The latest annual overdose report from the Penington Institute, published on Wednesday, came with a stark warning for Australia about the powerful opioid fentanyl.
“Australian overdose deaths involving fentanyl, along with two other synthetic opioids, pethidine and tramadol, have increased by 1,275% since 2006,” the report found. “Without decisive action, the slide into US-level overdose mortality seems not just possible, but assured.”
It’s a strong call given fentanyl, a highly potent, highly addictive synthetic opioid, is nowhere near as prevalent either through prescribing or the illicit market as it is in the US, where 56,516 overdose deaths involving synthetic opioids, primarily fentanyl, were reported in 2020. In the 12 months to April 2021, 100,000 people died of overdoses in the US, with fentanyl causing nearly two-thirds (64%) of them.
By 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 unintentional drug-induced deaths involving opioids.
It’s a sharp rise on the 12 deaths involving those three drugs reported in 2006, but a far cry from the number of deaths in the US, or in Canada, where fentanyl has been detected in the illegal drug supply in all jurisdictions.
So what is driving the concern?
Accidental overdose a significant risk
Pharmaceutical fentanyl is a restricted medicine used for anaesthesia and 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 showing up in other drugs such as heroin, methamphetamine and cocaine.
Fentanyl is between 50 and 100 times more concentrated than morphine, so accidental overdose is a significant risk.
Throughout the 1980s, US doctors increasingly prescribed the drug, and by the 90s, pharmaceutical companies were aggressively marketing it.
In Canada, more than 20m prescriptions for opioids were dispensed in 2016, making it the second-largest consumer of prescription opioids in the world.
As addiction and overdoses became increasingly prevalent, tougher prescribing guidelines were introduced. But drug cartels filled the gap, flooding the US and Canada with synthetic opioids – particularly fentanyl.
Australia has been protected from a crisis on a similar scale largely by advertising laws which 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 quantities than their US counterparts. Less potent (though still problematic) opioids such as oxycodone are also favoured in Australia over fentanyl.
As a result, concerns about opioid‐related harms 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 increased monitoring and restriction of opioid prescriptions, and a lack of good alternative options for treating opioid dependence and chronic pain, might have the unintended consequence of shifting patients to illicit sources of opioid drugs, as has been seen overseas.
There are also fears that those using other drugs such as cocaine and methamphetamine will become unknowing fentanyl overdose victims, the chief executive of the Penington Institute, John Ryan, tells Guardian Australia.
“We don’t even need a huge opioid-dependent population for the fentanyl traffickers,” Ryan says. “Fentanyl could just find its way into the rest of the drug supply chain, and that’s what’s happening in the US now. People using cocaine on the weekend are finding it had fentanyl in it.”
‘Not an exact science’
Last month the Australian federal police announced that more than 11kg of pure powdered fentanyl, enough for about 5m doses, had been found in a container that arrived in Melbourne, the largest seizure ever made in the country.
An AFP spokeswoman said the seizure was “an anomaly”.
“Australia’s illicit fentanyl market is small, and mostly served by pharmaceutical diversion and gram-quantity dark web imports. Based on the information available to the AFP at this stage, no other broad warning systems, including wastewater rates, indicate a substantial increase in the fentanyl threat.”
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 dependence on opioids. However, predicting future drug trends is not an exact science.”
The latest Australian Criminal Intelligence Commission wastewater report, published earlier this year, found consumption of oxycodone and fentanyl remained low and relatively stable, despite some fluctuation.
In December, the levels of fentanyl detected in wastewater in regional Australia by the commission were the lowest recorded, the report found. “The average consumption of fentanyl has been mostly unchanged since June 2021, also at the lowest levels since the start of the program,” it said.
Acic’s principal drugs adviser, Shane Neilson, says wastewater monitoring cannot distinguish between illicit and legitimate fentanyl consumption. But “Acic regards multi-kilogram importations of powder fentanyl as a significant concern, as at present the illicit market for fentanyl is largely supplied by diversion from the legitimate market, with small quantities being purchased online”.
“We have seen no evidence to date that there is a major change in sources of supply to the market or in consumption levels, but the situation is being closely monitored,” he says.
“With fentanyl, we have no evidence that large quantities of the drug are being imported or diverted domestically, otherwise this would be reflected in wastewater analysis and health data, and in hospital presentations.”
However, the US data and social science research organisation Mathematica has said wastewater testing may be of limited use for detecting synthetic fentanyl, because the drug’s high potency means only small amounts are ingested, so the levels excreted may not always be detectable.
‘Entrepreneurial drug traffickers’
Ryan says the Penington Institute’s warnings on fentanyl should not be dismissed simply because 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 consumed illicit drug nationwide.
Ryan says most overdose deaths can be prevented by making the overdose-reversing drug naloxone more widely accessible, testing illicit substances for fentanyl, and expanding safe drug injecting and use sites – which remain controversial despite overwhelming evidence that they save lives.
It is clear from overseas, and from attempts to tackle other drugs in Australia, that tightening prescribing and seizing illicit drugs alone will not prevent the harm from escalating, Ryan says.
“We need to dramatically reduce the population of people who are problematic drug users and that’s not easy, but it’s doable if we develop a national strategy involving increasing access to the evidence-based treatments we already have here, but also increasing access to new opioid substitution treatments available overseas but not here,” Ryan says.
“It would be negligent not to do so. Because for crime 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’re going to find entrepreneurial drug traffickers will give fentanyl a good go.
“Well done to Australian law enforcement who detected that 11 kilos, but they will never claim that they’ll be able to get 100% of the drug coming into Australia.
“And once it’s here, we will be left mopping up an absolute mess.”
• In Australia, the Opioid Treatment Line is at 1800 642 428 or call the National Alcohol and Other Drug Hotline on 1800 250 015. In the UK, Action on Addiction is available on 0300 330 0659. In the US, SAMHSA’s National Helpline is at 800-662-4357