Supporting patients through opioid analgesic discontinuations

A further 7 opioid analgesics will be removed from the Australian market this year, following Mundipharma’s announcement based on the ‘complexity of continuing to provide these products’. With patients at risk of crippling pain,  what alternatives will be available?

Mr B C, a 73-year-old man, lives with chronic pain after several work-related spinal injuries, along with peripheral vascular disease and rheumatoid arthritis.

After some trial and error, Mr B C managed to find a medicine regimen that allows him to go about his activities of daily living (ADLs), including:

• etanercept, administered weekly
• oxycodone (OxyNorm) 10 mg, taken four times daily
• doxepin (Deptran)  25 mg, taken at night 
• guselkumab injection every 8 weeks
• regular paracetamol
• Non-steroidal anti-inflammatory (Naproxen SR), taken on occasion.
  

Upon hearing about the impending discontinuation of OxyNorm, Mr B C expressed concern –  having previously experienced withdrawal effects when altering his drug regimen.

Without OxyNorm, he also struggles to perform his ADLs, participate in social activities, such as target shooting at the local gun club, and drive to access services.

While he has a good relationship with his pain specialist, he’s worried other doctors may label him as a drug seeker if he needs to see someone else.

Mr B C is just one of thousands of Australians in palliative care or living with chronic pain whose medicine options will be limited this year. More than 12 opioid medicines were discontinued in 2023, including Ordine (morphine liquid) and Jurnista (hydromorphone hydrochloride) – with an estimated 270,000 scripts of the discontinued drugs filled each year, and further discontinuations on the way.

‘Not good enough’ for patients

With pharmaceutical companies applying for listing through both the Therapeutic Goods Administration (TGA) and the Pharmaceutical Benefits Scheme (PBS), the decision to supply medicines into the Australian market is a commercial one, said palliative care expert and PSA SA/NT State Manager Helen Stone MPS.

‘Lack of a proactive formulary specifying the medicines we need in Australia has left us scrambling on behalf of our patients,’ she said.

Often, there are no direct substitutes. ‘One pharmacist I spoke with has a patient who takes Ordine (morphine liquid) on a strength that won’t be available through section 19A,’ said Ms Stone.

The patient, who has been on the same dose long-term, will now need to adjust to a new dose and formulation.

‘The new, stronger [medicine] that’s available through section 19A is dispensed by drops, not mL,’ she said.

In a further complication, the medicine label is in Swedish. ‘The TGA has requested that the medicine is supplied with a letter addressed to health professionals and the package information in a ziplock bag,’ said Ms Stone.

In these situations, pharmacists need to be extra vigilant during the dispensing process.

‘There’s big implications if we get it wrong,’ she said. ‘The patient is either going to be in pain, or it could go the other way and they could overdose.’

When will stock run out?

Pharmacists should conduct an audit on their dispensing system to determine if anyone in their current patient groups is prescribed opioid strengths and formulations that are due to be discontinued, said Ms Stone.

These include:

• MS Mono (morphine sulfate pentahydrate) capsules 30 mg, September 2024
• MS Mono (morphine sulfate pentahydrate) capsules 60 mg, October 2024
• MS Mono (morphine sulfate pentahydrate) capsules 90 mg, August 2024
• MS Mono (morphine sulfate pentahydrate) capsules 120 mg, September 2024
• Sevredol (morphine sulfate pentahydrate) tablets 10mg, July 2024
• Sevredol (morphine sulfate pentahydrate)tablets 20mg, April 2024
• OxyNorm (oxycodone hydrochloride) gen capsules 5 mg, March 2025
• OxyNorm (oxycodone hydrochloride) capsules 10 mg, June 2024
• OxyNorm (oxycodone hydrochloride) capsules 20 mg, March 2025.

‘If you haven’t got any stock and you know they’re due for a repeat soon, initiate a conversation with the patient and their prescriber to put a plan in place to change them to something else.’

Pharmacists could also do a stocktake of opioid products set to be discontinued.

‘If you don’t have patients who use these medicines, reach out to colleagues at other pharmacies to let them know that you’ve got supplies so the available stock can be used by patients who need it.’

Searching for alternatives

Pharmacists should engage in some ‘detective work’ to see what alternative opioids might be available, suggested Ms Stone.

The TGA recently provided updated information about the discontinuation of opioid formulations to keep healthcare professionals and patients in the loop about alternative supply options for MS Mono capsules, Sevredol tablets, and OxyNorm capsules.

For Ordine alternatives, information on the PBS listing of the substitute overseas-registered oral liquid morphine products has also been updated.

But ensure both patient and prescriber know it won’t be a ‘straight switch’ from one opioid to another, said Ms Stone.

If they’re using a liquid rather than a capsule, or the dosing frequency changes and they have to adjust their schedule, it will take a bit of patience and open communication to help them through.’

Strategies for switching opioids

Discussing opioid management options is best practice when patients living with chronic pain have been on opioids long term, said Nicolette Ellis MPS, President of Chronic Pain Australia.

‘A good strategy could be opioid rotation. For example, rotating from morphine to buprenorphine,’ she said.

‘Rotating opioids can be effective as we know opioids inevitably cause tolerance, and patients generally report improved pain management.’

Importantly, the total oral morphine equivalent of the original dose should be reduced by 30–50% to avoid opioid toxicity during the process, Ms Ellis recommends.

‘Regular contact with the patient when undergoing changes to opioids is also crucial to make sure the patient has someone to guide them if changes are not tolerated,’ said Ms Ellis. ‘These conversations could also warrant a more in-depth review via a MedsCheck or Home Medicines Review.’

Take-home naloxone (THN) should also be recommended to patients when switching opioids.

‘But no opioid dose is safe, and this is a great opportunity to discuss THN and other harm-minimisation strategies,’ she said.

People living with chronic pain are at a higher risk of suicidal ideation, as identified by the 2023 National Pain Survey, which found 50% of people living with pain have thought of suicide. 

‘We know changes to opioid therapy, particularly if not agreed to by the patient, can worsen mental health and/or a cause of suicidal ideation,’ said Ms Ellis.  

Pharmacists should check in with patients for signs of suicidal ideation, and refer them to  peer-to-peer Pain Link. 

‘This service allows people living with chronic pain to receive support from others who live with chronic pain,’ she added.

Tips for safe substitutions

Changing opioids and titrating doses might not be something pharmacists typically encounter, but need to ‘get right’, said Ms Stone.  

Some handy references to ensure substitutions take place safely include:

• Opioid conversion chapter in section 6 in the Australian Pharmaceutical Formulary and Handbook
• The Australian & New Zealand College of Anaesthetists Faculty of Pain Medicine’s Opioid Calculator.