Australia

"In 2019, 11.0% of Australians smoked tobacco daily, down from 12.2% in 2016 and 24% in 1991. These falls were mainly driven by younger generations not taking up smoking."

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"Between 2016 and 2019, the proportion of ex‑drinkers rose from 7.6% to 8.9%. There was also a rise in the number of people cutting back on alcohol, with 31% of people saying they had reduced the number of alcoholic drinks they consumed at any 1 time, up from 28% in 2016. The main reason people gave for reducing their intake was ‘health reasons’ (such as weight loss or avoiding hangovers).

"Despite this, there has been little change in the proportion of people drinking at risky levels. In 2019, 1 in 4 (25%) people drank at a risky level on a single occasion at least monthly, while about 1 in 6 (16.8%) exceeded the lifetime risk guideline. While the proportion exceeding the single occasion risk and lifetime risk guidelines has remained stable in recent years, it has improved since the guidelines were introduced in 2009 (was 29% and 21% respectively in 2010)."

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"In 2019, 43% of Australians aged 14 and over had illicitly used a drug at some point in their life (including pharmaceuticals used for non‑medical purposes) and 16.4% had used one in the last 12 months. This has been fairly stable since 2016, but up from 38% and 13.4% in 2007.

"Cannabis was the most commonly used illicit drug in 2019, with 11.6% of Australians using it in the last 12 months. This was followed by cocaine (4.2%), ecstasy (3.0%) and non‑medical use of pain‑killers and opioids (2.7%). Use of cannabis, cocaine and ecstasy all rose between 2016 and 2019, as did the use of inhalants, hallucinogens, and ketamine, while the non‑medical use of pain‑killers and opioids fell over the same period.

"While the use of cocaine and ecstasy in the previous 12 months increased between 2016 and 2019, use of meth/amphetamines remained stable (1.4% in 2016 and 1.3% in 2019). However, people who used meth/amphetamines continued to use them more frequently than people who used cocaine and ecstasy. Cannabis continued to be the most frequently used illicit drug, with 37% using it weekly or more often; this was followed by meth/amphetamine use with 17% using it at least weekly. This increased to 29% among those who used crystal/ice as their main form of meth/amphetamines. Very few people who used ecstasy or cocaine used it weekly or more often—6.7% and 4.5% respectively."

"Among people who did use pain‑killers and opioids for non‑medical purposes, those who used them at least weekly declined from 29% in 2016 to 19.5% in 2019, while the proportion who used them only once or twice a year increased from 28% to 43% (Table 5.10).

"Despite this reduction, many people still struggled to cut down on their non‑medical use of pain‑killers and opioids. Of all people who had used them in the previous 12 months, 31% said they could not cut down on their non‑medical use, even though they had wanted to or attempted to stop (Table 4.35a)."

"Illicit drug use at music festivals has been the subject of Australian public and media attention following the drug-related deaths of six young Australians across two festival seasons in 2019 and 2020 (Lee, 2019), and a further young Australian at a festival in February 2023 (Australian Associated Press, 2023). Internationally, studies show higher rates of drug use among music festival attendees compared to the general population (Day et al., 2018; Fox et al., 2018; Hughes et al., 2019; Hughes et al., 2017; Measham and Simmons, 2022). A substantial proportion of the health risks associated with illicit drug use relate to the lack of regulated drug supply caused by prohibition; for example, there is risk of variable purity, whereby the substance is stronger than anticipated (Day et al., 2018; Hughes et al., 2017), or risk of unexpected substances (e.g., fentanyl) being ingested at unknown doses or causing harm via interaction effects due to adulteration (Atherton et al., 2019; Karamouzian et al., 2018; Maghsoudi et al., 2022).

"Methods used to characterise drug use at music festivals include drug checking, in situ surveys and wastewater analysis. Drug checking services conduct chemical analyses of substances of concern submitted directly by the public and return the results to the service user through a tailored intervention that aims to reduce drug-related harms (Barratt and Measham, 2022). A secondary benefit of these services is their ability to generate unique and timely information about drug markets that can be disseminated rapidly via text message or social media alerts (Barratt and Ezard, 2016; Brien et al., 2023; Sample, 2015; Measham, 2019). Next, a handful of studies have used in situ patron surveys to investigate patterns of drug use at music festivals (e.g., (Day et al., 2018; Barratt et al., 2018; Southey et al., 2020)); while valuable, surveys are limited in their ability to accurately capture the full range of substances used due to sampling constraints and reliance on self-report (Lancaster et al., 2019; Zuccato et al., 2005; Tscharke et al., 2015; Gjerde et al., 2019). In contrast, other studies have analysed wastewater samples collected from festival-based sewage sources, essentially conducting an anonymised urine test on the whole festival (Bijlsma et al., 2020; Lai et al., 2013; Bade et al., 2020; Mackulak et al., 2019). While wastewater analysis cannot provide insight into individuals' experiences of substance use (e.g., amount used per person, motivations for use), it provides an objective, non-intrusive method of measuring substance use without raising major ethical issues (Gjerde et al., 2019; Lai et al., 2013; Mackulak et al., 2019; Mackulak et al., 2015), thus overcoming many of the limitations of survey data in these settings. A novel approach combines survey and wastewater data to compare substances that participants believe that they are using (via surveys) versus the drugs they are actually using (via wastewater analysis). We are aware of only one study internationally using this method among festival attendees; Brett and colleagues (2022) reported the detection of cathinones in wastewater at music festivals in New South Wales, Australia, yet no survey respondents reported intentional cathinone use, showing the value of this complementary approach (Brett et al., 2022). Using similar methodology to Brett et al. (Brett et al., 2022), and within the context of the imminent implementation of drug checking services in Queensland, this study aims to characterise the differences between drugs that participants self-report using or intending to use in surveys versus the drugs detected in wastewater at a Queensland-based music festival across two consecutive years (2021 and 2022)."

"In 2016, the non‑medical use of pain‑killers/pain‑relievers and opioids (referred to as pain‑killers and opioids) were the second most common illicitly used drug in the previous 12 months, behind cannabis. However, in 2019, they were the fourth most common, after cannabis, cocaine and ecstasy (Table 4.6).

