3303.0 - Causes of Death, Australia, 2016  
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Drug Induced Deaths in Australia: A changing story

Harmful drug use continues to be a serious public health issue in Australia with 1,808 drug induced deaths registered in 2016. This is the highest number of drug deaths in twenty years, and is similar to the number recorded in the late 1990s, when a steep increase in opioid use, specifically heroin, led to deaths peaking at 1,740 in 1999. Although the number of drug induced deaths is the highest on record, the death rate per capita of 7.5 per 100,000 people is lower than that in 1999 (9.2 deaths per 100,000 people).

Changes in drug deaths have been significant over this period. In 2016, an individual dying from a drug induced death in Australia was most likely to be a middle aged male, living outside of a capital city who is misusing prescription drugs such as benzodiazepines or oxycodone in a polypharmacy (the use of multiple drugs) setting. The death was most likely to be an accident. This profile is quite different from that in 1999, where a person who died from a drug induced death was most likely to be younger (early 30s) with morphine, heroin or benzodiazepines detected on toxicology at death.

The 2016 National Drug Strategy Household Survey (AIHW, 2017b) reported that methamphetamines (including the drug ice) were the drugs causing most concern to communities. There was also a perception among respondents that it caused the most drug deaths (when excluding alcohol and tobacco). While prescription drugs actually cause the highest numbers of drug induced deaths, there has been a rapid increase in the number of methamphetamine deaths, with the death rate in 2016 four times that in 1999 (1.6 deaths compared to 0.4 deaths per 100,00 persons respectively).

Across the whole population, younger Australians (under 35 years of age) have lower rates of drug induced death when compared to 1999, while older Australians (45 and over) generally have higher rates. This also reflects changes in the types of drugs causing death. Deaths from illicit substances like heroin and methamphetamines tend to occur among younger age groups, while deaths from benzodiazepines and prescription opiates tend to occur among older people.

This article provides further information and analysis on drug induced deaths in Australia in 2016.

If you are concerned about your own drug use or that of a family member, friend, or colleague, talk to your general practitioner. There are also many organisations which are able to provide help and support. A list of contacts is included at the end of this article.


Defining a Drug Induced Death

Understanding what constitutes a drug death is complex as mortality from drug use manifests in a multitude of forms. Deaths can be directly attributable to drug abuse such as overdoses, or deaths can occur where a drug is found to be a contributory factor such as a traffic accident where the deceased was found to be under the influence of a substance at time of death. This article focusses in the main on drug induced deaths. Information on drug related deaths is included towards the end of the article.

Deaths are considered “drug induced” if directly attributable to drug use (e.g. overdose example), and “drug related” where drugs played a contributory factor (e.g. traffic accident example).

In Australia, acute drug overdose deaths are referred to a coroner and subject to forensic pathology and toxicology. Autopsy and toxicology reports provide detailed drug information including the identification of specific drugs in the system, approximate levels of drugs in the system and the relatedness of drugs to the death. The Australian Bureau of Statistics accesses this information via the National Coronial Information System and applies codes from the International Classification of Diseases, 10th Revision, to the medical text for tabulation into statistical output.

For the purposes of this report, deaths are output using a modified version of a drug induced death tabulation created by the United States Center for Disease Control and Prevention (CDC). The tabulation, which consists of ICD-10 codes can be found here. The CDC drug induced death listing includes overdose deaths of all intents (i.e. accident, suicide, homicide and undetermined intent), as well as mental and behavioural conditions caused by drug abuse (e.g. addiction) and chronic health conditions such as drug induced circulatory diseases. Tobacco has been removed from the tabulation, as the links between smoking and premature mortality, especially in relation to chronic respiratory diseases, is well documented.

Excluded from the article are deaths due to drug use in a surgical procedure (e.g. anaphylactic reaction to anaesthetic), and deaths due solely to alcohol misuse. Deaths due exclusively to alcohol abuse require specific demographic considerations, and display complications which are distinctive compared to those of drug deaths.. Therefore alcohol related deaths will be explored in future analytical work.

Drug Induced Deaths over time

Following peak rates of deaths in the late 90s, rates of drug deaths were relatively stable in the early to mid-2000s. From 2011 there has been a significant increase in rates of drug induced deaths, with a preliminary rate of 7.5 deaths per 100,000 people recorded in 2016.

The table below shows a 20 year time series of age standardised death rates per 100,000 persons. In addition to demonstrating the peak period of drug deaths in 1999 and the significant increases in recent years, the table also shows the consistently higher rates of drug induced deaths in males. Over the last two decades, the death rate for males has on average been 1.9 times higher than females for drug induced deaths. Although the incline in death rates is more defined in males, both males and females have experienced significant increases over the last five years.

The National Drug Strategy Household Survey 2016 (AIHW, 2017b) found that males were more likely to misuse illicit drugs (including misuse of pharmaceuticals). It is therefore expected that rates of drug induced deaths would be higher among males.

