A nationwide study of the extent and factors associated with fentanyl use in Australia
Introduction
The role of fentanyl is well established as a second-line treatment option in the management of severe and chronic pain conditions that are either cancer or non-cancer related.1, 2 Due to the availability of controlled-release formulations and advanced delivery methods, substantial increases in the use of fentanyl worldwide have been observed since the 1990s.3 Transdermal fentanyl patches in particular, offer an alternative treatment option when oral formulations cannot be tolerated and have the convenience of twice weekly dosing. Consequently, in 2013, fentanyl recorded the highest rate of global consumption in terms of daily doses across all synthetic opioids with an estimated 2.8 billion statistical Defined Daily Doses (or S-DDDs) consumed over the year.3 Countries currently leading the global consumption of fentanyl are the United States, Germany, Spain, France and Canada.3 In Australia, fentanyl accounts for 2% of all opioid pack sales in the community and 24% of total use when accounting for potency differences across a common metric (oral morphine equivalents).4
The high potency of fentanyl relative to morphine and other pharmaceutical opioids also increases its attractiveness in illicit drug markets. Accordingly, alongside increases in the use of fentanyl, reports of misuse and associated harms have been growing in countries such as the United States, Canada, Australia, Estonia and other parts of Europe.5, 6, 7, 8 Although mortality related to fentanyl is currently low in Australia, there is evidence that rates are increasing.5, 9 Many of these deaths appear to be the result of injecting fentanyl extracted from transdermal patches.9
In order to minimise potential misuse of transdermal fentanyl patches in the Australian community, one response has been to alert health practitioners in some jurisdictions to be cautious when prescribing and dispensing fentanyl.10, 11 In light of the high potency and rising rates of misuse and overdose related to fentanyl,5 as well as previous findings highlighting that there is regional variation in strong opioid use across Australia and that use is higher among more disadvantaged communities,4, 12 there is a need to examine the extent of use of fentanyl more broadly across Australia and the factors driving this use. Therefore, the overall aim of this study was to examine fentanyl utilisation in the Australian community, with the specific aims of:
- (1)
Estimating total fentanyl utilisation across Australia and across different geographical areas and;
- (2)
Examining the geographic and socio-demographic factors associated with higher rates of fentanyl utilisation.
Section snippets
Fentanyl sales data
A third party access request to obtain pharmaceutical opioid sales data in Australia was approved by IMS Health. IMS Health collect data on sales of prescription and non-prescription items through pharmaceutical wholesalers and manufacturers who sell direct to pharmacies, representing over 94% coverage of the Australian market.13 This study focused on fentanyl items sold in the community, representing approximately 5450 pharmacies in operation across Australia between 2013 and 2014,14 and
Fentanyl utilisation in pack sales
A total of 859,518 fentanyl packs were sold across Australia in 2013: transdermal patches accounted for 99% (850,923) of all pack sales and lozenges accounted for 1% (8595) of all pack sales. After taking into account population size, approximately 0.04 fentanyl packs were used per person over the year (Table S1). The highest rate of fentanyl utilisation per person was observed in South Australia (0.06 packs/person; 95% CI 0.06–0.06 packs/person). The Australian Capital Territory, New South
Discussion
This is the first nationwide study examining the extent and factors associated with fentanyl use in the Australian community. Similar to earlier findings,5 transdermal fentanyl patches continue to constitute the majority of total fentanyl use across Australia. Given the increasing concern about the misuse of fentanyl patches previously reported in some parts of Australia,10, 11 the findings of this study are particularly useful in understanding geographical differences in fentanyl utilisation.
Conclusions
Transdermal fentanyl patches account for the majority of fentanyl utilisation in the Australian community. There is marked variation in fentanyl utilisation across geographic areas with higher use apparent in areas with a higher proportion of older people and indicators of greater socio-economic disadvantage, which is consistent with characteristics common among people with chronic pain. Given that there is significant concern about the misuse of fentanyl in some parts of the Australian
Funding
NG, BL, SN and LD are supported by NHMRC research fellowships (#1091878; #1073858; #1013803, #1132433; and #1041472). The National Drug and Alcohol Research Centre at UNSW is supported by funding from the Australian Government under the Substance Misuse Prevention and Service Improvements Grant Fund. BL, SN, RB and LD have all been investigators on untied investigator-driven educational grants from Reckitt Benckiser. BL, RB and LD have received an untied educational grant from Mundipharma for
Acknowledgements
The authors are very grateful for Billy Henderson's (Mundipharma) advice and assistance in facilitating access to the data analysed in this study.
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