"From 2016 to 2019, the proportion of people using pain‑killers and opioids non‑medically in the previous week, month, 12 months and in their lifetime declined (Figure 5.1).

"Use remained stable or declined across all age groups between 2016 and 2019. The decline was most pronounced among young people aged 14–19, who in 2019 were half as likely to have used pain‑killers and opioids non‑medically in their lifetime as 14–19 year olds in 2016, and only a third as likely to have done so in the previous 12 months (tables 5.4 and 5.5)."

"In 2017, 82% of all secondary students in Australia had never smoked (Table 3.1). Levels of experimental and regular smoking increased with age, but by age 17 most students (65%) had still never smoked.

"Overall, around 2% of all students had smoked more than 100 cigarettes in their lifetime (6% of 17 year olds). The lowest proportion of students to have smoked in the past month was among 12 and 13 year olds (2%), and this level rose to 16% among 17 year olds. A similar pattern was evident among students who had smoked in the past week (i.e., current smokers), from 1-2% of 12 and 13 year olds to 11% of 17 year olds. Only around 3% of all students had smoked on three or more days during the past week (committed smokers), with this being highest among 17 year olds (6%)."

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"Of all students surveyed, 34% reported never having consumed alcohol (Table 4.1). Alcohol use was more common among older students, with 76% of 17 year olds having consumed alcohol in the past year, compared to 17% of 12 year olds (Table 4.1).

"Current drinking (in the past week) was more common among older than younger students. Overall, a greater proportion of male (16%) than female (14%) students were current drinkers."

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"Among the 14% of students who had used cannabis in the past year, 30% of males and 37% of females had used cannabis once or twice, while 38% of males and 29% of females had used it on 10 or more occasions (regular use). Regular use tended to be more common among older than younger students (10% of 12 year olds; 37% of 17 year olds), and among male than female students from age 13."

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"Very few students reported that they had ever used amphetamines for non-medicinal reasons (dexamphetamines: 2%; methamphetamines: 2%, Table 6.3).

"The highest prevalence of lifetime amphetamine use was among older students (16-17, dexamphetamines: 2%; methamphetamines: 3%).

"Overall, use in the past month (1%) or year (1%) was also very low for each kind of amphetamine and 41% of students who reported past year use of dexamphetamines (methamphetamines: 35%) had tried them only once or twice."

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"Student use of heroin was extremely low (Table 6.5). In the past year, 1% of students reported using heroin, and around 30% of these past year users had used it only once or twice.

"For the first time in 2017, we asked students about their use of other opiates (e.g. morphine, oxycodone, codeine) other than for medical reasons separate from their use of heroin (Table 6.5). Results suggest that students might have reported medicinal as well as nonmedicinal use of these drugs (5% ever used). Around 47% of those who reported having used other opiates in the past year had used them only once or twice. Past month use was reported by 2% of students."

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"Most secondary school students had never tried cocaine (98%, Table 6.7). Only 1% of students had used cocaine in the past month.

"Among the 2% who had used cocaine in the past year, 45% of males and 66% of females had used it only once or twice."

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"Most secondary school students (95%) had never used ecstasy (Table 6.13). Lifetime use increased with age (13 year olds, 2%; 17 year olds, 11%). In the past year, 4% of students had used ecstasy (past month, 2%), with around 47% of these students having used it only once or twice.

"Male students were more likely than female students to have used ecstasy in each recency period."

"Use of painkillers or analgesics (e.g., Disprin, Panadol, or Nurofen) is common among secondary students. Ninety-five per cent of students had ever used an analgesic, and around two-thirds of students had used them in the past month (Table 5.1).

"Use increased with age (e.g., past month use by 12 year olds: 55%; 17 year olds: 71%) and was higher among female than male students for lifetime, past year, past month, and past week.

"Among past year users, 52% of females and 42% of males had used analgesics 10 or more times in this period, while 16% of males and 11% of females had used analgesics only once or twice. Regular use (10 or more times) was higher among females than males at older ages.

"Of students who had used analgesics in the past week, 70% of males and 68% of females had used them once or twice."

"Around 19% of all students had used tranquilisers at least once for a non-medical reason (Table 5.5). Use was higher among older students (12 year olds: 15%; 17 year olds: 22%). Past month use was low across all ages (5%) and only 3% had used tranquilisers in the past week.

"Sources of tranquilisers
"Parents were the most common source of tranquilisers for students who had used them for non-medicinal reasons in the past year (65%, Table 5.6). Reported use of prescribed tranquilisers for non-medicinal reasons might include incorrectly reported medical use.

"Changes in tranquiliser use over time
"Overall, lifetime, past month, and past week tranquiliser use was higher in 2017 than 2011 (Table 5.7)."

"Cannabis was the most commonly used illicit substance among secondary students. Use increased with age in all recency periods (Table 6.1). Overall, use tended to be higher among male than female students. In the older age group (16 and 17 year olds), males were more likely than females to have used cannabis in the past week, past month and in their lifetime.

"Regular use
"Among the 14% of students who had used cannabis in the past year, 30% of males and 37% of females had used cannabis once or twice, while 38% of males and 29% of females had used it on 10 or more occasions (regular use). Regular use tended to be more common among older than younger students (10% of 12 year olds; 37% of 17 year olds), and among male than female students from age 13.

"How do students use cannabis?
"Past year cannabis users most commonly used a bong (63% of males and 52% of females) or smoked it in a joint (male: 31%; female: 44%). Use of a bong was more common among regular cannabis users while smoking it in a joint was more common among occasional users. Most students had used cannabis with others (81%), most commonly at a friend’s home (37%).

"Cannabis use at home was more common for regular (22%) than occasional (14%) users, while cannabis use at a party was more common for occasional (24%) than regular (13%) users.

"Prevalence 2011-2017
"Among older female students, past month cannabis use was higher in 2017 than in 2014 or 2011. There was no change in lifetime and past week use of cannabis between 2011 and 2017 (Table 6.2)."

"In 2017, 82% of all secondary students in Australia had never smoked (Table 3.1). Levels of experimental and regular smoking increased with age, but by age 17 most students (65%) had still never smoked.

