Drug and Alcohol Problems

📋 Key Information Summary

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Adverse drug reactions (ADRs) account for ~2–4% of Australian hospital admissions; report suspected ADRs to the TGA via the Blue Card scheme (online or phone 1800 044 114).
Tobacco smoking remains the leading preventable cause of death in Australia (~20,000 deaths/year); the 5A framework (Ask, Assess, Advise, Assist, Arrange) is the evidence-based GP brief intervention model.
Nicotine replacement therapy (NRT), varenicline (Champix®) and bupropion (Zyban®) are PBS-listed first-line pharmacotherapies for smoking cessation; varenicline has the highest single-agent quit rate.
Risky drinking is defined as >4 standard drinks on any single occasion or >10 per week; use the AUDIT-C or AUDIT tool to screen all adults in primary care.
Alcohol withdrawal can be life-threatening — seizures and delirium tremens require urgent benzodiazepine management (symptom-triggered chlordiazepoxide or diazepam) with CIWA-Ar monitoring.
Thiamine (vitamin B1) must be given to all at-risk drinkers BEFORE glucose-containing fluids to prevent Wernicke's encephalopathy — 100–300 mg IV initially, then 100–300 mg PO TDS.
Methadone and buprenorphine-naloxone (Suboxone®) are PBS Authority Required for opioid dependence; buprenorphine-naloxone is preferred in primary care due to superior safety profile.
Ice (methamphetamine) is the most commonly used illicit stimulant in Australia; acute intoxication is a medical emergency — use benzodiazepines for agitation, avoid antipsychotics if possible.
Cannabis is the most widely used illicit drug in Australia; offer behavioural interventions; no PBS-listed pharmacotherapy exists.
Naloxone (Nyxoid® nasal spray) is available OTC without prescription for opioid overdose reversal — prescribe to all patients on long-term opioids and their families.
Aboriginal and Torres Strait Islander Australians experience 2–5 times the burden of substance-related harm compared with non-Indigenous Australians; culturally safe, trauma-informed care and integration with ACCHOs are essential.
Fetal alcohol spectrum disorder (FASD) is the leading preventable cause of non-genetic intellectual disability; advise zero alcohol in pregnancy.

Introduction & Australian Epidemiology

Substance use disorders — encompassing tobacco dependence, harmful alcohol use and illicit drug use — are among the most common presentations in Australian general practice. Collectively, they account for a substantial proportion of the burden of disease, healthcare expenditure and preventable mortality. General practitioners are ideally placed to screen, intervene early, manage withdrawal and coordinate long-term recovery.

The National Drug Strategy Household Survey (2022–2023) reports that approximately 11% of Australians aged 14 and over smoked daily, 25% exceeded the single-occasion risk guideline for alcohol, and 16% had used an illicit substance in the preceding 12 months. Methamphetamine, cannabis, cocaine and MDMA remain the most commonly used illicit substances. Opioid-related deaths have risen, driven by pharmaceutical opioids and increasingly illicit fentanyl.

The economic cost of alcohol, tobacco and illicit drug use in Australia is estimated at over billion annually (Collins & Lapsley, 2016 AIHW update). General practice-based screening and brief intervention (SBI) is cost-effective and has Level I evidence for reducing risky alcohol consumption and improving smoking cessation rates. This article provides a practical framework for managing substance-related problems in Australian primary care, with reference to PBS-listed therapies, Therapeutic Guidelines and current evidence.

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Key Australian statistics (AIHW, 2024):

Tobacco: ~20,000 deaths/year; responsible for ~12% of the total disease burden.
Alcohol: ~4,500 deaths/year; ~70,000 hospitalisations/year.
Illicit drugs: ~2,300 deaths/year; opioid overdose is the leading cause.
Aboriginal and Torres Strait Islander Australians are 2.2× more likely to smoke, 1.6× more likely to drink at risky levels, and 2.3× more likely to use illicit substances.

Adverse Drug Reactions

Adverse drug reactions (ADRs) are a significant cause of morbidity, hospitalisation and mortality in Australia. The Australian Commission on Safety and Quality in Health Care (ACSQHC) recognises ADRs as a major medication safety concern. GPs play a central role in identifying, reporting and managing ADRs, and in educating patients about medication safety.

Classification of ADRs

Type	Mechanism	Examples	Characteristics
Type A (Augmented)	Dose-dependent, predictable, related to known pharmacology	Bleeding with warfarin; hypoglycaemia with insulin; bradycardia with beta-blockers	~80% of ADRs; dose reduction or withdrawal usually resolves
Type B (Bizarre)	Dose-independent, unpredictable, often immune-mediated	Anaphylaxis (penicillin); Stevens-Johnson syndrome (carbamazepine); agranulocytosis (clozapine)	~10–15% of ADRs; potentially fatal; requires drug withdrawal
Type C (Chronic)	Cumulative dose-related, long-term use	Analgesic nephropathy; osteoporosis with corticosteroids; tardive dyskinesia with antipsychotics	Develops over months to years
Type D (Delayed)	Latency period after exposure	Carcinogenesis (e.g. cyclophosphamide → bladder cancer); teratogenesis	May take years to manifest
Type E (End-of-use)	Withdrawal reactions	Benzodiazepine withdrawal seizures; SSRI discontinuation syndrome; rebound hypertension (clonidine)	Occurs on drug cessation; gradual taper may prevent

