Twenty-one years of heroin-related mortality in Australia: Joinpoint regression analysis of trends by age and gender

Background: Opioid-related deaths in Australia have continued to increase over the last 20 years, with increasing numbers of deaths attributed to pharmaceutical opioids occurring throughout this period. Heroin deaths remained stable between 2001 to 2012, however, they are increasing again in Australia. This paper sought to analyse trends over 21 years by age and gender. Trends in heroin deaths will be discussed within the context of drug markets, rising methamphetamine-related mortality, and declining fentanyl-related mortality. Methods:  Analysis of deaths attributed by the coroner to heroin (and other drug) toxicity, extracted for the period 2001-2022 from the NCIS, an online national coronial database available in Australia. Joinpoint regression analysis is undertaken on gender and age for trends and changepoints. Results: There have been 7,233 heroin-related deaths in Australia between 2001 and 2022. The majority (80%) of deaths occurred among males. Rates of deaths increased significantly from 1.2 per 100,000 population in 2001 to 2.5 per 100,000 in 2019, with an annual percentage change (APC) of 4.04%.  Joinpoint analysis identified one significant changepoint in the trend in 2020, with a decrease occurring (an APC of -28.52%) at this time. Deaths among males increased significantly to 2019, with an APC of 3.3%, while deaths among females increased at a higher rate (an associated APC of 4.94%). Interestingly the decline in 2020 in deaths among males was greater (with an APC of -42%) than among females (APC of -28.9%). Deaths among Australians under 30 have been declining over the 21-year period (with an APC of -4.6%). Deaths among Australians aged 30 to 49 years increased significantly to 2019 (with an APC of 6.06%) while deaths among Australians over 50 years increased at more than twice this rate (APC of 16.9%)during the same period. Deaths among the older age groups significantly declined from 2020 onwards (30 to 49, APC -35.96%; 50 and over, APC -33%) Conclusions: Increasing attention needs to be given to older Australians using heroin, particularly in the context of other underlying (particularly cardiac) disease and, increasingly, concurrent use of methamphetamine. Greater efforts to engage women who use heroin in health and harm reduction services is also warranted given that deaths among women increased at a higher rate. While the decline in heroin deaths from 2020 may be partly due to incomplete coronial investigations, it is also likely that the COVID-19 pandemic has impacted these deaths, with disruptions recorded in Australian heroin markets early in the pandemic. This trend contrasts with North America, where opioid-related deaths have further increased since the onset of the pandemic.