Opioid Use in Palliative Care

Last updated 1 Jun 2026 · Palliative care

📋 Key Information Summary

📋

Opioids are the mainstay for moderate-to-severe pain and refractory breathlessness in palliative care, but require individualised selection, careful titration, and proactive adverse-effect management.
Morphine remains the first-line strong opioid for most palliative patients in Australia; use immediate-release formulations for initial titration, then convert to modified-release once stable.
Renal impairment mandates opioid choice changes — avoid morphine (active metabolites accumulate); prefer hydromorphone, fentanyl, or methadone with dose reduction.
Breakthrough (rescue) doses should be 10–20% of the total 24-hour opioid dose, given at the same frequency as the background preparation (e.g., 4-hourly for morphine IR).
Opioid switching (rotation) is indicated for intolerable adverse effects, inadequate analgesia despite dose titration, or route change needs — always reduce the calculated equianalgesic dose by 25–50% to account for incomplete cross-tolerance.
Common adverse effects — constipation (treat prophylactically with aperients in ALL patients), nausea, sedation, and delirium — should be anticipated and managed rather than tolerated.
Respiratory depression is rare at standard palliative doses titrated to effect; fear of respiratory depression should not prevent adequate opioid use at end of life.
Subcutaneous (SC) and sublingual routes are preferred when oral intake is compromised; continuous SC infusions via syringe driver (e.g., CADD-MS 3 or Graseby) are standard in Australian palliative care.
Equianalgesic conversion tables are guides only — clinical judgement and dose reduction of 25–50% on switching are essential to prevent overdose.
Opioid-induced constipation does not develop tolerance — laxatives (macrogols ± stimulant) must be co-prescribed from initiation.
Codeine and tramadol are not recommended as sole agents for moderate-to-severe pain in palliative care due to ceiling effects, variable metabolism (CYP2D6), and lower efficacy.
Fentanyl transdermal patches are unsuitable for rapid dose titration and should only be used once opioid requirements are stable; patches are NOT equivalent to IV/SC fentanyl per microgram.
Aboriginal and Torres Strait Islander patients in remote areas face barriers to opioid access, health literacy, and culturally safe communication — engage Indigenous health workers early.

Introduction & Australian Epidemiology

Opioid prescribing is a cornerstone of symptom management in palliative and end-of-life care. In Australia, approximately 160,000 people die each year, with the majority experiencing pain or breathlessness in the final months of life. Effective opioid use can transform quality of life when prescribed knowledgeably, titrated carefully, and monitored proactively. Concerns about opioid-related harm — including dependence, respiratory depression, and regulatory scrutiny — must be balanced against the very real suffering caused by under-treatment of symptoms in advanced illness.

Palliative care in Australia is delivered across diverse settings — specialist inpatient units, hospital consultation teams, community palliative care services, residential aged-care facilities, and general practice. Access varies significantly by geography: metropolitan patients may access multidisciplinary specialist palliative care, while those in rural and remote areas frequently rely on generalists with limited specialist support. The Australian Institute of Health and Welfare (AIHW) reports that only about 50% of people who could benefit from palliative care actually receive it, with significant gaps for Aboriginal and Torres Strait Islander communities, culturally and linguistically diverse populations, and those in regional Australia.

This topic provides an evidence-based, Australian-contextualised framework for safe opioid prescribing in advanced illness, covering opioid selection, breakthrough dosing, opioid switching, and adverse-effect management.

Choice of Opioid

The World Health Organization (WHO) analgesic ladder and the Palliative Care Expert Group of Therapeutic Guidelines (eTG) recommend opioids titrated to effect as the mainstay for moderate-to-severe pain in advanced disease. Opioid selection depends on pain severity, renal and hepatic function, patient preference, route availability, prior opioid exposure, and cost/access considerations.

WHO Step 3 Opioids — Strong Opioids for Palliative Care

💊

Morphine

MS Contin® · Kapanol® · Sevredol® · Ordine® · μ-opioid agonist

Role First-line strong opioid for most palliative patients

Adult dose (opioid-naïve) IR morphine (Ordine®) 2.5–5 mg PO every 4 hours; titrate every 24–48 hours. Convert to MR (MS Contin®) once stable.

SC infusion (syringe driver) 50% of the 24-hour oral dose as SC over 24 hours (morphine IV/SC ≈ oral ratio 1:2–3)

Renal adjustment Avoid or reduce dose significantly in eGFR <30 mL/min — active metabolites (M6G, M3G) accumulate. Consider hydromorphone or fentanyl instead.

