The diversion and supply of pharmaceutical drugs for non-medical use

Consistent with international trends, in 2016 Australia experienced its highest number of drug-related deaths in 20 years, with most attributed to pharmaceutical opioids and benzodiazepines. A large international evidence-base exists on mechanisms, drivers and profitability of illicit drug supply, yet equivalent research examining pharmaceutical drugs is scarce. This thesis aimed to fill this gap by examining, through four empirical studies, the diversion and supply of pharmaceutical drugs for non-medical use. First, a systematic review and meta-analysis pooled results from 34 international studies to estimate the prevalence of medical and non-medical/intermediary sourcing and diversion. Most pharmaceuticals for non-medical use were sourced via friends/family (57%, 95% CI 53%-62%) and few studies examined supply beyond end-user perspectives. Addressing this gap, the role of health practitioners and suppliers in Australia was explored next. Diversion from the medical system was examined through 117 cases of health practitioner misconduct using AustLII records. Persistent over-prescribing by a small number of practitioners due to inadequate skills to manage complex patient groups was identified. The final two empirical chapters analysed data from semi-structured interviews with 51 people involved in supplying pharmaceutical drugs. Negative binomial regressions and thematic analysis explored drug sourcing and motivations. Suppliers used medical (47% legitimate, 7% illegitimate prescriptions) and intermediary sources (e.g. 18% friends/family) and were financially (65%) and/or altruistically (61%) motivated. Those using illegitimate medical sources distributed larger quantities, while altruistically motivated suppliers distributed smaller quantities (e.g. leftover supplies) to people with perceived therapeutic need. Mark-up calculations showed that for every dollar-invested, suppliers earned $3.19 (median) or $19.90 (mean). Mixed-effects regressions found mark-up was predicted by source, such that mark-up was higher for medically sourced drugs, compared with those sourced via intermediaries (median $13.49 cf. $1.23). This research holds implications for research, policy and practice. The supply chain for pharmaceutical diversion is shorter than for illicit drugs and supply mechanisms and motives are diverse, warranting multifaceted responses. For example: 1) prescription monitoring for the small number of high-volume suppliers, 2) broader education for social supply, 3) consideration of supplier motive at sentencing, 4) support for health practitioners, and 5) addressing demand factors in marginalised populations