Anne Denton: Cuts to drug funds mean more suffering for the dying

COMMENT

In the Western world cancer continues to increase as one of the leading causes of death. Almost one in three New Zealanders will develop it in their lifetimes and one in five will die from it.

Critical to the management of any terminal illness in its later stages is palliative care, which becomes the best option when treatment is no longer possible, because it concentrates on improving quality of life, addressing pain control and other causes of suffering.

In New Zealand, most people referred for palliative care have cancer. Typically, studies show that more than 70 per cent of cancer patients report pain, with about 36 per cent having pain severe enough to impair function, sometimes leading to care in a hospice or other institution.

Often pain can also be psychologically devastating because it is a constant reminder to patients, their families and clinicians of the incurable and progressive nature of cancer.

The World Health Organisation's expert committee on cancer pain relief and active supportive care has said that pain and symptom control should be a high priority in cancer care.

Indeed, it recommended greater allocation of resources to palliative interventions for managing cancer.

Unfortunately, in New Zealand the WHO guidelines are not being adhered to; the resources allocated to palliative care medicines are being reduced rather than increased.

This was demonstrated by the decision of the drug-funding agency Pharmac late last year to reduce the amount being spent on subsidies for drugs for terminally ill people - for example, a range of morphine sulphate drugs. Typically those receiving palliative care are also receiving morphine.

Pharmac's decision-making committee decided to reduce the funding on this group of medications by about 60 per cent, a level that the other manufacturers were unable to meet. This effectively meant that only one drug would be fully funded.

This was done without apparent consultation with practising pharmacists. Pharmacists deal with the terminally ill daily, so most are aware of how critical their medication is in treating pain.

To save $2.5 million a year (which equates to less than 0.5 per cent of the health budget), Pharmac is prepared to offer all dying patients with pain only one fully funded morphine brand. At the expense of further confusion and suffering for those who are already vulnerable, it decided that it could use the money to subsidise other drugs in the health system.

Pharmac's decision was extraordinary for several reasons. The new cheaper drug, m-Eslon, has practical limitations. It is not available in the choice of strengths previously available with the other brands. This has meant confusion for some patients and an increased number of capsules having to be taken to equal the previous regime.

Also, the drug is available only as a capsule; it cannot be used rectally as the tablet form can. This is less than ideal for patients who can no longer swallow.

In many patients it has been found that m-Eslon does not last more than eight hours. For patients who were previously pain-free on alternative slow-acting morphine medication, this is a significant reversal in their quality of life.

One overseas study concluded that 75 to 85 per cent of patients received adequate pain control with oral, rectal and transdermal (through the skin) drugs. Oral administration is still the most usual method of medicating patients in serious pain.

Morphine, with the flexibility to be administered in several ways, is preferred. Because of Pharmac's decision to dramatically lower the level of subsidy, patients are now denied that flexibility and choice.

Since every person is unique (in personality, chemistry, physiology and so on), pain management is a complex science. Some patients will not get relief from just one form of treatment. Thus, pain is accepted by clinicians as being whatever the patient who experiences it says it is.

Pharmac's decisions effectively deny patients the choice of other funded medications effective in controlling pain - for example, some medications work better on bone pain while others do better on nerve-related pain. This lack of choice puts New Zealand's approach to managing serious pain on a Third World level.

It is one of few Western countries not to have a full range of subsidised medications available for serious pain relief.

As a pharmacist whose practice includes many hospice patients, I believe New Zealand can do far better for its terminally ill people.

Preventing access to the most effective medicines just to save money is not the answer and may be merely cost shifting. We should be ensuring a choice of medications that gives the best quality of life.

To do otherwise puts more pressure on patients and families at a time when they should be able to focus on simply being together.

* Anne Denton is a consulting pharmacist and executive member of Hospice New Zealand.