The high number of heroin related deaths in 1999 and corresponding decrease in the early 2000s has been well documented and reported (Degenhardt et al., 2006). It should be noted that this period also corresponds with the ABS changing classifications from ICD-9 to ICD-10 and the subsequent move to utilising the National Coronial Information System for accessing information relating to a death. However, it is not expected that these administrative changes would have significantly impacted drug death data over this period.

Graph Image for Drug induced deaths, standardised death rates 1997-2016 (a)(b)(c)(d)(e)(f)

Footnote(s): (a) Standardised death rates. Deaths per 100,000 of estimated mid-year population. See Glossary for further information. (b) The age-standardised death rates for 2012-2015 presented in this table have been recalculated using 2016-census-based population estimates. As a result, these rates may differ from those previously published. (c) Causes of death data for 2016 are preliminary and subject to a revisions process. See Explanatory Notes 55-58 and A More Timely Annual Collection: Changes to ABS Processes (Technical Note) in this publication. (d) See Explanatory Notes 72-101 for further information on specific issues related to interpreting time-series and 2016 data (e) All causes of death data from 2006 onward are subject to a revisions process - once data for a reference year are 'final', they are no longer revised. Affected data in this table are: 1997-2013 (final), 2014 (revised), 2015-2016 (preliminary). See Explanatory Notes 52-55 in this publication. See also Causes of Death Revisions, 2012 and 2013 (Technical Note) in Causes of Death, Australia, 2014 (cat. no. 3303.0). (f) Deaths registered on Norfolk Island from 1 July 2016 are included in this publication for the first time, see Explanatory Notes 12-15

Source(s): Drug induced deaths, standardised death rates 1997-2016 (a)(b)(c)(d)(e)(f)-Drug induced deaths, standardised death rates 1997-2007



Premature mortality and Drug Induced Deaths

Australians currently boast an estimated life expectancy at birth of 82.4 years (ABS, cat. no. 3302.0.55.001), with life expectancy predicted to continue to increase in future (Kontis et al, 2017). With a high life expectancy over 50% of all deaths in Australia currently occur after the age of 80.

Looking at a cumulative frequency of deaths for the whole population and comparing that to a cumulative frequency for drug induced deaths, the links of drug misuse to premature mortality are stark. The table below shows that approximately 50% of drug induced deaths in 2016 occurred by age 44, with 90% of all drug deaths having occurred by age 64. On average, a person who dies from a drug induced death loses 33.7 years from their life.


Graph Image for Cumulative proportion of Drug induced deaths by selected age groups, 2016 (a)(b)(c)

Footnote(s): (a) Causes of death data for 2016 are preliminary and subject to a revisions process. See Explanatory Notes 55-58 and A More Timely Annual Collection: Changes to ABS Processes (Technical Note) in this publication. (b) See Explanatory Notes 72-101 for further information on specific issues related to interpreting time-series and 2016 data (c) Deaths registered on Norfolk Island from 1 July 2016 are included in this publication for the first time, see Explanatory Notes 12-15

Source(s): Cumulative proportion of Drug induced deaths by selected age groups, 2016 (a)(b)(c)-cummaltive frequency




The reasons for the relationship between drug induced deaths and premature mortality are varied. Drug misuse is linked to a number of adverse social and health factors, with Australia’s Health Report 2016 (AIHW, 2017a) reporting that unemployment, living in a lower socioeconomic area and suffering high emotional distress are all associated with higher illicit drug use. Of note, 669 people (37.0%) who died of a drug induced death in 2016 had a mental health condition (including depression, schizophrenia and anxiety disorders) coded as a contributory factor to the death event. In addition, many people who died from a drug induced death were living with a chronic health condition. For example, 118 people (6.5%) were known to be suffering from viral hepatitis, particularly Hepatitis C, at the time of their death. Understanding the social and health determinants behind drug misuse and mortality aids in the formulation of effective policy and prevention programs.

Composition of Drug Induced Deaths

The majority of drug induced deaths in 2016 were due to acute accidental overdoses (71.3%), followed by suicidal overdoses (22.7%). Other types of drug deaths, including addictions and chronic complications of drug abuse as well as homicide and undetermined intent accounted for the remaining 6.0%.

The table below highlights that the composition of drug induced deaths is similar for both males and females. Notably, females have a higher proportion of suicidal drug overdoses (31.2%) compared with males (18.0%). On average, for both males and females, accidental drug induced deaths occurred at an earlier age than intentional overdoses. Accidental drug overdoses in 2016 had a median age of 42 years for men and 46 years for women. In contrast, suicidal overdoses recorded a median age of death of 51 for men and 52 for women.

Proportion of acute drug deaths by sex, 2016 (a)(b)
Diagram: Proportion of acute drug deaths by sex, 2016 (a)(b)
(a) Causes of death data for 2016 are preliminary and subject to a revisions process. See Explanatory Notes 55-58 and A More Timely Annual Collection: Changes to ABS Processes (Technical Note) in this publication.
(b) Deaths registered on Norfolk Island from 1 July 2016 are included in this publication for the first time, see Explanatory Notes 12-15


Over half (59.0%) of all acute drug deaths had two or more substances identified on the toxicology report at death. This proportion was similar for accidental, intentional and undetermined intent drug induced deaths as shown in the graph below. Single capture of narcotics (where only one drug in the body system is reported), which includes illicit and prescription opioids as well as substances such as cocaine were more common in accidental drug deaths. Single capture of sedative and psychostimulant use, which includes benzodiazepines, antidepressants and amphetamines are more common in intentional self harm drug deaths.