"Overall, around 2% of all students had smoked more than 100 cigarettes in their lifetime (6% of 17 year olds). The lowest proportion of students to have smoked in the past month was among 12 and 13 year olds (2%), and this level rose to 16% among 17 year olds. A similar pattern was evident among students who had smoked in the past week (i.e., current smokers), from 1-2% of 12 and 13 year olds to 11% of 17 year olds. Only around 3% of all students had smoked on three or more days during the past week (committed smokers), with this being highest among 17 year olds (6%).

"We found only three sex differences in smoking rates within these time periods when looking at each age separately. For 13 year olds, more male than female students had ever smoked, while among 17 year olds, more male than female students had smoked 100 cigarettes in their lifetime1. Committed smoking was more common among males than females aged 17.

"Patterns in current smoking
"Around 33% of current smokers aged 12 to 17 had smoked on only one day of the past week (Table 3.2). Around half had smoked on three or more days of the past week, with around 22% smoking daily.

"The frequency of smoking increased with age among male current smokers. There was a tendency for more younger male current smokers to smoke on only one day of the week (12-15: 35%; 16-17 students: 27%), and for more older male current smokers to smoke on three or more days of the past week (16-17: 57%; 12-15: 50%).

"The opposite pattern was evident in female current smokers. For this group, there was a tendency for more older students to smoke on only one day of the past week (16-17: 38%; 12-15: 30%), while more younger female current smokers smoked on at least three days of the past week (12-15: 53%; 16-17: 47%).

"Over all ages, male current smokers tended to smoke on more days per week than female current smokers. This was mainly due to older male students smoking on more days per week.

"Male smokers also used a higher number of cigarettes each week than female current smokers (Table 3.2). Students aged 16 and 17 smoked more cigarettes per week (M = 18) than those aged 12 to 15 (M = 15).

"Current smokers who did not smoke every day used substantially fewer cigarettes per week (M = 8) than daily smokers (M = 45). Among females, older daily smokers smoked more cigarettes in a week (M = 47) than younger daily smokers (M = 29). A similar age effect was not found for male students."

"Of all students surveyed, 34% reported never having consumed alcohol (Table 4.1). Alcohol use was more common among older students, with 76% of 17 year olds having consumed alcohol in the past year, compared to 17% of 12 year olds (Table 4.1).

"Current drinking (in the past week) was more common among older than younger students. Overall, a greater proportion of male (16%) than female (14%) students were current drinkers.

"Risky drinking
"While any alcohol consumption is risky for teenagers, drinking five or more drinks on one occasion in the past week indicates risky levels of drinking for adults, according to the NHMRC guidelines. In 2017, risky drinking was more common among males (6%) than females (4%) overall (Table 4.1).

"Around 33% of all students surveyed reported risky drinking on at least one occasion in their lifetime (Table 4.2). Risky drinking in the last two weeks, past month, past year, and in their lifetime, was more common in older than younger students. Risky drinking in the last two weeks was more common among male than female older students, but there was no sex difference in students aged 12 to 15.

"Drinking five or more drinks on at least one occasion in the past seven days among current drinkers followed a similar pattern, with the proportion greater among male than female students, and among older than younger students (Table 4.3). Among current drinkers, male students reported a higher average number of drinks consumed (M = 8) than female students (M = 5), and older students drank more on average (M = 7) than younger students (M = 5)."

"Within a large cohort of people with opioid use disorder in New South Wales, Australia, we performed a self-controlled study to test the effect of incarceration and OAT transitions on the risk of hospitalization with injection drug use-associated bacterial infections. Compared to time between five and 52 weeks continuously living in the community, incidence of injecting-related infections increased before incarceration; was similar during the first two weeks of incarceration; and then substantially decreased among people in prison for more than three weeks. Risk was again elevated in the weeks immediately following release from prison. Compared to time between five and 52 weeks continuously receiving OAT, incidence of injecting-related infections was highest during the weeks both before and after OAT initiation and OAT discontinuation. Overall, we found that risk for injecting-related bacterial infections varies greatly within-individuals over time. Social contextual factors likely contribute to the substantially raised risks around transitions in incarceration and OAT exposure. People entering and leaving prison, and people starting and stopping OAT, may benefit from improved access to harm reduction programs and health and social services to prevent injecting-related bacterial infections. Changes in the risk of hospital admissions with injecting-related infections in and out of prison and OAT may also reflect changes in the ability to access primary and secondary health services.

"The increase in risk immediately following prison release may reflect return to injection use, poor access to health and social supports, and material deprivation (poverty and homelessness) (Binswanger et al., 2012; Joudrey et al., 2019; Treloar et al., 2021). This underscores that people leaving prison would benefit from better health, social, and economic supports, and linkages to harm reduction services and primary care. The excess risk for injecting-related infections during this time period (when compared to people injecting drugs in the community at other times, we estimate 1.45 times the risk, 95% CI 1.22-1.72) may be more modest than that seen for overdose (e.g., 2.44 times higher fatal overdose rate in a cohort study from New South Wales, Australia (Degenhardt et al., 2014); 2.76 times higher nonfatal overdose risk in a self-controlled cases series from British Columbia, Canada (Keen et al., 2021)). Incarceration often leads to loss of opioid tolerance, especially among people not receiving OAT in prison (Degenhardt et al., 2014; Joudrey et al., 2019), which likely increases overdose risk more so than infection risk. Given that the median duration of prison stay was only 16 days, excess risk of infection-related hospitalization after release may also reflect people seeking treatment outside prison for infections that initially developed before or during incarceration (Lloyd et al., 2015)."