Common Medication Classes and ADRs in General Practice

Drug Class	Common ADRs	Monitoring Required
ACE inhibitors	Cough (10–15%), hyperkalaemia, angioedema (rare), renal impairment	U&E, eGFR at baseline, 1–2 weeks and ongoing
Anticoagulants (warfarin, DOACs)	Bleeding, bruising; warfarin: skin necrosis, teratogenicity	INR (warfarin); renal function (DOACs)
Metformin	GI upset, B12 deficiency, lactic acidosis (rare)	eGFR, B12 levels annually
Statins	Myalgia (5–10%), hepatotoxicity (rare), new-onset diabetes	LFTs baseline, CK if symptomatic
SSRIs / SNRIs	GI upset, sexual dysfunction, SIADH (elderly), serotonin syndrome	Clinical review at 2, 4, 6 weeks; Na⁺ in elderly
NSAIDs	GI bleeding, renal impairment, cardiovascular events, fluid retention	BP, eGFR, FBC if prolonged use
Opioids	Constipation, sedation, respiratory depression, dependence, hormonal effects	Pain scores, bowel function, opioid risk assessment tools
Methotrexate	Hepatotoxicity, myelosuppression, pneumonitis, stomatitis	FBC, LFTs, eGFR every 2–4 weeks initially; CXR if cough

Drug Interactions of Particular Relevance

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Dangerous combinations encountered in substance-use settings:

Opioids + benzodiazepines: synergistic respiratory depression — highest risk of fatal overdose; use lowest effective doses if combination unavoidable.
MAOIs + SSRIs / tyramine-rich foods: serotonin syndrome / hypertensive crisis — allow 14-day washout.
Methadone + benzodiazepines + alcohol: QTc prolongation and respiratory depression — ECG monitoring recommended.
Alcohol + paracetamol: increased risk of hepatotoxicity at lower doses (enzyme induction of CYP2E1).
Warfarin + alcohol (acute binge): INR elevation and bleeding risk.

Reporting ADRs

All suspected ADRs — especially serious, unexpected or newly marketed drug reactions — should be reported to the Therapeutic Goods Administration (TGA) through:

Blue Card (online): www.tga.gov.au/reporting-problems
Phone: 1800 044 114
ADR reporting is mandatory for certain high-risk drugs (e.g. clozapine) and is a professional obligation under the Medical Board of Australia's Good Medical Practice guidelines.

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Medication reconciliation should be performed at every transition of care. Patients with substance use disorders frequently see multiple prescribers, increasing the risk of inadvertent drug interactions and duplicate prescribing.

Tobacco Use & Smoking Cessation (5A Framework)

Tobacco smoking is the single greatest preventable cause of death and disease in Australia. Despite declining prevalence (~11% daily smokers in 2022–2023), smoking remains responsible for approximately 20,000 deaths annually and accounts for ~12% of the total burden of disease. Brief intervention by GPs increases quit attempts and long-term abstinence. The RACGP and NHMRC recommend the 5A framework for every consultation.

The 5A Framework for Smoking Cessation

1

ASK

Identify and document tobacco use status at every consultation. Use the patient's own language. Ask about all forms: cigarettes, roll-your-own, shisha, e-cigarettes/vapes, heated tobacco, smokeless tobacco. Record pack-year history.

2

ASSESS

Determine readiness to quit using the Stages of Change model. Assess nicotine dependence (Fagerström Test for Nicotine Dependence — FTND ≥6 = high dependence). Identify co-morbidities, previous quit attempts, triggers, and concurrent substance use.

3

ADVISE

Provide clear, personalised, non-judgemental advice about the health benefits of quitting. Emphasise that any reduction in smoking is beneficial but complete cessation is the goal. Use motivational framing: "Stopping smoking is the single best thing you can do for your health."

4

ASSIST

Set a quit date. Offer pharmacotherapy (NRT, varenicline, bupropion). Provide behavioural support (counselling, self-help materials, digital tools like QuitCoach, My QuitBuddy app). Consider referral to Quitline (13 7848). Combine pharmacotherapy + behavioural support for best outcomes.

5

ARRANGE

Schedule follow-up within 1–2 weeks of quit date, then at 1, 3 and 6 months. Relapse is common — frame as a learning opportunity, not failure. Reassess and adjust pharmacotherapy. Repeat the 5As at every subsequent visit.

Pharmacotherapy for Smoking Cessation

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Varenicline

Champix® · Partial nicotinic acetylcholine receptor agonist

Adult dose 0.5 mg PO OD for Days 1–3 → 0.5 mg PO BD for Days 4–7 → 1 mg PO BD for Weeks 2–12 (start 1 week before quit date). May extend to 24 weeks to prevent relapse.

Paediatric dose Not recommended <18 years

Renal adjustment eGFR 30–50: max 1 mg OD; eGFR <30: 0.5 mg OD

Key side effects Nausea (most common ~30%), vivid dreams, insomnia, mood changes. Monitor for neuropsychiatric symptoms (depression, suicidal ideation — TGA alert).