Hepatic adjustment Reduce dose 25–50% in severe hepatic impairment; monitor closely.

PBS status ✔ PBS General Benefit — morphine IR and MR formulations

💊

Oxycodone

OxyNorm® · Endone® · OxyContin® · μ-opioid agonist

Role Alternative first-line; useful when morphine not tolerated

Adult dose (opioid-naïve) IR oxycodone 2.5–5 mg PO every 4–6 hours; titrate. Convert to MR (OxyContin® 5–10 mg BD) once stable.

Potency Approximately 1.5× morphine by mouth (i.e., 10 mg oral morphine ≈ 5–7 mg oral oxycodone)

Renal adjustment Reduce dose in eGFR <30; active metabolite (noroxycodone) may accumulate. Not as problematic as morphine.

Hepatic adjustment Reduce dose 50% in severe hepatic impairment.

PBS status ✔ PBS General Benefit

💊

Hydromorphone

Jurnista® · Dilaudid® · μ-opioid agonist

Role Second-line; preferred in moderate-to-severe renal impairment

Adult dose (opioid-naïve) IR hydromorphone 0.5–1 mg PO every 4 hours; titrate. MR (Jurnista®) once stable.

Potency Approximately 5× morphine PO (i.e., 5 mg oral morphine ≈ 1 mg oral hydromorphone); SC ratio 1:1 to oral (dose-sparing volume).

Renal adjustment Safer than morphine in renal impairment — metabolite (H3G) less active. Still reduce starting dose; extend interval.

PBS status ✔ PBS General Benefit

💊

Fentanyl

Durogesic® (patch) · Actiq® / Abstral® (buccal) · Sublimaze® (IV) · μ-opioid agonist

Role Preferred in severe renal impairment; transdermal for stable requirements; IV/SC for syringe driver.

Transdermal patch 12 mcg/hr patch = approximately 30 mg oral morphine/24 hr equivalence (guide only). Apply to non-irradiated, non-oedematous skin; change every 72 hours.

SC infusion Dose is not interchangeable with patch doses — fentanyl 100 mcg SC ≈ morphine 10 mg SC (approximate). Titrate carefully.

Renal adjustment Preferred opioid in significant renal impairment (no active metabolites). Use with caution; still titrate slowly.

PBS status 🔶 PBS Authority Required — patches and buccal formulations

💊

Methadone

Physeptone® · μ-agonist + NMDA antagonist + serotonin/noradrenaline reuptake inhibitor

Role Complex multi-mechanism opioid for refractory pain (neuropathic, opioid-resistant). Requires specialist initiation due to variable half-life and complex pharmacology.

Adult dose Start 2.5–5 mg PO/SC BD–TDS; titrate cautiously every 5–7 days. Equianalgesic ratios are highly variable and dose-dependent.

Key warning Variable elimination half-life (15–60+ hours); risk of delayed accumulation and respiratory depression. Do NOT use standard equianalgesic conversion tables — requires specialist guidance.

Renal adjustment Use with extreme caution; metabolites accumulate. Reduce dose and extend interval.

PBS status ✔ PBS General Benefit (dispensed under state/territory opioid regulations)

💊

Buprenorphine

Norspan® (patch) · partial μ-agonist / κ-antagonist

Role Transdermal option for mild-to-moderate pain; ceiling effect limits use in severe pain.

Adult dose Norspan® 5 mcg/hr patch, change weekly; can titrate to 10–20 mcg/hr. Not for rapid titration.

Renal adjustment Safe in renal impairment — no significant active metabolite accumulation.

PBS status 🔶 PBS Authority Required

⚠️

Codeine and tramadol are NOT recommended as sole agents for moderate-to-severe palliative pain. Codeine has a ceiling dose (60 mg), highly variable CYP2D6 metabolism (poor metabolisers get no effect; ultra-rapid metabolisers risk toxicity), and prodrug delay. Tramadol lowers seizure threshold, has unpredictable metabolism, and has serotonergic interactions. Use morphine, oxycodone, hydromorphone, or fentanyl as first-line strong opioids instead.