"The Global Commission on Drug Policy recently advised governments to make harm reduction measures, including drug checking services, widely accessible (Bewley-Taylor & Tinasti, 2020; Buxton et al., 2020). Although there have been calls for drug checking in Australia for some time (Ritter, 2020), initially there were only two Australian trials of drug checking, both performed in a festival context (Byrne et al., 2018; Olsen et al., 2019). This comprised a fixed site trial service launched in Canberra in 2022, which has been extended and is expected to become a permanent service (Olsen et al., 2022). In February 2023, the government of Queensland (the second largest and third most populous state in Australia) announced support for the introduction of drug checking services (Australian Broadcasting Corporation, 2023). The recent recommendation to make drug checking services widely accessible aligns with the harm reduction approach, which recognises the social context and influences surrounding substance use (Bewley-Taylor & Tinasti, 2020; Buxton et al., 2020). The support for introducing drug checking services by the government of Queensland reflects a step towards implementing population-level interventions aimed at reducing drug-related harms and addressing health inequalities. While previous studies surrounding these services have focused on populations such as the nightlife/festival attendees, particularly ecstasy consumers, there is still a gap in research regarding the perspectives and experiences of those involved in the consumption of performance and image enhancing drugs (PIEDs) such as anabolic-androgenic steroids (AAS). Therefore, in the context of the Queensland government's commitment to supporting such services, this study specifically aimed to explore AAS consumers attitudes, perceptions, and needs regarding drug checking. Doing so aligns service provision with broader goal of enhancing health outcomes for this population given the high representation of AAS consumption in Queensland, accounted for by the overrepresentation of AAS-related arrests compared to other states and territories (Australian Criminal Intelligence Commission, 2021)."

"Both lifetime and recent use of cannabis increased between 2016 and 2019. In 2019, 36% had used it in their lifetime (up from 35% in 2016) and 11.6% had used it in the last 12 months (up from 10.4%). In addition, more people reported using it in the month before the survey (from 5.8% to 6.6%) but there was no change in the frequency of use—about half of those who used cannabis did so monthly or more often (tables 4.16 and 4.20).

"The increase in lifetime use was due mainly to an increase among people aged 60 and over (from 13.8% to 18.9%) (Table 4.41). This could be due to an ageing cohort of people who had used cannabis, an increase in people deciding to try it, or to more people being willing to report their use.

"Between 2016 and 2019, recent use of cannabis increased among older people (Table 4.43). Recent use among those aged 50–59 and 60 and over is at the highest level since 2001. These age groups were also the most likely to use cannabis regularly, with almost half using it once a week or more."

"In 2010, for people aged 14 years or older who had used cannabis in the previous 12 months, only 7.2% had not used any other listed drugs while using cannabis (Table 6.10). Males were more likely than females to use any drug in combination with cannabis except for over-the-counter pain-killers, which had the same proportion for both sexes (2.9%). The most common drugs that were mixed with cannabis were alcohol (85.2%) and tobacco (68.8%). Ecstasy was the most common illicit drug to be used at the same time as cannabis (23.9%)."

"Compared with 2016, more people aged 14 and over reported they had used cocaine in their lifetime, previous 12 months, previous month and previous week (tables 4.15 and 4.16). Lifetime use of cocaine increased for both males and females, following an increasing trend that started in 2004. This was driven mainly by more people in their 20s, 40s and those aged 50 and over reporting in 2019 that they had used cocaine in their lifetime (Figure 4.5).

"Between 2016 and 2019, recent cocaine use increased across all age groups (except 14–19 year olds) and is at the highest proportion seen since 2001. The increase in recent use was driven mainly by the males in these age groups, but use among females in their 20s also increased. The proportion of males in their 20s using cocaine in the 12 months before the survey almost doubled (from 7.3% to 14.4%).

"People are using cocaine more frequently
"Lifetime and recent use of cocaine increased in 2019 and people who used cocaine also used it more often—at least monthly use increased from 10.1% to 16.8% between 2016 and 2019 (Figure 4.5)."

"The majority of drug deaths in an Australian study, conducted by the National Alcohol and Drug Research Centre, involved heroin in combination with either alcohol (40 percent) or tranquilizers (30 percent)."

"In 2013, about 1.3 million (7.0%) people had used meth/amphetamines in their lifetime and 400,000 (2.1%) had done so in the last 12 months (Online Table 5.5). Males were more likely than females to have used meth/amphetamines in their lifetime (8.6% and 5.3%, respectively) or in the last 12 months (2.7% and 1.5% respectively). In addition:
"• people aged 30–39 were slightly more likely than those in other age groups to have ever used meth/amphetamines (14.7%), while people aged 20–29 were more likely to have recently used meth/amphetamines (5.8%) (Online Table 5.7)
"• meth/amphetamine users are getting older; the average age of users was 24 in 2001, compared with 28 in 2013 (Online Table 5.16) and age of first use was also older, increasing from 17.9 in 2010 to 18.6 in 2013 among young people aged 14–24 (Online Table 5.10)
"• most people who were offered or had the opportunity to use meth/amphetamines didn’t use it—5.8% of people aged 14 or older were offered meth/amphetamines and 2.1% had used it (online tables 5.4 and 5.12)
"• among people aged 20–29, 14.1% had been offered or had the opportunity to use the drug, and 5.8% had used it (online tables 5.18 and S5.28)."

"The opportunity to use ecstasy was less common than cannabis with 7.2% of Australians stating they had been offered or had the opportunity to use the drug in the last 12 months (Online Table 5.12). Ecstasy was the second most commonly used illicit drug in a person’s lifetime, with 2.1 million (10.9%) people aged 14 or older reporting having ever used the drug and 500,000 had done so in the past 12 months, representing 2.5% of the population (Online Table 5.4). In addition:
"• the majority of recent ecstasy users only took ecstasy once or twice a year (54%) (Online Table 5.11)
"• the median age of recent ecstasy users was 25 (Online Table 5.16) and most people tried ecstasy as adults as the average age of initiation was 18.2 among people aged 14–24 (Online Table 5.10)
"• most ecstasy users claimed that at least some of their friends also used the drug; three-quarters said that about half or fewer of their friends currently used and one-quarter said all or most (Online Table 5.14)."

"Between 1993 and 2007, the daily drinking rate for people aged 14 or older remained largely unchanged, at around 8% (Figure 4.1). However, in 2010, there was a significant fall compared to 2007, and in 2013, the proportion drinking daily again declined from 7.2% to 6.5%. In addition:
"• in the previous 12 months, around three-quarters (78%) of the population aged 14 or older had consumed a full serve of alcohol, and 22% had not consumed alcohol
"• the proportion of people aged 14 or older who had never had a full serve of alcohol has risen since 2004, with an increase between 2010 and 2013 (from 12.1% to 13.8%)."