The presence of multiple drugs in drug induced deaths has been well documented through other studies (Roxburgh et al, 2015). When the ABS codes causes of death, information from the police, toxicology, autopsy and coronial finding is used to inform the tabulated information. There are jurisdictional differences in access to information, as well as differences in report availability depending on whether a case is open or closed. At times, the pathologist provides information on the main drug contributing to death, but provides no further information on additional substances identified at toxicology. For example, a death certificate may be recorded as "heroin overdose", even though a benzodiazepine was also present in the system. For cases where toxicology reports are not available at the time of coding, these deaths would be coded with a single drug (e.g. heroin T401). Drug induced deaths which have not been finalised by a coroner at the time of coding are subject to the ABS revisions process, whereby, updated information on drugs will be added to the case as further information becomes available. See explanatory notes 55-58 for further information on the ABS revisions process. Caution should be used when interpreting figures on multiple drug counts.

Proportion of multiple drug use, 2016 (a)(b)
Diagram: Proportion of multiple drug use, 2016 (a)(b)
(a) Causes of death data for 2016 are preliminary and subject to a revisions process. See Explanatory Notes 55-58 and A More Timely Annual Collection: Changes to ABS Processes (Technical Note) in this publication.
(b) Deaths registered on Norfolk Island from 1 July 2016 are included in this publication for the first time, see Explanatory Notes 12-15


Age profile of Drug Induced Deaths

Males and females differ in their peak ages of death from drug misuse. The graph below shows that the highest age-specific death rate (ASDR) for males is between ages 35 and 39 years, measuring at 24.3 deaths per 100,000 males. For females, the highest ASDR is for the 45 to 49 year age group, at 11.5 deaths per 100,000 females. For both males and females, drug induced deaths were lowest for the 15 to 19 year age group. The differences in age specific death rates for males and females are linked to the type and pattern of drug use. This is discussed further below.

Graph Image for Age-specific death rates for Drug induced deaths, by sex, 2016 (a)(b)(c)

Footnote(s): (a) Age-specific death rates. Deaths per 100,000 of estimated mid-year population. See Glossary for further information. (b) Causes of death data for 2016 are preliminary and subject to a revisions process. See Explanatory Notes 55-58 and A More Timely Annual Collection: Changes to ABS Processes (Technical Note) in this publication. (c) Deaths registered on Norfolk Island from 1 July 2016 are included in this publication for the first time, see Explanatory Notes 12-15

Source(s): Age-specific death rates for Drug induced deaths, by sex, 2016 (a)(b)(c)-Drug induced ASDR by sex, 2016




The age profile of drug induced deaths has changed over the last two decades. The graph below shows the ASDRs for males and females from 1999, alongside those of 2016. There has been a clear shift from peak rates of drug deaths in younger age groups to middle-aged groups. In 1999, males had the highest rate of death between ages 25 to 29, compared with 35 to 39 years in 2016. Females also had the highest rate of death between ages 25 to 29 in 1999. This peak rate has shifted in 2016, with women aged between 45 and 49 now recording the highest rate of death.

The shifting age profile of drug induced deaths is an important issue. It is clear that the rate of drug death among younger people has decreased significantly, yet among older age groups, the rate of drug induced is now much higher. This is especially the case among people between the age of 45 and 64.

The National Drug Strategy Household Survey 2016 (AIHW, 2017b) found that there has been shifting patterns in drug usage among the community. The average age of initiation of drug use has increased from 18.6 in 2001 to 19.7 years in 2016. In particular, there has been a large shift in average age of initiation for the misuse of pharmaceutical drugs, increasing from 20.1 in 2001 to 25.1 in 2016. There was also an increase in the proportion of people aged over 35 who used drugs illicitly compared with 2001, with the increase of drug use in 35-54 year olds being marked as significant. Older people have been identified by the National Drug Strategy (DoH, 2017) as a priority population, with unique health circumstances such as pain, co-morbidities, and social circumstances such as isolation, being highlighted as important contextual factors to consider in the context of drug use.


