The Penington Institute’s latest annual overdose report, released on Wednesday, came with a stark warning for Australia about the powerful opioid fentanyl.
“Australian overdose deaths from fentanyl, along with two other synthetic opioids, pethidine and tramadol, have increased by 1,275% since 2006,” the report found. “Without decisive action, a decline in overdose deaths at the US level appears not only possible, but assured.”
It’s a strong call given that fentanyl, a highly potent and highly addictive synthetic opioid, is not as prevalent either through prescription or on the illicit market as it is in the US, where 56,516 opioid overdose deaths were reported synthetics, primarily fentanyl, in 2020. In the 12 months to April 2021, 100,000 people died of overdoses in the United States, with fentanyl causing nearly two-thirds (64%) of them.
In comparison, the Penington report states that in Australia in 2020, there were 165 unintentional drug-induced deaths involving fentanyl, pethidine and tramadol, comprising 19.3% of opioid-related unintentional drug deaths.
That’s a sharp increase from the 12 deaths related to those three drugs reported in 2006, but a far cry from the number of deaths in the US or Canada, where fentanyl has been detected in the illegal supply of the drug in all jurisdictions.
So what is driving the concern?
Accidental overdose is a significant risk
Pharmaceutical fentanyl is a restricted drug used for anesthesia and is prescribed for severe pain caused by surgery, traumatic injury, or chronic conditions such as cancer.
Fentanyl is also manufactured for use in the illegal drug market and is appearing in other drugs such as heroin, methamphetamine, and cocaine.
Fentanyl is 50 to 100 times more concentrated than morphine, so accidental overdose is a significant risk.
Throughout the 1980s, American doctors increasingly prescribed the drug, and in the 1990s, drug companies aggressively marketed it.
Fentanyl is 50 to 100 times more concentrated than morphine. Photograph: AFP
In Canada, more than 20 million opioid prescriptions were dispensed in 2016, making it the second largest consumer of prescription opioids in the world.
As addiction and overdoses became more and more common, tougher prescribing guidelines were introduced. But drug cartels filled the void, flooding the US and Canada with synthetic opioids, particularly fentanyl.
Australia has been shielded from a crisis of a similar scale, largely by advertising laws that make it illegal for drug companies to market prescription drugs to consumers. Prescriptions in Australia have increased, but doctors generally prescribe the drugs at lower doses and in smaller amounts than their American counterparts. Less potent (though still problematic) opioids such as oxycodone are also favored in Australia over fentanyl.
As a result, concerns about opioid-related harm “are not at the same level” in Australia as in North America, a paper published last year in the Medical Journal of Australia found.
However, the same paper warned that greater control and restriction of opioid prescriptions, and the lack of good alternative options for treating opioid dependence and chronic pain, could have the unintended consequence of switching patients to illicit sources of opioid drugs, as seen overseas. .
There are also fears that those who use other drugs such as cocaine and methamphetamine may become unknowing victims of a fentanyl overdose, Penington Institute chief executive John Ryan told Guardian Australia.
“We don’t even need a large opioid-dependent population for fentanyl dealers,” Ryan says. “Fentanyl could find its way into the rest of the drug supply chain, and that’s what’s happening in the US now. People who use cocaine on the weekend find out that fentanyl was in there.”
“It’s not an exact science”
Last month, the Australian Federal Police announced that more than 11 kg of pure fentanyl powder, enough for about 5 million doses, had been found in a container that arrived in Melbourne, the largest seizure that has ever been done in the country.
An AFP spokeswoman said the seizure was “an anomaly”.
“Australia’s illicit fentanyl market is small, and is primarily served by pharmaceutical diversion and dark web gram imports. According to information available to AFP at this stage, no other broad warning system , including sewage rates, indicate a substantial increase in the threat of fentanyl.”
Sign up for Guardian Australia’s Morning Mail
Our Australian morning news email breaks down the day’s key national and international stories and why they matter
Privacy Notice: Newsletters may contain information about charities, online advertisements and content funded by third parties. For more information see our Privacy Policy. We use Google reCaptcha to protect our website and Google’s Privacy Policy and Terms of Service apply.
Asked if the AFP agreed with Penington that Australia was at risk of following the US, the spokeswoman said: “Australia does not have an entrenched addiction to opioids. However, predicting future drug trends is not an exact science “.
The Australian Criminal Intelligence Commission’s latest wastewater report, released earlier this year, found that consumption of oxycodone and fentanyl remained low and relatively stable, despite some fluctuations.
In December, levels of fentanyl detected in wastewater in regional Australia by the commission were the lowest on record, according to the report. “Average fentanyl use has remained nearly unchanged since June 2021, also at the lowest levels since the program began,” he said.
The AFP seized more than 11kg of pure fentanyl powder, enough for about 5 million doses, from a container that arrived in Melbourne. Photograph: AFP
Acic’s chief drugs adviser, Shane Neilson, says sewage control cannot distinguish between illicit and legitimate fentanyl use. But “Acic considers imports of multi-kilogram fentanyl powder to be a major concern, as the illicit fentanyl market is currently largely supplied by diversion from the legitimate market, with small amounts being bought online” .
“So far we haven’t seen any evidence of a major change in the sources of supply to the market or the levels of consumption, but the situation is being very much under control,” he says.
“With fentanyl, we have no evidence that large amounts of the drug are being imported or diverted into the country, otherwise this would be reflected in wastewater analysis and health data, and in hospital presentations” .
However, US data and social science research organization Mathematica has said that sewage testing may be of limited use for detecting synthetic fentanyl, because the drug’s high potency means that it is only ingested small amounts, so levels excreted may not always be detectable.
‘Entrepreneurial drug traffickers’
Ryan says the Penington Institute’s warnings about fentanyl should not be dismissed simply because the detected rates of the drug in Australia are low. He says he was accused of being alarmist when he called for action on methamphetamine a decade ago. It is now the most widely consumed illicit drug in the entire country.
Ryan says most overdose deaths can be prevented by making the overdose-reversing drug naloxone more accessible, testing illicit substances for fentanyl and expanding safe injection and drug use sites, which remain controversial despite overwhelming evidence that they save lives.
Ryan says it’s clear from overseas and from attempts to tackle other drugs in Australia that toughening the prescription and confiscation of illicit drugs won’t stop the harm from increasing.
“We need to dramatically reduce the population of people who are problem drug users and that’s not easy, but it’s doable if we develop a national strategy that includes increasing access to the evidence-based treatments we already have here, but also increasing access to new opioid replacement treatments available overseas but not here,” says Ryan.
“It would be negligent not to do it. Because for criminal groups, fentanyl is very easy to manufacture compared to heroin. It’s very easy to traffic because it’s more potent and you need to import less, and so logically, from a business perspective, we’ll find that enterprising drug traffickers will give fentanyl a good shot.
“Well done to Australian law enforcement who detected that 11 kilos, but they will never claim they can get 100% of the drug into Australia.
“And once it’s here, we’re going to clean up an absolute mess.”