"About 1 in 5 people in Australia aged 14 years or older consumed alcohol at a level that puts them at risk of harm from alcohol-related disease or injury over their lifetime (Table 4.4). Results from the 2010 survey showed that:
"• there was little change in the proportion of risky drinkers from 2007 (20.3%) to 2010 (20.1%)
"• more than 3.7 million people in Australia aged 14 years or older were at risk of an alcohol-related disease or injury over their lifetime based on their pattern of drinking in 2010 (up from 3.5 million in 2007)
"• people aged 18–29 years were more likely than any other age group to drink alcohol in a way that put them at risk of alcohol-related harm over their lifetime (31.7% for those aged 18–19 years and 26.9% for those aged 20–29 years)
"• males were twice as likely as females to drink alcohol in quantities that put them at risk of incurring an alcohol-related chronic disease or injury over their lifetime (29.0% and 11.3%, respectively)
"• according to guideline 3 of the 2009 guidelines, for those aged under 18 years, not drinking is the safest option, and this is especially important for children aged under 15 years. Positively, the proportion of people aged 12–15 years and 16–17 years abstaining from alcohol increased in 2010 (from 69.9% to 77.2% and from 24.4% to 31.6%, respectively)."

"In 2010, 15.1% of people in Australia aged 14 years or older were daily smokers, declining from 16.6% in 2007. Between 1991 and 2010, the proportion of daily smokers declined by almost 40% to the lowest levels seen over the 19-year period (Table 3.1). The proportion of people who had never smoked increased. Also:
"• the number of people smoking daily in 2010 decreased by approximately 100,000 people (2.9 million in 2007 down to 2.8 million in 2010)
"• just under one-quarter of the population (24.1%) were estimated to be ex-smokers and more than half (57.8%) had never smoked in their life in 2010
"In 2010, those people who had never smoked (10.6 million) and those who were ex-smokers (4.4 million) far exceeded the number of smokers (3.3 million) aged 14 years or older."

"Australia’s consumption of opioid analgesics is ranked 10th internationally; North America ranks first. Per capita consumption of oxycodone and morphine preparations in Australia is relatively high (ranked third and fifth respectively, internationally); Canada ranks first for oxycodone and Austria first for morphine.¹ Consumption levels in Australia are still well below the top-ranking countries. Previous research in Australia has documented increases in the number of prescriptions for morphine in the late 1990s^2,3 and, more recently, increases in consumption of oxycodone.⁴"

"Morphine prescriptions declined from 38.3 to 30.7 per 1000 population between 2002–03 and 2007–08, representing a decrease of about 20%. Box 1A shows trends in morphine prescriptions by 10-year age group. Prescriptions were most common among older people (aged 70–79 and 80+ years), and much less common among younger people (aged 20–29 and 30–39 years). Significant linear declines over time were apparent in all age groups except the 50–59-year group."

"• In 2009–10, cannabis accounted for the highest number of drug-related arrests. There were 57,170 arrests involving cannabis in 2009–10, an increase of three percent from 2008–09, but an overall decrease of 17 percent from the number of arrests recorded in 1996–97.
"• The number of arrests for heroin peaked in 1998–99 with 14,341 arrests. This number fell considerably between 1999–2000 and 2001–02 before declining fairly consistently over the next 10 year period. In 2009–10, 2,767 arrests were made that involved heroin—an 81 percent decrease in arrests over that time.
"• In 1996–97, the number of arrests involving amphetamines was slightly below that of arrests involving ‘other’ drugs. Since then, however, arrests involving amphetamines have generally increased more than those involving other drugs, although this difference diminished in 2010, with only 3,893 more amphetamine arrests than arrests for other drugs. Overall, however, there has been a 258 percent increase in the number of amphetamine-related arrests since 1996–97.
"• In 2009–10, the number of cocaine arrests increased by 47 percent, rising from 848 in 2008–09 to 1,244. Despite this, the overall number of cocaine arrests remained lower than for any other drug type throughout the period.
"• Drug arrests involving a consumer were far more common across all drug types than those involving a provider. The highest proportion of those arrested (both consumers and providers) were for crimes involving cannabis (86%).
"• Providers accounted for 32 percent of cocaine-related arrests, 31 percent of heroin-related arrests and 28 and 24 percent of amphetamine and other drug-related offences, respectively."

"Australia’s prisoner population is growing at a rate well in excess of natural population growth. There were 29 700 adults in full-time custody at 30 June 2010, representing a 15% increase in the incarceration rate from 2000 to 2010. Women comprise 8% of adult prisoners but this proportion is increasing annually. Indigenous Australians2 are over-represented by a factor of 14, and the gap between Indigenous and non-Indigenous incarceration rates continues to widen.¹"

"It has been estimated that a very low proportion of the Australian general population aged 14 years and over have ever injected or recently injected drugs. In 2010, 1.8% of the population had injected a drug in their lifetime, with 0.4% having injected a drug in the past year. More than one-quarter (27.1%) of recent users injected daily and the majority obtained their needles and syringes from a chemist (64.5%). Males were more likely to have recently injected drugs in the past year than females (0.6% versus 0.3%). Those in the 20-29 and 30-39 year age groups had a higher proportion of past-year injecting drug use (0.9% for each) than those in other age groups (Australian Institute of Health and Welfare, 2011).
"Another recent prevalence estimate of injecting in Australia in 15-64 year olds is 1.09% (range = 0.65%-1.50%) which equates to approximately 149,591 persons (range = 89,253-204,564) (Mathers, Degenhardt, Phillips et al., 2008)."

"In Australia it is estimated that about 13 per cent of people with HIV also have HCV. HIV shares major routes of transmission with both HCV and HBV. People who inject drugs are at particularly high risk for HCV and HIV co-infection.
"While HIV was not established in the Australian IDU population when NSPs were introduced, the prevalence of HCV was already high. HCV is a more robust virus than HIV and is transmitted more efficiently though blood-to-blood contact. Approximately 80 per cent of current HCV infections and 90 per cent of new infections are attributable to unsafe injecting practices (Commonwealth of Australia, 2005b). This explains IDUs being identified as a priority population within The Third National Hepatitis C Strategy."

