With many drug users making the shift from heroin to methamphetamine and crystal methamphetamine (‘ice’) over the past decade, Australians know there’s an addiction problem here that could become significantly worse.

Increasing use of synthetic opioids in Canada ^[1], the United Kingdom ^[2] and the United States ^[3] has caused devastation and death. The UN Office on Drugs and Crime says the number of opioid deaths in Canada and the US doubled between 2013 and 2017.

The information available indicates that Australia’s likely to follow down that deadly path. Knowing what the landscape looks like ahead will make us better prepared to deal with what’s coming.

The rapid increase in the use of synthetic opioids, especially fentanyl, has been identified in the Australian Criminal Intelligence Commission’s 2018 and 2019 wastewater monitoring reports ^[4], research by the Australian National University ^[5] and the most recent Pennington Institute report ^[6] on overdose deaths. The ABC ^[7] has confirmed how easy it is to purchase fentanyl and its precursors online. That’s no surprise to those who’ve watched this occur in Canada and the US over the past five years.

This ease of access to fentanyl, even in small amounts, should be of serious concern to Australians. The redirection of legal fentanyl into the illegal drug market is a serious enough problem, but in the US and Canada that was quickly followed by the large-scale illicit manufacturing of synthetic versions. That’s a wake-up call for Australia.

ANU researchers said access to ingredients through the dark web should be a great concern. The profitability of the illicit opioid market has never been greater. The US Drug Enforcement Agency estimates that it costs between US$1,500 and US$3,000 to produce a kilo of pure fentanyl. Turning that kilo into millions of dollars is easy for an enterprising manufacturer.

The DEA found that each tablet in a shipment of counterfeit oxycodone tablets it discovered contained between 0.03 to 1.99 milligrams of fentanyl. A kilogram of pure fentanyl could provide a million counterfeit tablets worth US$10–20 each on the street. Such a lucrative market will not go away easily or quietly. When investing a few thousand dollars can produce a financial reward in the millions, that far outweighs the risk for the trafficker.

In 2017, an Australian Bureau of Statistics report ^[8] tallied 1,808 drug-induced deaths in Australia in the previous year. The top four substances involved in death were benzodiazepines (such as Valium), opioids (such as oxycodone), methamphetamines and heroin, in that order. That report was a warning that the death toll would continue to climb, that current and previous drug strategies had not been effective, and that new and innovative thinking was required.

The abuse of opioids, both legal and illegal, has been a problem in Australia for decades.

An internal memo released as part of a civil suit against Purdue Pharma indicated that it was seeing illegal use and abuse of its legal synthetic opioids in Australia in the late 1990s. In 2016, the NSW Coroner ^[9] identified a wave of increased overdose deaths among heroin users and suggested that it was similar to a pattern seen in other countries where heroin had been laced with street-grade fentanyl.

It’s clear from attempts to combat the illegal drug trade in Australia, Canada and the US that the traditional ‘attack the trafficker’ model can’t succeed on its own.

Until there’s a shift in focus from the supply to the demand side of illegal drug use, we’ll suffer the same fate as other countries that are plagued by addiction.

Doing nothing is not an option—but nor should be continuing on the same path and failing once again.

The drug threat is changing, and it will get worse before it gets better. Australia must decide how to respond with the greatest effect.

Arguably, Australia’s law enforcement community could not be more successful in attacking the supply of illegal drugs into and within the country, with record seizures, charges and convictions. But the price of illegal drugs is steadily decreasing despite this success. The police are meeting their key performance indicators and deserve praise for their diligence, but they also stress that attacking the supply chain isn’t enough and needs to be combined with an aggressive strategy to reduce the demand for drugs.

The government and law enforcement are already putting their best efforts into reducing supplies, but to make a serious impact on illegal drugs they would need to at least triple the number of seizures, charges and convictions, and that’s neither a realistic nor a financially viable option. Australia needs an aggressive strategy for reducing demand if we’re to have an opportunity for any level of success.

A strategy to reduce demand must focus on the addict. The increased use of synthetic opioids will result in an increase in overdose deaths. Preventing that will require a pill-testing program, access to opioid replacement therapy, greater access to naloxone to treat overdoses and a strong education program. The strategic rollout of naloxone nasal spray ^[10] and the provision of training in its use to emergency services personnel will help Australia get ahead of the curve. Jurisdictions like Canada saw many preventable deaths before such action was taken.

Opioid replacement therapy must include methadone (daily use) and Buvidal (monthly use) programs to stop the craving often felt by addicts so that they can move towards a normal lifestyle. Pilot projects allowing diamorphine or a similar opioid replacement therapy should be seriously considered. This is often referred to as a medical heroin replacement, but it allows an addict to become stabilised and to move from a high-risk to a lower-risk lifestyle.

Australia can make the greatest difference through a strong and thorough education program targeting high-risk opioid users, recreational drug users and non-using but at-risk youth. As a lifesaving tool, it will help educate users about what we’re seeing elsewhere and make them aware that their regular supplies may be tainted by ‘basement grade’ fentanyl that could cause an overdose. Their increased understanding could persuade them to reduce their drug use and, sometimes, to look for alternatives.

Recreational users need to be warned about the potential for serious harm or death if they buy what looks like a legitimate oxycodone tablet which turns out to be a counterfeit cut with fentanyl. In Canada, cocaine, ecstasy and other drugs have included fentanyl without any knowledge of the purchaser.

Australia can get ahead of this looming problem—but we need to act now.