PBS status ✔ PBS General Benefit (12 weeks per quit attempt, max 2 courses/12 months)

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Bupropion

Zyban® · Noradrenaline-dopamine reuptake inhibitor

Adult dose 150 mg PO OD for Days 1–6 → 150 mg PO BD from Day 7 (start 1–2 weeks before quit date). Continue for 7–12 weeks.

Renal adjustment eGFR <30: max 150 mg OD

Key side effects Insomnia, dry mouth, headache. Contraindicated in seizure disorder, eating disorders, concurrent MAOIs.

PBS status ✔ PBS General Benefit

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Nicotine Replacement Therapy (NRT)

Nicabate®, Nicorette® · Multiple formulations

Formulations Patch: 21 mg, 14 mg, 7 mg/24 h (step-down over 8–12 weeks). Gum: 2 mg or 4 mg (max 15 pieces/day). Lozenge: 2 mg or 4 mg. Oral spray: 1 mg/spray. Inhalator: 15 mg cartridge.

Combination NRT Patch (background) + gum/lozenge/spray (rescue for cravings) is superior to monotherapy. Recommend for moderate–high dependence (FTND ≥4).

Paediatric dose Patches may be considered ≥12 years under specialist guidance; gum/lozenges ≥12 years

PBS status ✔ PBS General Benefit (patches); gum/lozenges/spray OTC (not PBS-listed)

E-Cigarettes / Vaping

Since October 2021, nicotine-containing e-cigarettes/vapes require a prescription in Australia. From 2024, further legislative changes restrict importation. Evidence for efficacy as a smoking cessation aid is evolving but less robust than established pharmacotherapies. The RACGP does not currently recommend e-cigarettes as first-line therapy. Advise patients that: e-cigarettes are not risk-free; long-term safety data are limited; and dual use (vaping + smoking) is not recommended. Discuss varenicline or combination NRT as evidence-based alternatives.

Special Considerations

Pregnancy: NRT patches (removing at night) are preferred if pharmacotherapy needed; avoid varenicline and bupropion. Emphasise behavioural support via Quitline. Smoking in pregnancy increases risk of miscarriage, preterm birth, low birth weight, SIDS and childhood asthma.
Mental illness: People with severe mental illness die 15–20 years earlier; smoking cessation improves psychiatric outcomes. Do not withhold treatment. Monitor mood with varenicline. Inpatient psychiatric settings should be smoke-free with NRT provided.
Socioeconomic disadvantage: Smoking rates are 2–3× higher in lower SES groups. Proactive outreach, free NRT programmes and culturally tailored interventions improve equity.

Excessive & Harmful Drinking / Alcohol Dependence

Alcohol is the most widely used psychoactive substance in Australia and contributes to significant morbidity, mortality and social harm. The NHMRC Australian Guidelines to Reduce Health Risks from Drinking (2020) recommend that healthy adults drink no more than 10 standard drinks per week and no more than 4 standard drinks on any one occasion to reduce the risk of alcohol-related disease and injury.

Screening Tools

Tool	Items	Cut-off	Setting
AUDIT-C	3 items (frequency, quantity, binge)	≥3 (M), ≥2 (F) = positive screen	Quick screen; all adults; MBS item-compatible
AUDIT (full)	10 items	8–15: risky; 16–19: harmful; ≥20: possible dependence	Positive AUDIT-C → full AUDIT
CAGE	4 items	≥2 = positive	Quick screen; less sensitive for women
AUDIT-PC	5 items	≥4 = positive	Primary care

Spectrum of Alcohol Use

Low Risk

Within NHMRC Guidelines

≤10 standard drinks/week AND ≤4 on any occasion. Reaffirm healthy habits; monitor at routine visits.

Setting: GP counselling

Risky / Harmful

Exceeding Guidelines Without Dependence

AUDIT 8–19. Physical, psychological or social harm developing. Brief intervention (SBIRT model) is effective. GP counselling + structured follow-up.

Setting: GP + possible referral to counselling

Dependence

Alcohol Use Disorder (Moderate–Severe)

AUDIT ≥20. Tolerance, withdrawal symptoms, loss of control, continued use despite harm. May require medically assisted withdrawal (community or inpatient), long-term pharmacotherapy and psychosocial support.

Setting: GP shared care, AOD services, inpatient if severe withdrawal risk

Brief Intervention for Risky Drinking

1

Raise the Topic

Normalise screening: "As part of routine health care, I ask all patients about alcohol use." Use non-judgemental language.

2

Provide Feedback

Share AUDIT score. Link drinking patterns to health outcomes (liver disease, cancer risk, hypertension, mental health).

3

Enhance Motivation

Explore readiness to change. Use motivational interviewing techniques: open questions, affirmations, reflective listening, summaries (OARS).

4

Negotiate a Plan

Agree on a drinking goal (reduction or abstinence). Set specific, measurable limits. Offer resources (Hello Sunday Morning app, DrinkTracker).

