with other opioids as the last drug injected) (Heard et al; Table 1.2.4).
• HIV prevalence was similar among those aged 45 years and over (2.4% in 2022) and those aged 35–44 years, 0.8% of people aged 25–34 and 0% for those under 25 years (Heard et al. 2023; Table 1.2.3).

Figure PWID4: HIV antibody prevalence by sex, 1995 to 2022 (percent)

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According to the ANSPS, Hepatitis C (HCV) is more common than HIV among PWID. Almost 1 in 3 (32%) of respondents were HCV antibody positive in 2022, a decline from 45% in 2018 (Heard et al. 2023, Table 1.3.1). 

• HCV antibody prevalence was higher among older respondents and those with longer injection histories.
• Prevalence of HCV antibodies continues to be higher among respondents reporting heroin or other opioids as the last drug injected (both 45%) compared to respondents who last injected methamphetamine (27%). 
• 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.
• HCV Direct Acting Antiviral (DAA) therapy was included on the Australian Government Pharmaceutical Benefits Scheme (PBS) from March 2016. Lifetime HCV treatment, among respondents eligible for treatment only, increased from 55% in 2018 to 68% in 2022 (Heard et al. 2023).

Data collection for the 2021 ANSPS was impacted by COVID-19 restrictions. The survey took place in several phases from September to December 2021, instead of the usual October timeframe. Victoria and NSW experienced outbreaks between June and November 2021, resulting in a reduction in the amount of participating NSP services. This should be taken into account when comparing data from 2021 with previous years.

Treatment

Data from the 2022 IDRS found that:

• Nearly 2 in 5 (38%) participants reported receiving treatment for substance use in 2022, similar to 2021 (37%).

Of participants not receiving treatment in 2021, 13% reported difficulties accessing treatment. 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 (AIHW 2020, Table 9.21)
• 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%) (AIHW 2020, Table 9.19).

Needle and syringe programs

All Australian states and territories operate needle syringe programs (NSPs), providing a range of services to PWID (Heard et al. 2022). See Harm reduction: Minimising risky behaviours

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 51). 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 4.95). 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.