Age-specific death rates for Drug Induced Deaths by sex, 1999 & 2016 (a)(b)(c)(d)

Diagram: Age-specific death rates for Drug induced deaths by sex, 1999 & 2016 (a)(b)(c)(d)
(a) Age-specific death rates. Deaths per 100,000 of estimated mid-year population. See Glossary for further information.
(b) Causes of death data for 2016 are preliminary and subject to a revisions process. See Explanatory Notes 55-58 and A More Timely Annual Collection: Changes to ABS Processes (Technical Note) in this publication.
(c) Deaths registered on Norfolk Island from 1 July 2016 are included in this publication for the first time, see Explanatory Notes 12-15
(d) See Explanatory Notes 72-101 for further information on specific issues related to interpreting time-series and 2016 data


Drug Induced Deaths by common drug classes

The most common class of drug identified on toxicology reports in drug induced deaths are opioids. Opioids have been the leading class of drug for the last twenty years (see table below). Opioids include both illicit and licit substances including heroin, opiate-based analgesics including codiene, oxycodone and morphine, and synthetic opioid prescriptions including tramadol, fentanyl and methadone. Opioid class drugs work by binding to opioid receptors in the brain which control pain and reward to inhibit messages of pain sent to the body (Merrer et al., 2009).

Depressants are a class of drug which slow down the activity of the central nervous system to ease anxiety, relax people and initiate sleep (DoH, 2004). Depressant drugs include benzodiazepines and barbituates. They have consistently been the second most common class of drug, with antidepressants the third most common present in drug induced deaths. Antidepressants are prescribed for the treatment of mental health disorders which may include major depressive disorder and obsessive compulsive disorder. In Australia, women are more likely to be prescribed antidepressants compared with males (ABS, cat no. 4329.0.00.003).

Apart from opioids, which had a well documented peak presence in drug induced deaths in the late 90s, all classes of drugs have reported a higher rate of presence in drug deaths per 100,000 persons when compared with 1999. In particular, the graph below shows a peak incline in rates of deaths associated with stimulants since 2011.


Common drug classes, Age-specific death rates, 1997-2016 (a)(b)(c)(d)(e)(f)
Diagram: Common drug classes, Age-specific death rates, 1997-2016 (a)(b)(c)(d)(e)(f)


(a)
Age-specific death rates. Deaths per 100,000 of estimated mid-year population. See Glossary for further information.
(b) ICD-10 codes: Opioids: T400-T404, T406; Depressants: T420-T429; Antidepressants T430-T432; Antipsychotics T433-T435; Cannabinoids T407, Non-Opioids Analgesics T390-T399; Stimulants T436 (Psychostimulants), T405 (Cocaine).
(c) The age-standardised death rates for 2012-2015 presented in this table have been recalculated using 2016-census-based population estimates. As a result, these rates may differ from those previously published.
(d) Causes of death data for 2016 are preliminary and subject to a revisions process. See Explanatory Notes 55-58 and A More Timely Annual Collection: Changes to ABS Processes (Technical Note) in this publication.
(e) See Explanatory Notes 72-101 for further information on specific issues related to interpreting time-series and 2016 data
(f) Deaths registered on Norfolk Island from 1 July 2016 are included in this publication for the first time, see Explanatory Notes 12-15


Focussing on classes of drugs provides important insights into drug mortality. Additional information can be gained by identifying individual drugs within those classes. This can be particularly useful in opioid class drugs where distinctions can be made between heroin, opiate-based painkillers and synthetic opioid analgesics. In addition, changes in prescription patterns and their relationship to mortality are more transparent at finer levels of analysis. The remainder of discussion on drug type is focussed on single ICD-10 poisoning codes.

Drug Induced Deaths by drug type

When analysed by single drug type, benzodiazepines were the most common substance present in drug induced deaths in 2016, being identified in 663 (36.7%) deaths (see table below). Benzodiazepines are drugs prescribed for the treatment of anxiety and insomnia, and are prone to tolerance and addiction. Benzodiazepines are associated with both accidental and intentional overdoses and were the most common drug in both unintentional and suicidal drug deaths in 2016. They can be dangerous when taken with other substances as they affect the central nervous system and may cause respiratory depression. In over 96% of drug deaths where benzodiazepines were present in 2016, they were taken in conjunction with other drugs including alcohol. Apart from 1999, when prescription opioids were the single most identified substances in drug induced deaths, benzodiazepines have consistently been the most common single substance identified on toxicology.

Prescription painkillers such as oxycodone, morphine and codeine, which are tabulated to the "other opioid" ICD-10 category, were present in over 30% of deaths in 2016. Similar to benzodiazepines, they are associated with addiction, polypharmacy misuse, and are common in both accidental and intentional drug induced deaths. Between 2010 and 2015 there was an increase of over 100% in prescriptions of oxycodone, a slow releasing opioid (PBS, 2015). Increases in prescriptions have been hypothesised to be correlated to a variety of social and health issues, including an aging population, living with chronic pain and increasing survivability from chronic illnesses such as cancer (Blanch, Pearson & Haber, 2014).

Although deaths directly attributable to alcohol are excluded from the analysis, alcohol was the seventh most common substance present in drug induced deaths. All of these deaths were due to multiple drug overdose. Alcohol is a depressant, and when mixed with other central nervous depressants in a polypharmacy setting, can exacerbate effects and lead to respiratory depression (Ren, Ding & Greer, 2012).