5

Follow Up

Review at 2–4 weeks. Acknowledge successes. Adjust the plan as needed. Refer if no improvement or if dependence suspected.

Alcohol Withdrawal

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Alcohol withdrawal can be fatal. Delirium tremens (DT) occurs in 3–5% of hospitalised patients with alcohol withdrawal and has a mortality of 5–15% if untreated. Always assess withdrawal risk using the CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol — Revised) protocol. Patients with a history of withdrawal seizures, DT, heavy daily drinking (>15 standard drinks/day), or significant co-morbidity should be considered for inpatient supervised withdrawal.

Phase	Timeline	Features	Management
Minor withdrawal	6–12 h post-last drink	Tremor, anxiety, nausea, insomnia, tachycardia, hypertension	Supportive care; monitor CIWA-Ar every 1–4 h; benzodiazepines if CIWA-Ar ≥10
Withdrawal seizures	12–48 h	Generalised tonic-clonic seizures (often 1–2); status epilepticus rare	Benzodiazepines (IV diazepam or lorazepam if seizing); phenytoin NOT effective for alcohol withdrawal seizures
Alcoholic hallucinosis	12–48 h	Visual, auditory or tactile hallucinations with intact sensorium	Benzodiazepines; low-dose antipsychotic (haloperidol 2.5–5 mg IM) if distressing
Delirium tremens	48–96 h (up to 7 days)	Agitation, confusion, autonomic instability (HR >120, temp >38.5°C), hallucinations, diaphoresis	Medical emergency — ICU/HDU. High-dose benzodiazepines (diazepam 20 mg IV, repeat); consider phenobarbitone adjunct; fluid resuscitation; correct electrolytes (Mg²⁺, K⁺, PO₄³⁻)

Benzodiazepines for Alcohol Withdrawal

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Chlordiazepoxide

Librium® · Long-acting benzodiazepine

Adult dose (symptom-triggered) 25–50 mg PO every 1–2 h PRN when CIWA-Ar ≥10 (max 250 mg/24 h). Fixed-schedule: 50 mg QDS on Day 1, taper by 10–20 mg/day over 5–7 days.

Renal / hepatic adjustment Use lorazepam (no active metabolites) in severe hepatic impairment; halve dose in elderly

PBS status ✔ PBS General Benefit

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Diazepam

Ducene® · Valium® · Long-acting benzodiazepine

Adult dose 10–20 mg PO every 1–2 h PRN for CIWA-Ar ≥10 (max 120 mg/24 h). IV: 5–10 mg for acute seizures, repeat at 5 min intervals (max 30 mg).

Renal / hepatic adjustment Avoid in severe hepatic impairment; use lorazepam as alternative. Reduce dose 50% in elderly.

PBS status ✔ PBS General Benefit

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Lorazepam

Ativan® · Intermediate-acting benzodiazepine

Adult dose 1–2 mg PO/IV/IM every 1–2 h PRN for CIWA-Ar ≥10. Preferred in hepatic impairment (no active metabolites).

PBS status ✔ PBS General Benefit

Thiamine Replacement — Wernicke's Encephalopathy Prevention

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CRITICAL: Administer thiamine (vitamin B1) BEFORE any glucose-containing fluid in at-risk patients. Wernicke's encephalopathy (triad of confusion, ataxia, ophthalmoplegia — only present simultaneously in ~16% of cases) is a medical emergency. If suspected: thiamine 300 mg IV stat, then 100–300 mg IV TDS for 3–5 days, followed by 100 mg PO TDS ongoing. Pabrinex® (combined B and C vitamins IV) or parenteral thiamine (where available).

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Thiamine (Vitamin B1)

Pabrinex® IV · Various oral brands

High-risk patients All patients with harmful alcohol use, malnutrition, homelessness, or acute withdrawal

Prophylactic dose 100 mg PO TDS (or 100–300 mg IM/IV daily for 3–5 days if oral absorption unreliable)

Treatment dose (Wernicke's) 300 mg IV stat → 100–300 mg IV TDS for 3–5 days → 100 mg PO TDS ongoing

PBS status ✔ PBS General Benefit (IV and oral)

Long-term Pharmacotherapy for Alcohol Dependence

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Naltrexone

Revia® · Oral opioid antagonist

Adult dose 25 mg PO OD for Days 1–3 → 50 mg PO OD. Continue for 3–12 months. Start only after ≥7 days alcohol-free (to avoid precipitating withdrawal).

Renal / hepatic adjustment Avoid in acute hepatitis or liver failure (hepatotoxic at high doses)

Key precautions Blocks opioid analgesia; ensure patient aware before any surgery. Contraindicated with current opioid use.

PBS status ⚠ PBS Authority Required

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Acamprosate

Campral® · Glutamate modulator

Adult dose 666 mg (2 × 333 mg tablets) PO TDS with meals. Continue for 6–12 months.

Renal adjustment Contraindicated if eGFR <30 mL/min. Reduce to 666 mg BD if eGFR 30–50.

