Opioid overdose mortality trends in Australia 10 mins with 5 for questions – about 10 slides Amanda Roxburgh, Wayne D Hall, Lucinda Burns and Louisa Degenhardt

Conflict of Interest Statement Professor Louisa Degenhardt has received untied educational grants from Reckitt Benckiser for the post-marketing surveillance of opioid substitution therapy medications in Australia, and the development of an opioid-related behaviour scale. Professor Degenhardt has also received untied educational grants from Mundipharma to conduct post-marketing surveillance of the use of oxycodone formulations in Australia. The current paper design, conduct and interpretation of findings are the work of the investigators; these funders had no role in this paper. None of the other authors have anything to declare.

Opioids in context - international Source: INCB 2011-13 data Berterame et al, Lancet (2016) 13,440 22,941 31,453 USA – 16,046 to 31,453 DDD per million popn per day Canada – 8,310 to 22,941 Australia – 3,287 to 13,440

Opioid use Australian context Heroin and pharmaceutical opioid injecting INCREASES Daily heroin use in NSW from 35 to 42%; QLD 9% to 15%; STABLE VIC – 33% to 35% DECREASES WA – 44% to 27%; SA 29% to 21% NO ONE IN TAS USING DAILY Overdose – VIC highest in 2017 at 21% but down from last year 32% NSW – 12% Source: Illicit Drug Reporting System

Methods Extracted data from the National Coronial Information System – 2001 to 2012 Online database – all deaths that are reportable to Coroner Not constrained by International Classification of Diseases Coding ICD has Morphine and Oxycodone together – fentanyl and tramadol together Only deaths where opioid toxicity was determined to have caused the death were included Decisions around distinguishing between heroin and morphine deaths Collected indicators of diversion, misuse, dependence

Distinguishing between heroin and morphine deaths

Findings: Opioid deaths in Australia Source: NCIS; Roxburgh et al, Drug and Alcohol Dependence 2017; ABS deaths data 2017

Findings: Opioid deaths in Australia U.S. All opioid deaths 2015 – 103 per million U.S. Heroin deaths 2015 – 40.4 per million Source: NCIS; Roxburgh et al, Drug and Alcohol Dependence 2017; ABS deaths data 2017

Findings: Opioid deaths in Australia Source: NCIS; Roxburgh et al, Drug and Alcohol Dependence 2017; ABS deaths data 2017

Pharmaceutical opioid deaths (by opioid) per million population Source: NCIS; Roxburgh et al, Drug and Alcohol Dependence 2017

Pharmaceutical opioid deaths (by opioid) per million population Source: NCIS; Roxburgh et al, Drug and Alcohol Dependence 2017

Pharmaceutical opioid deaths (by opioid) per 100,000 OME grams dispensed Source: NCIS; Roxburgh et al, Drug and Alcohol Dependence 2017

History of injecting drug use by opioid

Injected drug prior to death, by opioid

History of drug dependence by opioid

History of chronic pain by opioid

Opioid prescribed prior to death, by opioid

Discussion PO deaths significantly increased by 1.6 times the rate recorded in 2001. Occurring at 2.5 times the incident rate compared to heroin Morphine deaths remain highest when adjusted by OME grams dispensed 1.7 times the rate of oxycodone deaths; 2.2 times the rate of fentanyl deaths Fentanyl deaths when adjusted by OME grams dispensed Continued to increase but from relatively low level Increases in deaths appeared to exceed rates of prescribing Suggests extra-medical use occurring: High proportions injecting, drug dependence, Low proportions prescribed and chronic pain

Discussion continued Rates of heroin deaths remained relatively stable over longer term Some indications that the heroin market is picking up again in Australia Drug misuse and diversion more prevalent among fentanyl deaths. Drug dependence was a less discriminatory marker across POs and heroin deaths

Implications Changing prescribing practices not likely to be the only response to reduce opioid overdose deaths Diversion happening particularly among fentanyl deaths Diversification of opioid market Appearance of illicit fentanyl in North America Fentanyl deaths in 2016 higher than heroin in North America Pharmaceutical fentanyl remains predominant in Australia Only 3 reported using an illicit opioid (other than heroin) in 2017 Monitoring darknet markets for illicit fentanyl and fentanyl analogues Many of the PO death reports had info about people who had been prescribed these drugs using many other drugs in combination or in greater doses than prescribed for the purpose of treating unmanageable pain.

Implications continued Diversification in who develops dependence from PWID to those with chronic pain Providing treatment for pain and dependence across both groups important Increasing naloxone accessibility and affordability crucial in Australia Particularly in the context of illicit fentanyl – much more potent than pharmaceutical fentanyl Many of the PO death reports had info about people who had been prescribed these drugs using many other drugs in combination or in greater doses than prescribed for the purpose of treating unmanageable pain.

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