A nationwide study of the extent and factors associated with fentanyl use in Australia

Twenty-year trends in pharmaceutical fentanyl and illicit fentanyl deaths, Australia 2001-2021

BACKGROUND

Increasing overdose deaths attributable to illicitly manufactured fentanyl and fentanyl analogues in North America has driven international concern about the expansion of these substances into drug markets elsewhere. This paper investigates 20-year trends in fentanyl deaths in Australia, distinguishing between deaths attributable to pharmaceutical, and to illicitly manufactured fentanyl and fentanyl analogues.

METHODS

Analysis of fentanyl overdose deaths (2001-2021), extracted from the National Coronial Information System (NCIS).

RESULTS

833 fentanyl-related deaths were identified, predominantly occurring among males (73%), and people with a history of injecting drug use (67%). Rates of fentanyl deaths significantly increased between 2001 and 2014 and declined between 2015 and 2021. Drug dependence remained the most significant factor in deaths among people with a history of injecting drug use (87% vs 23% without such a history), while having died by suicide was the most significant factor for those without a history of injecting drug use (20% vs 4% respectively). Three quarters (72%) of deaths were attributable to pharmaceutical fentanyl and 21% to probable pharmaceutical fentanyl, with 5% attributable to fentanyl analogues (3%) (predominantly furanylfentanyl and acetylfentanyl) and illicitly manufactured fentanyl (2%). Deaths attributable to illicitly manufactured fentanyl and fentanyl analogues occurred from 2013 onwards.

CONCLUSION

Pharmaceutical fentanyl deaths in Australia have declined since 2015, in parallel with overall declines in pharmaceutical opioids (including fentanyl) dispensed since 2014. Deaths continue to occur among people with a history of injecting drug use and drug dependence. Deaths attributable to illicit fentanyl have emerged since 2013 but remain low in comparison to pharmaceutical fentanyl deaths.

Trends in transdermal fentanyl utilisation and fatal fentanyl overdose across Australia (2003-2015)

INTRODUCTION

Fentanyl-related overdose is an ongoing concern among countries with high prescription opioid utilisation. This study examines trends in transdermal fentanyl utilisation and fatal fentanyl overdose across Australia between 2003 and 2015, overall, and by age/sex.

METHODS

This was a retrospective nationwide study of prescription dispensings and coronial records. Transdermal fentanyl utilisation was examined using Pharmaceutical Benefits Scheme dispensing records. Details of fatal fentanyl overdoses were extracted from the National Coronial Information System.

RESULTS

Transdermal fentanyl utilisation increased 5.1-fold between 2003 and 2015, from 0.28 to 1.39 mg/1000 population/day and was consistently higher among females and adults aged ≥85 years. The utilisation of higher strength patches (75 and 100 mcg/h) was more common among males aged 25-44 years. A total of 291 fatal fentanyl overdoses were recorded, increasing from no recorded deaths in 2003 to 2.23 deaths/1 000 000 population in 2015. Rates were higher among males (increasing from 0 to 3.72 deaths/1 000 000 population) and for adults aged 25-44 years (increasing from 0 to 5.34 deaths/1 000 000 population). The number of deaths/kg fentanyl dispensed was highest among males aged <25 years (45.45, 95% confidence interval 21.80-83.59). Most deaths (70.1%) involved the intravenous administration of fentanyl from transdermal patches.

DISCUSSION AND CONCLUSIONS

Rates of transdermal fentanyl utilisation and fatal fentanyl overdose across Australia increased between 2003 and 2015. Although transdermal fentanyl utilisation was consistently greater among females and older adults, rates of fatal fentanyl overdose were highest among younger males. Interventions to reduce extramedical use among this high-risk population group are necessary to minimise fentanyl-related harms.

Illicit synthetic opioid consumption in Asia and the Pacific: Assessing the risks of a potential outbreak

BACKGROUND

Illegally manufactured potent synthetic opioids (IMPSO) like fentanyl have contributed to rises in overdose deaths in parts of North America and Europe. While many of these substances are produced in Asia, there is little evidence they have entered markets there. We consider the susceptibility to IMPSO's encroachment in markets in the Asia-Pacific region.

METHODS

Our analysis focuses on Australia, China, India, and Myanmar. Using a mixed-methods approach comprising interviews, literature review, and secondary data analyses, we examine factors facilitating or impeding incursion of IMPSO. Finally, we illustrate the potential for IMPSO fatalities in Australia.