Key side effects Diarrhoea (most common), nausea, abdominal pain, headache

PBS status ⚠ PBS Authority Required

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Disulfiram

Antabuse® · Aldehyde dehydrogenase inhibitor

Adult dose 500 mg PO OD for 1–2 weeks → maintenance 250 mg PO OD (range 125–500 mg). Must be alcohol-free at initiation and highly motivated.

Key side effects Disulfiram-alcohol reaction: flushing, nausea, vomiting, tachycardia, hypotension — can be severe. Contraindicated in severe cardiac disease, pregnancy, psychosis.

PBS status ⚠ PBS Authority Required

Referral and Support Services

National Alcohol and Other Drug Hotline: 1800 250 015 (24/7)
Alcoholics Anonymous Australia: www.aa.org.au
SMART Recovery: www.smartrecovery.org.au (evidence-based mutual support)
Local AOD services: Contact your Primary Health Network (PHN) for commissioned services
MBS items for chronic disease management: GP Management Plans (MBS 721) and Team Care Arrangements (MBS 723) may be used for patients with alcohol use disorder

Illicit Drug Use & Withdrawal

Illicit drug use is a significant public health concern in Australia. Cannabis remains the most widely used illicit substance, followed by cocaine, MDMA/ecstasy, methamphetamine and opioids (including diverted pharmaceutical opioids and heroin). General practitioners are often the first point of contact and play a vital role in harm reduction, withdrawal management, referral to specialist AOD services and long-term support.

General Principles of Management

Non-judgemental approach: Stigma is a major barrier to care. Use person-first language ("person who uses drugs" not "drug addict/junkie").
Harm reduction: If the patient is not ready for abstinence, reduce harm — safe injecting advice (Needle and Syringe Programs — NSP), naloxone provision, avoid mixing substances, regular health checks.
Screening: Use the ASSIST (Alcohol, Smoking and Substance Involvement Screening Test) tool for comprehensive substance use assessment.
Comorbidity: >50% of people with substance use disorders have co-occurring mental health conditions (dual diagnosis). Screen for depression (PHQ-9), anxiety (GAD-7), PTSD and psychosis.
Confidentiality: Assure patients of confidentiality; mandatory reporting obligations vary by state/territory (e.g. child protection, driving impairment).

Cannabis

Cannabis is the most commonly used illicit drug in Australia (~11.5% of the population aged 14+ in 2022–2023). Cannabis use disorder affects ~1 in 10 users. Long-term use is associated with psychosis risk (especially with high-THC strains), cognitive impairment, respiratory disease (if smoked), and dependence.

Withdrawal: Symptoms peak at Days 2–6 and resolve over 2 weeks. Features include irritability, anxiety, insomnia, decreased appetite, restlessness, cravings, abdominal pain. Generally managed supportively (CBT, psychoeducation, sleep hygiene).
Pharmacotherapy: No PBS-listed pharmacotherapy for cannabis use disorder. Evidence supports psychological interventions (CBT, motivational enhancement therapy, contingency management). Nabiximols (Sativex®) may assist withdrawal in specialist settings (not PBS for this indication).
Medicinal cannabis: Accessible via TGA Special Access Scheme (SAS) or Authorised Prescriber pathway for specific indications (chronic pain, chemotherapy-induced nausea, epilepsy). This is distinct from illicit use but GPs should be aware of overlap.

Methamphetamine (Ice)

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Methamphetamine use has stabilised but remains a significant concern, particularly in rural and remote Australia. Crystalline methamphetamine ("ice") is more potent and has higher addiction potential than powder ("speed"). Acute intoxication, prolonged psychosis and cardiovascular emergencies are the most common presentations to ED.

Phase	Features	Management
Acute intoxication	Agitation, tachycardia, hypertension, hyperthermia, psychosis, chest pain, rhabdomyolysis	De-escalation first. Benzodiazepines (diazepam 10–20 mg PO/IV or midazolam 5–10 mg IM) for agitation. Avoid antipsychotics if possible (lower seizure threshold, worsen hyperthermia). IV fluids. Active cooling if temp >40°C. ECG (QTc monitoring). Troponin if chest pain.
Withdrawal	Dysphoria, fatigue, increased appetite, insomnia or hypersomnia, vivid dreams, psychomotor retardation, depression. Peaks Days 2–7, resolves over 2–4 weeks.	Supportive care. No specific pharmacotherapy has strong evidence. Treat symptoms: sleep hygiene; short-term low-dose benzodiazepines for anxiety (caution re: dependence); antidepressants for protracted depression. Psychological interventions: CBT, contingency management.
Protracted withdrawal	Persistent cravings, anhedonia, cognitive difficulties, mood disturbance — can last weeks to months	Ongoing counselling. Regular exercise. SSRI/SNRI for comorbid depression/anxiety. Relapse prevention strategies. Pharmacotherapy trials underway (e.g. mirtazapine, naltrexone) but no PBS indication.

Opioid Dependence

Opioid dependence — whether to heroin, diverted pharmaceutical opioids (oxycodone, codeine, morphine) or illicitly manufactured fentanyl — is a chronic relapsing condition with significant mortality risk from overdose. Opioid agonist pharmacotherapy (OAT) is the gold-standard treatment, dramatically reducing mortality (50–75%), crime and injecting-related harm.

