1. 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

2. 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.

3. Opioids in context - international
Source: INCB 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

4. 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

5. 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

6. Distinguishing between heroin and morphine deaths

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

8. 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

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

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

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

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

13. History of injecting drug use by opioid

14. Injected drug prior to death, by opioid

15. History of drug dependence by opioid

16. History of chronic pain by opioid

17. Opioid prescribed prior to death, by opioid

18. 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

19. 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

20. 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.

21. 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.

22. THANK YOU