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) (UNODC 2020). In 2018 it was estimated that there were 11.3 million people worldwide who injected drugs (UNODC 2020).

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).

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. 2020; Peacock et al. 2021).

Estimates from the Illicit Drug Reporting System (IDRS) show that heroin remains the most common drug of choice among PWID, with a recent increase in use. Conversely, use of methamphetamine has decreased (Peacock et al. 2021).

Drug most often injected

Estimates from the 2020 IDRS showed that, among PWID who responded:

• heroin (46% of PWID) and methamphetamine (41%) were the most common drugs injected in the last month
• the proportion of people who said heroin was the drug they injected most often in the last month increased from 40% in 2019 to 46% in 2020, making it more common than methamphetamine for the first time since before 2016 (Table S2.50)
• 71% of people had used crystal methamphetamine in the preceding 6 months, with 95% of those people reporting the main route of administration was injecting
• almost 2 in 3 (63%) people reported using heroin in the preceding 6 months. This was an increase from 55% in 2019, but represents an overall decline from 79% in 2000 (Table S2.54)
• around 1 in 3 (36%) people who had recently used heroin reported using it daily (Peacock et al. 2021).

Data collection for the 2020 IDRS took place from June–September 2020, after COVID-19 restrictions were introduced in Australia (Peacock et al. 2021). This should be taken into account when comparing data from 2020 with 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 1995–2019 Australian Needle Syringe Program Survey showed that methamphetamine and heroin are the most common last drugs injected (Figure PWID2).

• In 2019, methamphetamine (49%) was the most commonly reported last drug injected nationally and across most jurisdictions (ranging from 34–67%). This figure has increased from 36% in 2015.
• Heroin (27%) was the second most commonly reported last injected drug in 2019. The proportion of respondents who reported last injecting heroin decreased from 31% in 2015.
• Pharmaceutical opioids (including morphine, oxycodone and fentanyl) were the third most commonly reported class of drugs last injected. However, prevalence declined from 10% in 2015 to 6% in 2019 (Heard et al. 2020) (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). 

Other frequently used drugs

Use of cannabis by PWID is also common. The 2020 IDRS showed that:

• over two-thirds (67%) of PWID had used cannabis in the last 6 months, declining from 74% in 2019
• just under half (48%) of those who had recently used cannabis reported daily use (Peacock et al. 2021).

PWID also use pharmaceutical drugs, particularly prescription opioids, at higher rates than the general population (Peacock et al. 2021). This likely reflects the practice of substituting pharmaceutical drugs for illicit drugs, such as heroin. Data from the 2020 IDRS showed that, in the last 6 months:

• 15% of participants had used non-prescribed morphine
• 11% had used non-prescribed oxycodone, down from 15% in 2019
• 9% had used non-prescribed buprenorphine-naloxone film, down from 12% in 2019
• 5% had used non-prescribed buprenorphine
• 6% had used non-prescribed fentanyl (Peacock et al. 2021).

Use of cocaine is also common among PWID, with 17% of participants in the 2020 IDRS reporting using cocaine in the last 6 months. This represents an increase from 13% in 2019 (Peacock 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

Unsafe injecting practices were responsible for 0.5% of the total burden of disease and injuries in 2015 (AIHW 2019).

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 75% and 37% of burden (respectively) (AIHW 2019). Chronic liver disease and liver cancer were each responsible for 24% of the burden due to unsafe injecting practices (AIHW 2019).

Injecting risk behaviours

Data from the Australian Needle Syringe Program (ANSP) 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) remained relatively stable over the past 5 years (25% in 2015 and 24% in 2019)
• the proportion of respondents reporting receptive sharing of needles and syringes in the last month was also stable over the past 5 years (16% in both 2015 and 2019) (Heard et al. 2020).

Data from the 2020 IDRS provide additional evidence of risks for harms, including:

• Almost 1 in 10 (9%) participants reported lending a needle to someone after they had used it, and 5% reported borrowing a needle after someone else had used it (down from 8% in 2019).
• Over 2 in 5 (44%) participants reporting re-using their own needle in the last month.
• One-quarter (25%) of participants reporting sharing other injecting equipment (for example, spoons) in the last month. This is a significant increase from 5% in 2019, but a decline from a high of 51% in 2000 (Peacock et al. 2021) (Table S3.63; Figure PWID3).

Injection-related health problems

In 2020, 29% of IDRS participants reported experiencing an injection-related health problem in the last month. This represents a decline from 45% in 2019 (Peacock et al. 2021). Of those who commented (n=879), in the last month:

• 12% experienced nerve damage, down from 20% in 2019
•  8% reported that they had experienced a ‘dirty hit’ (that is, a hit that made them feel sick), down from 22% in 2019
• 8% experienced an infection or abscess, down from 14% in 2019 (Peacock et al. 2021) (Table S3.64).

The ANSPS found that HIV antibody prevalence is low and stable nationally (1.7% to 2.3% between 2015 and 2019) (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 2015 and 2019, HIV prevalence was also higher among those who reported methamphetamine as the last drug injected (3.3% in 2019) compared to those who reported last injecting other drugs (1.7% for heroin as the last drug injected and 1.2% for those with other opiods as the last drug injected 2020).
• HIV prevalence was higher among those aged 45 years and over (3.4% in 2019), compared with 1.6% of people aged 25 to 44 and 0% for those aged under 25 (Heard et al. 2020).

According to the ANSPS, Hepatitis C (HCV) is more common than HIV among PWID. Less than half (45%) of respondents were HCV antibody positive in 2019, a decline from 57% in 2015 (Table S3.66).

• HCV antibody prevalence was higher among older respondents and those with longer injection histories.
• Prevalence of HCV was also higher among respondents reporting heroin or other opioids (65% and 53%, respectively) as the last drug injected compared to respondents who last injected methamphetamine (34%). 
• HCV RNA prevalence was consistently higher among respondents who reported imprisonment in the year preceding survey completion compared to those who had not been incarcerated and among respondents who reported receptive syringe sharing in the last month compared to respondents who did not report receptive syringe sharing (Heard et al. 2020).
• 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. The proportion of respondents reporting recent HCV treatment (in the last 12 months) increased from 2% in 2015 to 44% in 2019 (Heard et al. 2020).

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. 2019). 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 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.