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Buprenorphine-Naloxone

Suboxone® · Sublingual film/tablet · Partial opioid agonist + antagonist

Adult dose Initial: 2–4 mg buprenorphine SL, reassess after 1–2 h. Titrate to 8–16 mg/day SL (max 32 mg). Maintenance: daily or alternate-day supervised dosing (may transition to takeaway once stable). Long-acting injection (Sublocade®): 100–300 mg SC monthly.

Renal / hepatic adjustment No renal adjustment; use with caution in severe hepatic impairment (monitor LFTs)

Key advantages Lower overdose risk than methadone; office-based prescribing possible; ceiling effect on respiratory depression; less QTc prolongation

PBS status ⚠ PBS Authority Required (Opioid Dependence Treatment — S100 prescriber authorisation needed)

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Methadone

Methadone syrup · Full opioid agonist

Adult dose Initial: 10–30 mg PO OD (start lower in opioid-naïve). Titrate by 5–10 mg every 3–7 days. Maintenance: typically 60–120 mg/day. Daily supervised dosing initially.

Key risks QTc prolongation (ECG at baseline and dose >100 mg); respiratory depression (especially first 2 weeks); accumulation due to long half-life (15–60 h); fatal in opioid-naïve children

PBS status ⚠ PBS Authority Required (S100 prescriber authorisation needed)

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Naloxone

Nyxoid® nasal spray · Prenoxad® IM · Opioid antagonist

Indication Emergency reversal of opioid overdose

Adult dose Nyxoid®: 1.8 mg (1 spray) IN per nostril; may repeat after 2–3 min. Prenoxad®: 0.4 mg IM, may repeat every 2–3 min. Hospital IV: 40–100 mcg IV titrated every 2–3 min.

Key points Short half-life (30–90 min) — re-sedation possible; must call 000; observe for ≥4 h. Supply to all patients on OAT and their families/carers.

PBS status ✔ PBS General Benefit (Nyxoid® OTC also available without prescription since 2023)

Opioid Withdrawal

Onset	Peak	Duration	Features
Short-acting (heroin, oxycodone): 6–12 h	36–72 h	5–10 days	Piloerection ("goosebumps"), lacrimation, rhinorrhoea, yawning, mydriasis, muscle aches, N&V, diarrhoea, anxiety, insomnia, tachycardia
Long-acting (methadone): 24–36 h	Days 4–6	Up to 21 days	Similar but milder and more prolonged

Community withdrawal management: Lofexidine (Lucemyra®) is a non-opioid alpha-2 adrenergic agonist TGA-approved for opioid withdrawal symptom management (180 mcg PO QDS for up to 7 days). Clonidine (100–200 mcg PO TDS) may be used off-label as an alternative. Symptomatic relief with loperamide, ondansetron, paracetamol/ibuprofen, and short-acting benzodiazepines for anxiety (limited duration).

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Transition to OAT: Medically supervised withdrawal alone has poor long-term outcomes (80–90% relapse). Offer transition to buprenorphine-naloxone or methadone maintenance for patients with moderate–severe opioid use disorder. OAT can be initiated during withdrawal (buprenorphine at COWS ≥8; methadone at any stage).

MDMA (Ecstasy) & Cocaine

MDMA: Acute toxicity includes serotonin syndrome, hyperthermia, hyponatraemia (SIADH), rhabdomyolysis and cardiac arrhythmias. No specific antidote. Supportive care: cooling, benzodiazepines for agitation, avoid antipyretics (ineffective). Monitor Na⁺ (do not correct rapidly if hyponatraemia — risk of osmotic demyelination).
Cocaine: Acute effects include tachycardia, hypertension, chest pain, anxiety, psychosis, seizures. Chest pain requires ECG (ST changes) and troponin. Benzodiazepines are first-line. Avoid beta-blockers (risk of unopposed alpha-stimulation → worsened hypertension/vasospasm). Use phentolamine or GTN for cocaine-associated chest pain.

Needle and Syringe Programs (NSP) & Harm Reduction

NSPs are available across all Australian states/territories via pharmacies, vending machines, fixed sites and mobile outreach. They reduce bloodborne virus transmission (HIV, HCV) and serve as a gateway to treatment.
Safer injecting education: avoid sharing equipment; rotate injection sites; seek medical attention for abscesses, endocarditis signs (persistent fevers), DVT.
Bloodborne virus screening: Offer HIV, hepatitis B and hepatitis C testing to all people who inject drugs. HCV cure is now achievable with direct-acting antivirals (DAAs) — PBS-listed, 8–12 weeks oral therapy, >95% SVR.

Special Populations

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Pregnancy

Tobacco Smoking cessation is the single most important modifiable intervention in pregnancy. NRT patches (remove at night) are preferred pharmacotherapy. Varenicline and bupropion are contraindicated.

Alcohol Zero alcohol in pregnancy — NHMRC guideline. Fetal alcohol spectrum disorder (FASD) is the leading preventable cause of non-genetic intellectual disability. No safe level of consumption established.

Opioids OAT should continue in pregnancy — abrupt withdrawal risks miscarriage/preterm labour. Buprenorphine (without naloxone — Subutex®) is preferred over methadone in Australia. Neonatal abstinence syndrome (NAS) monitoring required.

