10 JUNE 2021

On 1 June 2021 a number of changes to the listings of opioid medications under the Palliative Care Schedule (PCS) of the Pharmaceutical Benefits scheme came into effect.

These changes will make it easier for patients undergoing palliative care to receive appropriate access to opioid medications. The changes include removal of:

• the criteria restricting use of opioid medications for palliative care patients undergoing cancer treatments; and
• the requirement for an annual review of opioid use.

The changes also allow greater quantities of opioid medications for immediate release preparations to be supplied where clinically indicated.

These changes are very welcome and follow advocacy from Painaustralia, along with a number of health and medical groups, concerned about potential unintended consequences flowing from restrictions on more general opioid prescribing and access.  The restrictions were introduced as part of international efforts to stem the rising global rates of prescription opioid related harms and overdose.

Readers may recall at that time that GPs were sent letters from Medicare warning them about their levels of opioid prescribing. These, together with restrictions on prescribing, had the effect of GPs reducing their level of opioid prescribing, including to palliative care patients whose pain was not responsive to other treatments.

While the reduction in the general level of opioid prescribing worked as the government intended, the impact on patients including the palliative care cohort of patients who lost access to the medications they desperately needed to address their ongoing pain was not.

This is a good example of the complexities of the health system and that a one size fits all approach may have widely varying impacts on different cohorts of patients. In this case, the harm reduction achieved through reduced use of opioids came into conflict with the rights enshrined in the Montreal Declaration for all people to have access to appropriate pain management.

Hopefully, the above changes to the PBS prescribing rules will bring what can be seen as conflicting objectives into much closer alignment.

As the opioid policy demonstrates, interventions in one area can have unintended consequences on other critical policies and practices.

Another example of wider policy consequences relates to assisted dying.  At the current time Australian jurisdictions are one after the other progressively introducing legislation that will legalise voluntary assisted dying. Public support for such schemes is very strong according to opinion polls. Despite public sentiment, voluntary assisted dying is still a very controversial area of public policy – especially within parts of the medical profession, including the palliative care community.

I won’t in today’s blog revisit all of the moral, ethical and medical arguments in relation to the introduction of voluntary assisted dying – they have been well canvassed elsewhere.

However, I did want to talk about one of the arguments that is commonly made in support of assisted dying, which is that for some patients it is the only way they are able to relieve pain that is otherwise unbearable. In the absence of alternatives, we know that some people already take matters into their own hands – sometimes with (unlawful) assistance from family, friends or a health professional.

We know that palliative care can provide relief from most pain, but there are a small cohort of patients for whom palliative care is unable to provide effective pain relief.

Additionally, there are patients for whom palliative care can help but who are unable to access the care they need. These barriers can include lack of service provision due to geographic distance, lack of trained workforce, as well as financial constraints.

And, to return to opioid policy, the regulatory barriers such as constraints on opioid prescribing can also act as a barrier to effective palliative care. Those who are enduring great pain and aren’t able to access pain relief, such as can be provided with appropriate opioid medication, will inevitably seek out ways of making their end of life more bearable. Hopefully, the changes that have just come into effect will make it easier for some patients to gain the effective pain relief they seek through timely palliative care and reduce the need to look for alternatives. 

Painaustralia is working every day to increase access to effective treatment and support for those experiencing chronic pain.  Reducing the availability of opioid related harm can certainly deliver some benefits to the Australian community, but these broader policy changes should never serve to reduce access to appropriate pain medication. The unintended consequences of not allowing people in pain to have access to the most appropriate medications can often flow well beyond the health system itself. 

The initial overlooking of people with pain in government changes to opioid prescribing provide a good case study in the importance of considering the real impact of health policy changes, especially for people with chronic conditions who already struggle to access best practice treatment.

Carol Bennett, Painaustralia CEO