Principles of Opioid Choice in Palliative Care

Start with morphine unless contraindicated (e.g., renal impairment, documented allergy, intolerance).
Use the lowest effective dose titrated to achieve acceptable pain relief with tolerable side effects.
Regular dosing (not PRN alone) for continuous pain — use modified-release formulations once stable.
Always prescribe a breakthrough (rescue) dose alongside regular opioid (see Breakthrough Dosing section).
Renal impairment — avoid morphine; prefer fentanyl or hydromorphone.
Hepatic impairment — reduce all opioid doses; avoid codeine entirely (reduced activation).
Route of administration — oral preferred; subcutaneous via syringe driver when oral not possible; avoid intramuscular in palliative care.

Breakthrough Dosing

Breakthrough (rescue) analgesia is an essential component of every opioid prescription in palliative care. Patients on regular background opioids will experience incident pain, end-of-dose failure, or unpredictable pain flares. A well-calculated breakthrough dose prevents both under-treatment and the cycle of pain-anxiety-pain.

Calculating the Breakthrough Dose

The standard recommendation is:

✅

Breakthrough dose = 10–20% of the total 24-hour regular opioid dose, given at the same frequency interval as the regular preparation. For morphine IR, this means every 4 hours PRN (up to 6 doses in 24 hours).

24-Hour Regular Dose	Breakthrough Dose (10–20%)	Frequency
Morphine 20 mg PO/24 hr	2.5–5 mg PO morphine IR	Every 4 hours PRN
Morphine 60 mg PO/24 hr	5–10 mg PO morphine IR	Every 4 hours PRN
Morphine 120 mg PO/24 hr	10–20 mg PO morphine IR	Every 4 hours PRN
Oxycodone 20 mg PO/24 hr	2.5–5 mg PO oxycodone IR	Every 4 hours PRN
Fentanyl patch 25 mcg/hr	Oral morphine IR 5–10 mg (or buccal fentanyl 100–200 mcg)	Every 4 hours PRN (morphine); every 4 hr (buccal)

When to Reassess the Background Dose

⚠️

If the patient requires ≥3 breakthrough doses in 24 hours, increase the regular (background) opioid dose and recalculate the breakthrough dose. Document this in the patient's medication chart and communicate changes to all team members including community pharmacy and after-hours services.

Subcutaneous Breakthrough Dosing

When the patient cannot swallow and is on a continuous SC opioid infusion (syringe driver), breakthrough doses are given as SC bolus injections:

Morphine SC bolus = 50% of the hourly SC infusion rate, given as stat dose every 1–2 hours PRN (equivalent to one-sixth of 24-hour SC dose).
Fentanyl SC bolus = 50–100% of the hourly SC infusion rate, given as stat dose every 15–30 minutes PRN (shorter onset and duration).
Hydromorphone SC bolus = dose calculation per equianalgesic ratios; consult specialist palliative care pharmacist or team.

Special Situation: Procedural Pain

For anticipated procedural pain (e.g., wound dressing changes, physiotherapy), pre-medicate with a breakthrough dose 30–60 minutes (oral) or 10–15 minutes (SC) before the procedure. For complex procedures, consider midazolam 2.5–5 mg SC co-administered for anxiolysis.

Switching Opioids (Opioid Rotation)

Opioid switching (also called opioid rotation) involves changing from one opioid to another, or from one route to another, due to adverse effects, inadequate analgesia, changing clinical circumstances (e.g., dysphagia), or practical considerations (e.g., syringe driver compatibility). This is a common and often highly effective strategy in palliative care — up to 50% of patients who switch opioids experience improved analgesia or reduced side effects.

Indications for Opioid Switching

Intolerable adverse effects (nausea, sedation, hallucinations, myoclonus) despite adequate dose titration
Uncontrolled pain despite dose escalation to unacceptable levels
Route change required (e.g., oral to subcutaneous due to dysphagia or vomiting)
Renal or hepatic function deterioration necessitating a safer agent
Practical issues — drug availability, syringe driver compatibility, cost
Patient preference or request

Key Conversion Principles

🚨

CRITICAL SAFETY RULE: When switching opioids, reduce the calculated equianalgesic dose by 25–50% to account for incomplete cross-tolerance. Failure to reduce dose risks overdose. When switching to methadone, standard equianalgesic tables do NOT apply — specialist guidance is essential.