Methamphetamine Associated with placental abruption, preterm birth, low birth weight, neurodevelopmental harm. No pharmacotherapy — behavioural interventions, close obstetric liaison.

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Paediatrics & Adolescents

Screening Use HEADSS assessment (Home, Education, Activities, Drugs, Sexuality, Suicide/depression) in adolescent consultations. CRAFFT tool (≥2 = positive) for substance use screening in <21 years.

E-cigarettes / vaping Rapidly increasing use among Australian adolescents (14–17 years). Educate on nicotine addiction risk, lung injury (EVALI). Quitline offers youth-specific support.

Cannabis Heavy adolescent use is associated with cognitive decline, psychosis risk and educational disengagement. Family-based interventions have strongest evidence base in this age group.

Pharmacotherapy NRT (≥12 years) may be considered for nicotine dependence. OAT in adolescents requires specialist paediatric/adolescent AOD service. Avoid bupropion (<18 years — increased suicidality signal). Varenicline — no data in <18 years.

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Older Adults (≥65 years)

Alcohol Lower threshold for harm due to reduced lean body mass, hepatic metabolism and polypharmacy. NHMRC recommends ≤10 standard drinks/week and ≤4 on any occasion, with an additional note that people aged ≥70 should drink even less. AUDIT-C cut-off: ≥2 (M and F). Alcohol-related falls, cognitive decline and medication interactions are major risks.

Benzodiazepines Avoid long-term benzodiazepine prescribing. Associated with falls, fractures, cognitive impairment and delirium. Taper slowly (10–25% every 2–4 weeks) if dependent.

Tobacco Never too late to quit. Cessation reduces cardiovascular risk within weeks. Consider NRT dose adjustments for slower metabolism.

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Renal Impairment

Acamprosate Contraindicated if eGFR <30 mL/min; reduce dose if eGFR 30–50.

Varenicline Dose reduction required: eGFR 30–50 → max 1 mg OD; eGFR <30 → 0.5 mg OD.

Methadone No specific renal dose adjustment but metabolites accumulate; use with caution and monitor closely.

Paracetamol (acute OD in CKD) Standard treatment algorithm applies but consider nephrotoxicity; ensure N-acetylcysteine is administered per protocol.

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Hepatic Impairment

Benzodiazepines Avoid long-acting benzodiazepines (diazepam, chlordiazepoxide) in cirrhosis. Use lorazepam or oxazepam (no active metabolites, Phase II conjugation only).

Naltrexone Hepatotoxic at high doses; use with caution in compensated cirrhosis; avoid in acute hepatitis/decompensated liver disease. Monitor LFTs.

Methadone Metabolised hepatically; dose reduction may be needed in severe liver disease.

Alcohol-related liver disease Screen all harmful drinkers with FIB-4 or ELF test; refer to hepatology if cirrhosis suspected. Absolute alcohol abstinence is essential.

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Immunocompromised

People who inject drugs (PWID) At high risk of HIV, hepatitis B/C, infective endocarditis, septic emboli, skin and soft tissue infections. Offer BBV screening (at minimum annually); vaccinate HBV if non-immune (PBS-listed). HCV treatment with DAAs is curative and PBS-listed.

People living with HIV on ART Significant drug interactions with OAT: methadone levels reduced by certain antiretrovirals (efavirenz, nevirapine); buprenorphine levels may be affected by ritonavir/cobicistat. Consult HIV pharmacist or Liverpool HIV Interactions database.

Immunosuppression + alcohol Alcohol impairs immune function, increasing infection risk. Combined with immunosuppressive medications, this significantly increases susceptibility to opportunistic infections.

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Health Considerations

Substance use disorders disproportionately affect Aboriginal and Torres Strait Islander Australians, contributing significantly to the health gap between Indigenous and non-Indigenous Australians. Culturally safe, trauma-informed and strengths-based approaches are essential. The National Aboriginal Community Controlled Health Organisation (NACCHO) and the Royal Australian College of General Practitioners (RACGP) emphasise that substance use must be understood within the broader context of intergenerational trauma, colonisation, dispossession, systemic racism and social determinants of health.

Key Statistics

Aboriginal and Torres Strait Islander Australians are 2.2× more likely to smoke daily than non-Indigenous Australians (~37% vs ~15% in some remote communities).
Alcohol-related hospitalisation rates are 4–5× higher for Indigenous Australians.
Cannabis use is approximately 2× more prevalent among Indigenous Australians, with particularly high rates in remote communities.
Volatile substance misuse (petrol sniffing, chroming) remains a concern in some remote communities, though prevalence has decreased with low-aromatic fuel and opal fuel programmes.
Fetal alcohol spectrum disorder (FASD) prevalence is significantly higher in some Indigenous communities, though data are limited by under-diagnosis.

Barriers to Care

Stigma and shame

Fear of judgement, child removal, involvement of child protection and justice systems deter help-seeking. Provide confidential, non-judgemental care. Use yarning-based consultations.