Drug Induced Deaths by drug type, 1999, 2007, 2016 (a)(b)(c)(d)(e)

Cause of Death and ICD-10 code(a)Common terms assigned to ICD-10 category
1999
no.
rank
2007
no.
rank
2016
no.
rank
Proportion (2016)
%
Median Age
(2016)

All Drug induced deaths
1,740
n/a
1,102
n/a
1,808
n/a
n/a
45.3
Benzodiazepines (T424)Alprazolam, Diazepam, Oxazepam, Clonazepam, Clozapine, Temazepam, Oxazepam
503
2
354
1
663
1
36.7%
44.6
Other opioids (T402) Oxycodone, Codeine, Oxycodone
678
1
292
2
550
2
30.4%
46.0
Psychostimulants with abuse potential (T436)Amphetamine, Ecstasy, MDA, MDMA, Speed, Methamphetamine, Ice, Caffeine
76
11
93
9
363
3
20.1%
39.4
Heroin (T401)Heroin, 6/3 Monoacetylmorphine
441
3
127
6
361
4
20.0%
41.2
Other and unspecified antidepressants (T432) Sertraline, Citalopram, Venlafaxine, Fluoxetine, Mirtazepine, Fluvoxamine, Paroxetine, Duloxetine, Bupropion
124
9
172
3
276
5
15.3%
48.1
Other synthetic narcotics (T404)Fentanyl, Tramadol, Pethidine
68
12
19
19
234
6
12.9%
41.3
Alcohol, unspecified (T519)Alcohol
252
4
132
4
222
7
12.3%
47.4
Other and unspecified antipsychotics and neuroleptics (T435)Quetiapine, Olanzapine, Antipsychotic, Risperidone
28
17
51
13
220
8
12.2%
45.2
Methadone (T403)Methodone
131
7
129
5
208
9
11.5%
43.2
4-Aminophenol derivatives (T391)Paracetamol
110
10
82
10
170
10
9.4%
50.5

(a) Causes of death data for 2016 are preliminary and subject to a revisions process. See Explanatory Notes 55-58 and A More Timely Annual Collection: Changes to ABS Processes (Technical Note) in this publication.
(b) See Explanatory Notes 72-101 for further information on specific issues related to interpreting time-series and 2016 data
(c) Deaths registered on Norfolk Island from 1 July 2016 are included in this publication for the first time, see Explanatory Notes 12-15
(d) See Explanatory Notes 72-101 for further information on specific issues related to interpreting time-series and 2016 data
(e) All causes of death data from 2006 onward are subject to a revisions process - once data for a reference year are 'final', they are no longer revised. Affected data in this table are: 1999 and 2007 (final), 2016 (preliminary). See Explanatory Notes 52-55 in this publication. See also Causes of Death Revisions, 2012 and 2013 (Technical Note) in Causes of Death, Australia, 2014 (cat. no. 3303.0).

Illicit drugs

Determining an exact number of "illicit drug overdoses" is difficult, as many legal substances are obtained or consumed in an illicit manner. For example, the National Drug Strategy Household Survey 2016 found that 4.8% of Australians had used pharmaceuticals, especially prescription opioids, for non-medicinal purposes in the 12 months prior to the survey. Pharmaceutical drugs are commonly used in conjunction with illicit substances to enhance drug affects, limit anxiety and stave off sleep issues. The third and fourth most common substances found present in drug induced deaths, meth/amphetamines and heroin, are considered illicit substances according to Australian law, and are the only illicit substances in the top 10 most common drugs.

One in five drug deaths had a psychostimulant present in 2016. The psychostimulant ICD-10 class, T436, includes meth/amphetamines such as ice and speed, but also stimulants such as MDMA (ecstasy) and ritalin. The majority of deaths coded to the category are of meth/amphetamines. Amphetamine use has actually declined since 2004 (AIHW, 2017b), however, since 1999, meth/amphetamines are nearly five times as likely to be present in a drug induced death. This may be related to the increase in ice use among current amphetamine users (AIHW). Meth/amphetamines are generally used in a recreational manner with their effect being to increase dopamine, "the feel good" chemical in the brain. Accordingly, 93.1% of drug induced psychostimulant deaths were unintentional. Methamphetamine deaths have the lowest median age of death, at 39.4 years. The average age of initiation for meth/amphetamines is 22.1 years of age, compared to pharmaceuticals, which has an average age of initiation of 25.1 years (AIHW).

Similar to psychostimulants, heroin was present in one in five drug induced deaths in 2016, and has the second lowest median age at death at 41.2 years. It is associated with recreational use, and death is most commonly due to accidental overdose (95% in 2016). Heroin is often taken with other drugs or alcohol, and the additive effect of such substances can lead to respiratory depression. Heroin has been a major public health issue in Australia at various points since the 1980s, and at its peak in 1999 was associated with up to 958 deaths, including overdose, addiction and chronic complications of heroin use (National Heroin Overdose Strategy, 2001). Although numbers are not as high as the late 90s, overdose deaths involving heroin have significantly increased over recent years. Caution must be used when interpreting numbers of heroin deaths, as heroin can be difficult to identify at toxicology. Heroin is rapidly metabolised by the body, and is converted to monoacetyl morphine (MAM) and then to morphine. The presence of MAM indicates heroin use as opposed to morphine use. At times, toxicology is not able to determine MAM, and in these cases the death is coded to T402 "Other opioids", as only the morphine derivative was identified.