RESULTS

Australia reports some signs of three facilitating factors to IMPSO's emergence: 1) existing illicit opioid markets, 2) disruption of opioid supply, and 3) user preferences. The other three countries report only existing illicit opioid markets. While diverted pharmaceutical opioids are a noted problem in Australia and India, heroin is the dominant opioid in all four countries. There are divergent trends in heroin use, with use declining in China, increasing in India, and stable in Australia and Myanmar. If IMPSO diffused in Australia as in North America from 2014 to 2018, and our assumptions generally hold, deaths from IMPSO could range from 1500-5700 over a five-year period.

CONCLUSIONS

This analysis and illustrative calculations serve as an early indication for policymakers. With the exception of Australia, many countries in the region fail to properly record overdose deaths or monitor changes in local drug markets. Early assessment and monitoring can give officials a better understanding of these changing threats.

The fentanyls: a 'future threat' for Australia?

OBJECTIVE

The fentanyls have emerged as a significant public health threat in North America but much less so in Australia. We sought to identify reasons for this discrepancy and highlight harm reduction approaches that may mitigate a future Australian fentanyl epidemic.

CONCLUSIONS

Differences in drug use 'culture' and a supply of cheap high-quality methamphetamine in Australia may be reasons for the observed difference in fentanyl-related harm. More worryingly, it is possible that Australia is following North American trends and that the fentanyl epidemic is still to come.

Characteristics and circumstances of heroin and pharmaceutical opioid overdose deaths: Comparison across opioids

BACKGROUND

Although much is known about the correlates of heroin overdose, less is known about pharmaceutical opioid (PO) overdose. This study aimed to examine correlates of opioid overdose deaths by opioid and compare correlates between opioids.

METHODS

Analysis of opioid overdose deaths in Australia between 2000-2015, extracted from the National Coronial Information System (NCIS). The NCIS is an online database of deaths reportable to the coroner, and contains coroner's findings, autopsy and toxicology reports. Deaths were categorized into mutually exclusive groups: 1) Heroin deaths; and 2) PO deaths (excluding heroin). PO deaths were examined by individual opioid.

RESULTS

There were 10,795 opioid overdose deaths over the study period. Relative to deaths occurring in major cities, deaths in regional/remote areas had 15.2 (95 % CI: 11.5-20.2) times the risk of being attributed to pharmaceutical fentanyl than heroin. Relative to deaths among people without a recorded history of chronic pain, deaths among people with a recorded history of chronic pain had a 1.9-10.7-fold increased risk of the death being attributed to POs than heroin. Deaths among people with a recorded history of substance use problems where the opioid was injected prior to death had 7.2 and 1.7 times the risk of being attributed to methadone and pharmaceutical fentanyl (respectively) than heroin.

CONCLUSIONS

Findings suggest the need to: educate PO consumers about the risks of overdose at the time of prescribing; increase coverage and engagement in opioid dependence treatment (particularly in regional/remote areas); and increase uptake of take-home naloxone to reduce opioid overdose mortality.

A population-based study of transdermal fentanyl initiation in Australian clinical practice

PURPOSE

Although guidelines caution against initiation of transdermal (TD) fentanyl among those who are opioid naïve, there is concern that not all people receive adequate prior opioid exposure. This study examined the percentage of people who are opioid naïve at the time of TD fentanyl initiation in Australia; strengths initiated; and characteristics associated with being opioid naïve.

METHODS

This is a national retrospective cohort study derived from a 10% sample of Pharmaceutical Benefits Scheme concessional beneficiaries initiating TD fentanyl between 29 September 2009-31 December 2013. Individuals were deemed opioid naïve if they had no opioid dispensings in the previous 90 days. Logistic regression was used to determine characteristics associated with being opioid naïve, including socio-demographics, likely comorbidities and previous analgesic use.

RESULTS

A total of 13,166 people initiated TD fentanyl; 60.4% were female and 76.2% were aged ≥ 65 years. Three in ten (30.4%) were opioid naïve and 63.2% initiated the 12 mcg/h patch. Those who were opioid naïve were more likely to be female (adjusted odds ratio (aOR) 1.35; 95% CI 1.25-1.46), older (aOR 1.85; 95% CI 1.54-2.28 for those ≥ 85 years) and previously dispensed medicines for dementia (aOR 1.37; 95% CI 1.04-1.80). People previously dispensed medicines for cancer were less likely to be opioid naïve (aOR 0.57; 95% CI 0.48-0.67).

CONCLUSIONS

Three in ten Australians initiating TD fentanyl are opioid naïve. Our findings suggest that specific patient sub-populations already at increased risk of opioid-related adverse events are not receiving prior opioid treatment before initiation, highlighting the need for greater adherence to current treatment guidelines.