Remote and rural access

Limited AOD services, specialist prescribers, and pharmacotherapy supply in remote areas. Telehealth OAT consultations (under state/territory opioid treatment legislation) have expanded access. Patient Assisted Travel Schemes (PATS) available in most jurisdictions.

Cultural safety

Mainstream services may not be culturally appropriate. Aboriginal Community Controlled Health Organisations (ACCHOs) provide holistic, culturally safe care. Engage Aboriginal Health Workers/Practitioners (AHW/Ps) in care planning and delivery.

Intergenerational trauma

The legacy of the Stolen Generations, forced removals and institutionalisation. Substance use often co-occurs with complex trauma and grief. Trauma-informed care models (e.g. We Al-Li, AIMhi Stay Strong) should be used.

Polypharmacy and compliance

Mobility between communities, transient living situations and limited pharmacy access affect medication continuity. Use Long-Acting Injectable Naltrexone (Vivitrol®) or buprenorphine depot (Sublocade®) where appropriate to reduce daily dosing burden.

Best Practice Approaches

Engage ACCHOs: Partner with local Aboriginal Community Controlled Health Organisations for shared care, health promotion and culturally grounded treatment programmes.
Aboriginal Health Workers/Practitioners: Include AHWs/AHPs in the multidisciplinary team. They provide culturally safe health education, advocacy and linkages to community services.
Social and Emotional Wellbeing (SEW) framework: Use the holistic SEW model (encompassing connection to body, mind, family, community, culture, Country and spirituality) rather than a purely biomedical model of addiction.
Harm reduction in communities: Opal fuel programmes (replacing regular petrol with low-aromatic fuel) have dramatically reduced petrol sniffing. NSPs and peer-based harm reduction programmes are effective. Support community-led alcohol management plans where communities request them.
Smoking cessation: The Tackling Indigenous Smoking (TIS) programme funds regional teams to deliver culturally tailored quit support. Avoid the "deficit" framing — emphasise that many Indigenous Australians are non-smokers and celebrate smoke-free role models.
Children and families: Early childhood development programmes (e.g. Connected Beginnings, Australian Nurse-Family Partnership Programme) target substance use in the perinatal period. Use non-punitive, family-centred approaches to child safety.

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Strengths-based approach: Aboriginal and Torres Strait Islander peoples have deep cultural strengths, resilience and connection to Country. Effective treatment programmes build on these strengths — incorporating culture, ceremony, Elders, art, sport and Country-based healing programmes alongside clinical care.

📚 References

1. National Health and Medical Research Council (NHMRC). Australian Guidelines to Reduce Health Risks from Drinking. Canberra: NHMRC; 2020.
2. Australian Institute of Health and Welfare (AIHW). National Drug Strategy Household Survey 2022–2023. Drug Statistics Series no. 41. Canberra: AIHW; 2024.
3. Australian Institute of Health and Welfare (AIHW). Alcohol, tobacco & other drugs in Australia. AIHW Cat. no. PHE 292. Canberra: AIHW; 2024.
4. The Royal Australian College of General Practitioners (RACGP). Smoking cessation — Supporting smoking cessation: A guide for health professionals. 2nd edn. Melbourne: RACGP; 2024.
5. Haber PS, Riordan BC, Winter DT, et al. New Australian guidelines for the treatment of alcohol problems: an overview of recommendations. Med J Aust. 2021;215(S7):S3–S32.
6. Commonwealth Department of Health. National Opioid Pharmacotherapy Statistics Annual Data (NOPSAD) Report. Canberra: Australian Government; 2024.
7. Dowell D, Ragan KR, Jones CM, et al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep. 2022;71(No. RR-3):1–95.
8. National Aboriginal Community Controlled Health Organisation (NACCHO). National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait Islander People. 3rd edn. Melbourne: RACGP/NACCHO; 2018.
9. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
10. Drugs of Dependence Act 1985 (ACT); Drugs, Poisons and Controlled Substances Act 1981 (Vic); Misuse of Drugs Act 1981 (WA); Controlled Substances Act 1984 (SA); Drugs Misuse Act 1986 (Qld); Misuse of Drugs Act 2001 (NT); Poisons and Therapeutic Goods Act 1966 (NSW); relevant state/territory opioid treatment programme legislation.
11. Therapeutic Goods Administration (TGA). Reporting medicine and vaccine adverse events. Australian Government Department of Health and Aged Care; 2024. Available at: www.tga.gov.au.
12. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. 2nd edn. Sydney: ACSQHC; 2021.
13. Shakeshaft A, Clifford A, Shakeshaft M, et al. Alcohol and other drug treatment services in the Aboriginal and Torres Strait Islander context. Aust N Z J Public Health. 2019;43(1):10–13.
14. Farrell M, Martin NK, Stockings E, et al. Responding to global stimulant use: challenges and opportunities. Lancet. 2019;394(10209):1652–1667.
15. Degenhardt L, Charlson F, Stanaway J, et al. Estimating the burden of disease attributable to injecting drug use as a risk factor for HIV, hepatitis C, and hepatitis B: findings from the Global Burden of Disease Study 2013. Lancet Infect Dis. 2016;16(12):1385–1398.