Drug Induced Death by sex

Benzodiazepines and opiate-based painkillers are the top two drugs present in drug induced deaths for both males and females. However, the profile of substances present for males and females differs for ranks three to ten. Illicit drugs including heroin and meth/amphetamines were the third and fourth most common drugs for males. In contrast, the third most common drugs for females were antidepressants including those of the selective serotonin reuptake inhibitor (SSRI) class (e.g. fluoxetine), and the fourth most common drug was antipsychotics, (e.g. quetapine), which are prescribed for mental health conditions including schizophrenia and bipolar disorder. Although antidepressants and antipsychotics are more highly ranked for their presence in drug induced deaths in females, the number of deaths with these substances present is still higher in males.

Graph Image for Common substance types for drug induced deaths in males, 2016 (a)(b)(c)

Footnote(s): (a) Causes of death data for 2016 are preliminary and subject to a revisions process. See Explanatory Notes 55-58 and A More Timely Annual Collection: Changes to ABS Processes (Technical Note) in this publication. (b) See Explanatory Notes 72-101 for further information on specific issues related to interpreting time-series and 2016 data (c) Deaths registered on Norfolk Island from 1 July 2016 are included in this publication for the first time, see Explanatory Notes 12-15

Source(s): Common substance types for drug induced deaths in males, 2016 (a)(b)(c)-Male Drug Type



Graph Image for Common substance types for drug induced deaths in females, 2016 (a)(b)(c)

Footnote(s): (a) Causes of death data for 2016 are preliminary and subject to a revisions process. See Explanatory Notes 55-58 and A More Timely Annual Collection: Changes to ABS Processes (Technical Note) in this publication. (b) See Explanatory Notes 72-101 for further information on specific issues related to interpreting time-series and 2016 data (c) Deaths registered on Norfolk Island from 1 July 2016 are included in this publication for the first time, see Explanatory Notes 12-15

Source(s): Common substance types for drug induced deaths in females, 2016 (a)(b)(c)-Female Drug Type




Age specific death rates by drug type and sex

Males

Males aged between 35 and 39 experience the highest rate of drug induced deaths. Benzodiazepines are the most common substance present in deaths of males of this age group, followed by psychostimulants including ice. Opioids, including oxycodone and heroin are the third and fourth most common drugs in this age group. The table below shows selected substances present in drug induced deaths for males of selected ages and measures their proportional presence per 100,000 deaths.

Between ages 25 and 54, benzodiazepines are the most common drugs present in these deaths. From age 55, males are more likely to have opiate based pain-killers present on toxicology than other substances. Males aged between 20 and 24 are the only age group to have an illict drug as the most common substance present in drug induced deaths, with heroin being present in 1.6 deaths per 100,00 males. The use of benzodiazepines in a non-medicinal polypharmacy setting with illicit substances such as heroin or ice raises particular health concerns, as it increases the risk of overdose (Jann, Kennedy & Lopez, 2014). Studies have shown that benzodiazepines being mixed with other central nervous system depressants such as oxycodone or heroin can greatly increase the chance of overdose, both fatal and non-fatal (Dietze et al. 2005).

Graph Image for Drug induced deaths, male age-specific death rate by drug type, 2016 (a)(b)(c)

Footnote(s): (a) Age-specific death rates. Deaths per 100,000 of estimated mid-year population. See Glossary for further information. (b) Causes of death data for 2016 are preliminary and subject to a revisions process. See Explanatory Notes 55-58 and A More Timely Annual Collection: Changes to ABS Processes (Technical Note) in this publication. (c) Deaths registered on Norfolk Island from 1 July 2016 are included in this publication for the first time, see Explanatory Notes 12-15

Source(s): Drug induced deaths, male age-specific death rate by drug type, 2016 (a)(b)(c)-2016 Male ASDR by Drug Type




The age profile of substance use has changed since 1999 when the most common drug present in males between ages 15 and 49 were opiates, including heroin. Although benzodiazepines were still present, they were the third most common substance present in deaths amongst this cohort. In 1999, psychostimulants were present in 54 deaths of males( 0.6 deaths per 100,000) compared with 274 deaths in 2016 (2.4 deaths per 100,000).

Females

The age at which women experience the highest rate of drug induced deaths is in their mid to late-40s. Benzodiazepines, opiate-based painkillers and SSRI class anti-depressants are the most common drugs for this age group. The graph below represents six selected drugs as an age-specific death rate, highlighting their presence in drug induced deaths for women in 2016. Benzodiazepines are the most common substance in drug deaths for women from age 20 to their mid-60s, with its peak age involvement in death occurring for women in their early 40s (5.4 deaths per 100,000 females). It is the most common drug present in both accidental and intentional overdoses.