"In 2012, IDRS participants were asked questions about BBVI [Blood-Borne Viral Infection] testing and vaccinations. Of those who commented, 93% reported testing for HBV in their lifetime compared to 96% for HCV and 94% for HIV.
"Of those who were tested for HBV, two-thirds (62%) had a test within the past year and one-third (30%) within the last three months. Six percent reported a positive result and 4% had been treated for HBV (anti-viral therapy only). Two-thirds (61%) had been vaccinated again HBV, with 87% having completed the course. The main reason for HBV vaccination was due to a history of injecting drug use (38%) (Table 81).
"Among those tested for HCV, two-thirds (65%) had a test within the past year and one-third (31%) within the last three months. Nearly half reported a positive result. Ten percent of those who commented had been treated for HCV (anti-viral therapy only), with 22% receiving HCV treatment (currently or in the last 12 months). The main reason for HCV testing on the last occasion was a ‘matter of routine’ (38%) and ‘it was a responsible thing to do’ (14%; Table 82)."

(Prevalence of HIV Among Injection Drug Users in Australia) "The prevalence of HIV among people who inject drugs in Australia has remained low at 2.1% or less since 1995. The prevalence of HIV in 2011 was 1.2% (Figure 46). HCV prevalence among this group was much higher at 61% to 62% from 2005 to 2008, however this figure was lower at 53% 2011 (Figure 46) (Iversen and Maher, 2012)."

"Approximately 83 per cent of HCV infections have resulted from unsafe injecting drug use practices. In Australia in 2006 it was estimated that approximately 264,000 people had been exposed to HCV and had HCV antibodies with around 197,000 living with chronic hepatitis C. The estimated number of new cases of HCV infection has declined from 16,000 per annum in 2001 to 10,000 in 2005. The majority (65 per cent) of people with HCV are aged between 20 and 39 years and 35 per cent of national notifications of HCV are in women.
"While 25 per cent of HCV infections clear spontaneously within two to six months 75 per cent develop into chronic infections. Chronically infected persons will continue to be able to transmit the virus including those who experience no noticeable illness or symptoms. After 20 years, between 5 and 10 per cent of infections will have resulted in cirrhosis of the liver, with 2 to 5 per cent progressing to liver failure or a form of liver cancer known as hepatocellular carcinoma."

(Methamphetamine Use and Health) "This section compares meth/amphetamines use patterns with general health, selected health conditions, psychological distress (see Glossary for definition of the Kessler Psychological Distress Scale) and body mass index in people aged 18 years or older. The data are based on self-reported assessments and are not empirically verified. Table 8.7 shows there was a relationship between recent use of meth/amphetamines and a person’s mental health and body mass index. In addition:
"• recent users were twice as likely to report high or very high levels of psychological distress as those who had not used meth/amphetamines in the last 12 months (20.8% compared with 9.6%)
"• recent users were also twice as likely as non-recent users to report being diagnosed or treated for a mental illness in the previous 12 months (25.6% compared with 11.7%)
"• recent users of meth/amphetamines were less likely to be obese than non-users (14.6% and 21.8%, respectively)."

"In 2010, there appeared to be a relationship between a person’s cocaine use and his or her mental health, psychological distress (see Glossary for definition of the Kessler Psychological Distress Scale) and body mass index (Table 9.7). In addition:
"• people who recently used cocaine were more likely to have been diagnosed with or treated for a mental illness (17.4% for recent users compared with 11.9%), and have high or very high levels of psychological distress (17.5% for recent users compared with 9.7%) than those who had not used cocaine in the previous 12 months
"• recent cocaine users were more likely to be underweight (5.0% for recent users compared with 2.3%), and considerably less likely to be obese (8.2% for recent users compared with 22.0%) than those who had not used cocaine in the previous 12 months."

"There were 465 oxycodone-related deaths identified between 2001 and 2009. Box 3 shows deaths by year from 2002 to 2008, with the largest number occurring in 2007. Deaths adjusted for quantity of oxycodone prescribed each year fluctuated between 3.8 and 8 deaths per million defined daily doses (Box 3). Only 10% of these deaths were due to oxycodone toxicity alone. Multiple drug toxicity was more predominant (82% of deaths), with benzodiazepines and alcohol commonly implicated in these deaths. The remaining 8% were from other causes (eg, pneumonia or cardiac failure), with drug toxicity (including oxycodone toxicity) being a contributory cause (data not shown)."

"A striking finding from the toxicological data was the relatively small number of subjects in whom morphine only was detected. Most died with more drugs than heroin alone 'on board', with alcohol detected in 45% of subjects and benzodiazepines in just over a quarter. Both of these drugs act as central nervous system depressants and can enhance and prolong the depressant effects of heroin."

"The disadvantage of continuing to describe heroin-related fatalities as 'overdoses' is that it attributes the cause of death solely to heroin and detracts attention from the contribution of other drugs to the cause of death. Heroin users need to be educated about the potentially dangerous practice of concurrent polydrug and heroin use."

"Treatment episodes for problematic morphine use remained relatively stable during 2002–03 to 2007–08 (0.07 per 1000 population in 2007–08). Episodes for problematic oxycodone use doubled, from 0.01 per 1000 population in 2002–03 to 0.02 per 1000 population in 2007–08 (Box 2B)."

"• The number of needles and syringes distributed in Australia increased during the past decade (from ~27 million to ~31 million).
"• Expenditure on NSPs increased by 36% (adjusted for inflation) over this time period, mostly associated with personnel and not principally for equipment (Table a); a significant portion of the increased investment has been the Illicit Diversion Supporting Measures for NSPs to increase referrals to drug treatment and other services.
"Over the last decade there has been
"• Increases in funding for primary sites.
"• Increases in the number of secondary sites.
"• Increases (by 15%) in the numbers of units of equipment provided.
"• Stable spending on sterile injection equipment.
"• At the time of writing there were 85 primary sites, 737 secondary sites, 20 enhanced secondary sites, and 118 vending machines."

"Needle and syringe programs (NSP) were by far the most common source of needles and syringes in the preceding six months (95%), followed by chemists (16%). NSP vending machines were used by 33% of participants in TAS and 29% in NSW. Proportions reporting a friend, partner and/or dealer varied by jurisdiction. Hospitals and outreach/peer workers were also accessed (Table 75).

"In comparison, data from the 2010 National Drug Strategy Household survey reported that around 65% of recent injectors (used in the previous 12 months) obtained needles and syringes from a chemist, followed by 37% at NSP (Australian Institute of Health and Welfare, 2011)."

"It was estimated that: "

• For every one dollar invested in NSPs, more than four dollars were returned (additional to the investment) in healthcare cost-savings in the short-term (ten years) if only direct costs are included; greater returns are expected over longer time horizons. "

• NSPs were found to be cost-saving over 2000-2009 in seven of eight jurisdictions and cost-effective in the other jurisdiction. Over the longer term, NSPs are highly cost saving in all jurisdictions. "

• The majority of the cost savings were found to be associated with HCV-related outcomes. However, when only HIV-related outcomes were considered in the analysis, it cost $4,500 per DALY gained associated with HIV infection. "

• If patient/client costs and productivity gains and losses are included in the analysis, then the net present value of NSPs is $5.85bn; that is, for every one dollar invested in NSPs (2000-2009), $27 is returned in cost savings. This return increases considerably over a longer time horizon. "

• NSPs are very cost-effective compared to other common public health interventions, such as vaccinations (median cost per QALY of $58,000), allied health, lifestyle, and in-patient interventions (median cost of $9,000 per DALY gained), and interventions addressing diabetes and impaired glucose tolerance or alcohol and drug dependence (median cost of $3,700 per DALY gained)[2]."

"Investment in NSPs (2000-2009) has resulted in: " 

• An estimated 32,050 HIV infections and 96,667 HCV infections averted; " 

• Substantial healthcare cost savings to government related to HCV and HIV; " 

• Substantial gains in Disability Adjusted Life years. "For every dollar currently spent on the activities of NSP, more than four dollars will be returned (in addition to the investment; i.e., five times the investment) and approximately 0.2 days of disability-adjusted life gained. Over a longer time horizon there is even greater return."

"Nuns who run one of Australia's best known hospitals are to operate the country's first legal and medically supervised heroin injecting room after a radical overhaul of the drug laws in New South Wales. The 18 month trial will be administered by the Sisters of Charity, who also run Sydney's inner city St Vincent's Hospital.
"An estimated 50 000 visits a year by drug users are expected at the centre, which will be staffed by a medical supervisor, a registered nurse, and security staff. The controversial plan will include the provision of clean needles and syringes; users must supply their own drugs."

"In Australia the [Needle and Syringe] Program is the single most important and cost-effective strategy in reducing drug-related harms among IDUs. Australian Governments invested $130 million in NSPs between 1991 and 2000 resulting in the prevention of an estimated 25,000 HIV infections and 21,000 HCV infections, with savings from avoided treatment costs of up to $7.8 billion (Health Outcomes International et al., 2002). In the decade 2000-2009, the gross funding for NSPs was $243 million. This investment yielded healthcare cost savings of $1.28 billion; a gain of approximately 140,000 Disability-Adjusted Life Years (DALYs); and a net cost saving of $1.03 billion. During this time, NSPs have averted 32,061 new HIV infections and 96,918 new HCV infections (NCHECR, 2009)."

"In summary, the evidence available from this Evaluation indicates that:

"• operation of the MSIC in the King Cross area is feasible;

"• the MSIC made service contact with its target population, including many who had no prior treatment for drug dependence;

"• there was no detectable change in heroin overdoses at the community level;

"• a small number of opioid overdoses managed at the MSIC may have been fatal had they occurred elsewhere;

"• the MSIC made referrals for drug treatment, especially among frequent attenders;

"• there was no increase in risk of blod borne virus transmission;

"• there was no overall loss of public amenity;

"• there was no increase of crime;

"• the majority of the community accepted the MSIC initiative;

"• the MSIC has afforded an opportunity to improve knowledge that can guide public health responses to drug injecting and its harms."

"Of the total social cost of drug abuse in 2004/05 of $55.2 billion, alcohol accounted for $15.3 billion (27.3 per cent of the unadjusted total), tobacco for $31.5 billion (56.2 per cent), and illicit drugs $8.2 billion (14.6 per cent). Alcohol and illicit drugs acting together accounted for another $1.1 billion (1.9 per cent)."

"Of the total net production costs of $13.2 billion, tobacco accounted for by far the largest share (60.7 per cent or $8.0 billion). Alcohol represented 26.8 per cent ($3.5 billion) and illicit drugs 12.5 per cent ($1.6 billion). Of the gross production costs of $22.9 billion, workforce losses represented 47.9 per cent ($11.0 billion) and household losses 52.1 per cent ($11.9 billion)."

"The public health burden of cannabis use is probably modest compared with that of alcohol, tobacco, and other illicit drugs. A recent Australian study⁹⁶ estimated that cannabis use caused 0·2% of total disease burden in Australia—a country with one of the highest reported rates of cannabis use. Cannabis accounted for 10% of the burden attributable to all illicit drugs (including heroin, cocaine, and amphetamines). It also accounted for around 10% of the proportion of disease burden attributed to alcohol (2·3%), but only 2·5% of that attributable to tobacco (7·8%)."

"The harms to individuals, families, communities and Australian society as a whole from alcohol, tobacco and other drugs are well known. For example, the cost to Australian society of alcohol, tobacco and other drug misuse1 in the financial year 2004–05 was estimated at $56.1 billion, including costs to the health and hospitals system, lost workplace productivity, road accidents and crime." 

"The overarching approach of harm minimisation, which has guided the National Drug Strategy since its inception in 1985, will continue through 2010–2015. This encompasses the three pillars of: "

• demand reduction to prevent the uptake and/or delay the onset of use of alcohol, tobacco and other drugs; reduce the misuse of alcohol and the use of tobacco and other drugs in the community; and support people to recover from dependence and reintegrate with the community "

• supply reduction to prevent, stop, disrupt or otherwise reduce the production and supply of illegal drugs; and control, manage and/or regulate the availability of legal drugs "

• harm reduction to reduce the adverse health, social and economic consequences of the use of alcohol, tobacco and other drugs.