Methamphetamines were the second most common drug present in drug induced deaths of younger women (age 20-29). Deaths were commonly in a polypharmacy setting, but specifically, in one third of methamphetamine deaths in younger women, both a psychostimulant and a benzodiazepine were present. The presence of heroin and illegal psychostimulants in drug induced deaths of women peak between ages 35 and 44, and by age 64, there are no drug induced deaths with a psychostimulant or heroin present.

For females, the changes in substances in drug induced deaths from 1999 is more subtle than that of males. Apart from ages 20 to 24 where heroin was most common in drug deaths, benzodiazepines were generally the most commonly detected drug. The third most common substances for women in 1999 were tricyclic and tetracyclic antidepressants, a class of drugs used to treat depression by increasing neurotransmitter levels related to mood and happiness in the brain. Tricyclic antidepressants can cause a number of side effects including serious cardiovascular problems such as arrhythmia, and anticholinergic factors such as dry mouth and blurred vision. This has led to the SSRI class of antidepressants being more commonly prescribed, as they are thought to have higher tolerability with less chance of overdose (McManus et al, 2001). The SSRI class of antidepressants is now the third most common drug for women identified in drug induced deaths, and tricyclic antidepressants the eleventh most common substance.

Graph Image for Drug induced deaths, female, age-specific death rate by drug type, 2016 (a)(b)(c)

Footnote(s): (a) Age-specific death rates. Deaths per 100,000 of estimated mid-year population. See Glossary for further information. (b) Causes of death data for 2016 are preliminary and subject to a revisions process. See Explanatory Notes 55-58 and A More Timely Annual Collection: Changes to ABS Processes (Technical Note) in this publication. (c) Deaths registered on Norfolk Island from 1 July 2016 are included in this publication for the first time, see Explanatory Notes 12-15

Source(s): Drug induced deaths, female, age-specific death rate by drug type, 2016 (a)(b)(c)-2016 Female ASDR by Drug Type




Drug Induced Deaths by region of usual residence

New South Wales recorded the largest number of drug induced mortality in 2016 with 547 deaths, however the highest rate of death was in Western Australia, which has an age standardised rate of 9.9 deaths per 100,000 persons. Queensland recorded the lowest rate of drug induced deaths at 7.0 deaths per 100,000 persons. In general, people were more like die from drug use outside of a capital city. However, the table below shows that Perth, Hobart and Adelaide had a higher rate of death than regions outside of the capital city in each respective state. It is well documented that people residing outside of capital cities may have barriers to accessing health care, as well as experience higher levels of social disadvantage. Both of these factors adversely influence drug usage (National Rural Health Alliance).


Drug Induced Deaths by region of usual residence, 2016 (a)(b)

Region of Usual Residence
no.
rate
proportion of region

New South Wales
547
7.1
100.0
Greater Sydney
300
5.9
54.8
Rest of NSW
239
9.6
43.7
Victoria
459
7.6
100.0
Greater Melbourne
347
7.4
75.6
Rest of VIC
109
8.0
23.7
Queensland
332
7.0
100.0
Greater Brisbane
148
6.4
44.6
Rest of QLD
183
7.6
55.1
South Australia
126
7.6
100.0
Greater Adelaide
103
8.0
81.7
Rest of SA
23
5.7
18.3
Western Australia
252
9.9
100.0
Greater Perth
197
9.8
78.2
Rest of WA
52
9.5
20.6
Tasmania
52
9.4
100.0
Greater Hobart
27
11.5
51.9
Rest of TAS
25
8.0
48.1
Northern Territory
8
np
100.0
Greater Darwin
np
np
na
Rest of NT
np
np
na
Australian Capital Territory
32
7.9
100.0
Capital Cities
1158
7.1
64.0
Remainder of States
635
8.3
35.1
Australia
1808
7.5
100.0

(a) Standardised death rates. Deaths per 100,000 of estimated mid-year population. See Glossary for further information.
(b) Causes of death data for 2016 are preliminary and subject to a revisions process. See Explanatory Notes 55-58 and A More Timely Annual Collection: Changes to ABS Processes (Technical Note) in this publication.
(c) Deaths registered on Norfolk Island from 1 July 2016 are included in this publication for the first time, see Explanatory Notes 12-15


Drug Related Deaths

In addition to the 1,808 drug induced deaths in 2016, there were an additional 1,387 deaths where drugs were identified as a contributory cause. The majority of drug related deaths (72.6%, or 1,005) were from external causes (excluding drug overdoses). The chart below shows that suicides of mechanism other than drug overdose were the most likely external cause of death to have a drug found to be a contributory factor. Both addiction to substances and acute intoxication were recorded as being contributory factors to suicides. Research has shown that people with substance abuse issues share many risk factors to people at risk of self harm (Pompili et al., 2012). These risks include both social factors such as socioeconomic status and health factors such as a greater likelihood to suffer a mood disorder. This highlights the importance of understanding drug use history in people at risk of self harm.