 "The three pillars apply across all drug types but in different ways, for example, depending on whether the drugs being used are legal or illegal. The approaches in the three pillars will be applied with sensitivity to age and stage of life, disadvantaged populations, and settings of use and intervention."

"Since the inception of the National Campaign Against Drug Abuse in 1985, Australia has had major successes in reducing the prevalence of, and harms from, drug use.
"&#149 Far fewer Australians are smoking and being exposed to second-hand smoke as a result of comprehensive public health approaches, including bans on advertising, bans on smoking in enclosed public spaces and significant investments in public education and media campaigns. The daily smoking rate among Australians aged 14 years and over has fallen from 30.5 per cent in 1988 to 16.6 per cent in 2007.
"• Far fewer people are using illegal drugs. The 2007 National Drug Strategy Household Survey shows the proportion of people reporting recent use of illegal drugs fell from 22 per cent in 1998 to 13.4 per cent in 2007. The recent use of cannabis—the most commonly used illegal drug—fell from 17.9 per cent in 1998 to 9.1 per cent in 2007.
"• Law enforcement agencies have continued to be effective in detecting and seizing illegal drugs to disrupt supply. The number of illegal drug seizures increased by almost 70 per cent between 1999–2000 and 2008–09, and the collective weight of seizures increased by about 116 per cent.
"• The heroin shortage that began in 2000 has been sustained, with heroin use remaining at low levels since then.
• Harms associated with injecting drug use have also been reduced. It is estimated that from 2000–2009 needle and syringe programs, which ensure the safe supply and disposal of syringes to injecting drug users, have directly averted over 32 000 new HIV infections and nearly 97 000 hepatitis C infections."

"Australia’s first NSP was trialled in New South Wales in 1986 with the provision of NSP services becoming New South Wales Government policy in early 1987 and the remaining states and territories implementing NSPs soon after via primary, secondary and pharmacy outlets (Dolan et al., 2005). This occurred following the discovery of HIV and the potential threat that this virus posed to the Australian community. The establishment of NSPs throughout Australia would not have been possible without bipartisan political support which continues to be an important element in the continuing existence and operation of NSPs."

"Commitment to evidence
"An important aspect of Australia’s approach to drug use has been the commitment to a comprehensive evidence base. Under the National Drug Strategy 2010–2015 there is a continued commitment to evidence-based and evidence-informed practice. Evidence-based practice means using approaches which have proven to be effective. For example, the continuing provision of detoxification, pharmacological therapies including opioid substitution therapies and cognitive behavioural therapies for alcohol, tobacco and other drug treatment is based on an extensive body of evidence in Australia and internationally.
"Evidence-informed practice involves integrating existing evidence with professional expertise to develop optimal approaches, including new or innovative approaches in a given situation. The National Drug Strategy 2010–2015 includes a commitment to innovation and trialling new approaches. For example, the introduction of the Illicit Drug Diversion Initiative (IDDI) supported police-based diversion in early intervention and prevention programs before there was comprehensive evidence supporting this approach. The success of IDDI was a catalyst for its expansion into court-based diversion and treatment at correctional centres. IDDI demonstrates that where there is little evidence, leadership is needed to support innovation. Allowing room for the development of such creative approaches to be developed in the future will require new evidence to be collected so that the impact and quality of new interventions is well-understood."

"• There is strong evidence of an association between social determinants—such as unemployment, homelessness, poverty, and family breakdown—and drug use. Socio-economic status has been associated with drug-related harms such as foetal alcohol syndrome, alcohol and other drug disorders, hospital admissions due to diagnoses related to alcoholism, lung cancer, drug overdoses and alcohol-related assault. In the 2007 National Drug Strategy Household Survey the highest prevalence of recent illegal drug use was reported by unemployed people—23.3 per cent compared with 13.4 per cent of the general population. Alcohol, tobacco and other drug use among homeless people is common. One study estimated the overall 12-month prevalence of harmful alcohol use for homeless people in Sydney at 41 per cent and the prevalence of drug use at 36 per cent. Family factors—including poor parent–child relationships, family disorganisation, chaos and stress and family conflict and marital discord with verbal, physical or sexual abuse—also have a strong association with drug use. There are a number of strong protective factors that guard against problematic alcohol and other drug use. These include having a job, a stable family life and stable housing. These factors can be important in preventing or overcoming drug-related problems."

"The only comprehensive evaluation of a medically supervised injecting centre was conducted during the 18 month trial of the Sydney centre. Staff intervened in 329 overdoses over one year with an estimate of at least four lives saved a year. There was no increase in reported hepatitis B or C infections in the area that the medically supervised injecting centre served despite an increase elsewhere in Sydney.

"The report described a decreased frequency of injecting related problems among clients. Half the centre's clients reported that their injecting practices had become less risky since using the centre. Furthermore, clients were more likely than other injectors to report that they had started treatment for their drug use; 11% of clients were referred to treatment for drug dependence. An economic evaluation of deaths averted by intervention of the medically supervised injecting centre showed that costs were comparable to those of other widely accepted public health measures.

"The centre also had benefits for the local community. Residents and business respondents reported fewer sightings of public injection and syringes discarded in public places, and syringe counts in the vicinity of the centre were lower after it opened than before. In addition, there was no evidence of an increased number of theft and robbery incidents in the area. Acceptance of the medically supervised injecting centre increased among both businesses and residents over the study period."

"Prescribing injectable opiates is one of many options in a range of treatments for opiate-dependent drug users. In showing that it attracts and retains long term resistant opiate-dependent drug users in treatment and that it is associated with significant and sustained reductions in drug use and improvements in health and social status, our findings endorse the view that it is a feasible option."

"The results of this study are important for the child protection field. They show that, rather than severity of substance use being associated with mothers’ involvement with the child protection system, other factors are of greater importance. Of particular interest was the finding that having greater social support, particularly from parents, significantly reduced the likelihood of being involved with the child protection system."