Transport accidents were the second most common type of drug related death with 14.5% (210 deaths) having a drug contributing to the death (excluding alcohol). For these deaths, psychotropic substances which alter brain functioning such as perception, mood and consciousness such as meth/amphetamines were the most common drugs identified on toxicology reports. Cannabis was the second most common drug identified at toxicology for transport accident deaths. Roadside drug testing has become more commonplace in Australia in recent years as governments seek to address the problems associated with people driving while under the influence of illicit substances.

There were 382 natural disease drug related deaths. The three most common were circulatory diseases (35.1%), cancers (15.2%) and respiratory conditions (14.7%) (see chart below). Natural causes were most likely to have a chronic drug misuse disorder such as addiction listed on the death certificate. These addictions are most commonly described as mental and behavioural disorders due to multiple drug abuse. Psychostimulants including methamphetamines were more likely to be a contributory factor in deaths due to heart diseases than other natural diseases.

Proportion of external Drug Related Deaths, 2016 (a)(b)
Diagram: Proportion of external Drug Related Deaths, 2016 (a)(b)
(a) Causes of death data for 2016 are preliminary and subject to a revisions process. See Explanatory Notes 55-58 and A More Timely Annual Collection: Changes to ABS Processes (Technical Note) in this publication.
(b) Deaths registered on Norfolk Island from 1 July 2016 are included in this publication for the first time, see Explanatory Notes 12-15


Proportion of natural Drug Related Deaths, 2016 (a)(b)
Diagram: Proportion of natural Drug Related Deaths, 2016 (a)(b)
(a) Causes of death data for 2016 are preliminary and subject to a revisions process. See Explanatory Notes 55-58 and A More Timely Annual Collection: Changes to ABS Processes (Technical Note) in this publication.
(b) Deaths registered on Norfolk Island from 1 July 2016 are included in this publication for the first time, see Explanatory Notes 12-15


International comparison

Other countries with comparable statistics have also reported increases in drug induced deaths. England and Wales have recorded the largest number and rate of drug induced deaths on record. Opiates were the most common drug present in drug deaths, particularly heroin and morphine (Office for National Statistics, 2017). Similarly, the European Monitoring Centre for Drugs and Drug Addiction, recently released the 2017 European Drug Report. It showed that although reporting standards varied across Europe, opioid users, especially those who used heroin, were more likely to die of overdose, and many countries have recorded increases in drug induced deaths over recent years. In the United States of America (USA), deaths from prescription opioids, especially oxycodone and fentanyl, are now considered an epidemic, with the CDC reporting that drug induced deaths are the leading cause of injury death. Opioids are present in over 60% of deaths in the USA.

Public health initiatives in Australia

Drug use and drug mortality is an issue which affects the whole of the Australian community. The approach to addressing drug use is multi-dimensional, and includes the scheduling of pharmaceuticals, law enforcement practices, support and intervention services and positive public health messaging.

Australia has implemented the seventh iteration of the National Drug Strategy, with the framework in place from 2017-2026. The strategy aims to minimise the harms associated with alcohol, tobacco and other drugs through demand reduction (delaying or preventing uptake of drug use), supply reduction (e.g. preventing supply of illegal drugs) and harm reduction (e.g. reducing adverse health consequences for drug users). The strategy cites the importance of collaboration and partnerships both nationally and by jurisdiction to address drug harm in Australia.

The Therapeutic Goods Administration (TGA) is Australia's body for regulating pharmaceuticals are responsible for the scheduling of drugs. The scheduling of drugs refers to a national classification system that controls how drugs are made available to the public. The TGA has proposed that from February 2018, any codiene products in Schedule 2 or 3 of the Standard for the Uniform Scheduling of Medicines and Poisons, will be up-scheduled to Schedule 4, prescription only. In a report outlining the decision, the Therapeutic Goods Administration outlines the increasing misuse of codeine based products in Australia as one influencing factor for the change (TGA, 2017).

The change of profile in drug induced deaths from that of younger people overdosing from heroin, to middle aged people dying from misuse of prescription drugs in a polypharmacy setting has been well reported over recent years. State and territory health departments actively work to promote safety in relation to drug use. A number of fact sheets and guidelines for safe drug consumption are available online. In addition, the Royal Australian College of General Practitioners provides assistance and advice in relation to prescribing drugs of dependence in general practice, with a particular focus on benzodiazepines and opioids. Positive health messaging, along with policy and prevention informed by evidence are important factors for preventing drug induced deaths in Australia.

For free and confidential advice about alcohol and other drugs, call the National Alcohol and Other Drug hotline on 1800 250 015. It will automatically direct you to the Alcohol and Drug Information Service in your state or territory. These local alcohol and other drug telephone services offer support, information, counselling and referral to services.

Crisis helplines

Alcohol and Drug Information Service: 1800 250 015

Narcotics Anonymous Australia: 1300 652 820

Lifeline: 13 11 14

Suicide Call Back Service:1300 659 467

Kids Helpline (for young people aged 5 to 25 years): 1800 55 1800


Resources

Alcohol and Drug Foundation: Drug Facts

Prescribing Drugs of Dependence in General Practice

New South Wales Health Fact Sheets: Drug and Alcohol

Queensland Health Drug Education Information


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