Approximate Equianalgesic Doses (Oral, Single-Dose Data — Guides Only)

Opioid	Approximate Equianalgesic Oral Dose	Approximate Parenteral Dose	Oral:Parenteral Ratio
Morphine	30 mg PO	10 mg SC/IV	3:1
Oxycodone	20 mg PO	10 mg SC (limited data)	2:1
Hydromorphone	6 mg PO	1.5 mg SC	4:1 (note: some references 5:1 oral)
Fentanyl	N/A (transdermal / buccal / IV only)	100 mcg SC ≈ morphine 10 mg SC	—
Codeine	200 mg PO (not recommended in palliative)	—	—
Tramadol	150 mg PO (not recommended in palliative)	—	—

Step-by-Step Opioid Switch Process

Calculate total 24-hour dose of current opioid

Add regular dose + breakthrough doses used in the last 24 hours to determine the total daily requirement.

Convert to equianalgesic dose of the new opioid

Use equianalgesic tables (above) to calculate the equivalent 24-hour dose of the new opioid.

Reduce dose by 25–50%

Account for incomplete cross-tolerance. Use 25% reduction for similar potency switches (e.g., morphine → oxycodone); use 50% reduction when switching to a more lipophilic agent or with clinical concern.

Initiate the new opioid with breakthrough available

Start the new regular dose and provide breakthrough doses (10–20% of new 24-hour dose). Stagger the switch — stop the old opioid and start the new opioid within 2–4 hours for short-acting agents.

Monitor and titrate

Reassess pain and adverse effects within 24–48 hours. Titrate the new opioid as needed. Document the switch clearly in the medication chart, discharge summary, and handover.

Common Switch Scenarios

Scenario	Suggested Switch	Notes
Morphine + renal impairment (eGFR <30)	→ Fentanyl (SC or patch) or hydromorphone	Fentanyl preferred; no active metabolites. Hydromorphone safer than morphine but still has some metabolite accumulation.
Morphine + intolerable nausea/hallucinations	→ Oxycodone or hydromorphone	Different opioid often resolves neuropsychiatric effects. Reduce dose by 25–50%.
Oral morphine + dysphagia/vomiting	→ SC morphine or SC fentanyl (syringe driver)	SC morphine dose = ~50% of 24-hr oral dose. Also consider sublingual fentanyl if mouth intact.
Patch needs (stable dose only)	→ Fentanyl transdermal patch (Durogesic®)	Only for stable requirements; NOT for titration. Must have oral/SC breakthrough available. Patches NOT interchangeable dose-for-dose with IV fentanyl.
Neuropathic pain unresponsive to morphine	→ Methadone (specialist supervision) or trial hydromorphone	Methadone has NMDA antagonism — helpful for opioid-resistant neuropathic pain. Complex initiation.

🚨

Fentanyl patches (Durogesic®) are NOT interchangeable with IV/SC fentanyl in dose calculations. The transdermal route has variable absorption and a 12–16 hour onset lag. Never cut fentanyl patches (unless specifically designed for it, e.g., some 12 mcg formulations). Patches are unsuitable for rapid titration or unstable pain.

Adverse Effects

Proactive management of opioid adverse effects is as important as pain relief. Under-treatment of side effects leads to dose reduction, inadequate analgesia, and diminished quality of life. Most opioid adverse effects are predictable, dose-related, and manageable with appropriate interventions.

Opioid-Induced Constipation (OIC)

⚠️

Constipation occurs in >70% of patients on regular opioids and does NOT develop tolerance. ALL patients commencing regular opioids must be prescribed concurrent laxatives from day one.

💊

Macrogol 3350 + Electrolytes

Movicol® · Osmotic laxative

Adult dose 1–3 sachets daily in water; titrate to effect

PBS status ✔ PBS General Benefit

💊

Senna

Senokot® · Stimulant laxative

Adult dose 2–4 tablets (15 mg) at night; titrate to 8 tablets BD

PBS status ✔ PBS General Benefit

💊

Docusate sodium + Senna

Coloxyl with Senna® · Stool softener + stimulant

Adult dose 1–2 tablets BD

PBS status ✔ PBS General Benefit

💊

Naloxegol

Moventig® · Peripherally-acting μ-opioid receptor antagonist (PAMORA)

Adult dose 25 mg PO once daily in the morning, on empty stomach. Reduce to 12.5 mg if CYP3A4 inhibitor co-administered.

Indication OIC unresponsive to conventional laxatives. Does NOT reverse central opioid analgesia.

PBS status 🔶 PBS Authority Required

Opioid-Induced Nausea and Vomiting (OINV)

Nausea affects 30–40% of patients at opioid initiation and usually resolves within 5–7 days. Mechanisms include stimulation of the chemoreceptor trigger zone (CTZ), delayed gastric emptying, and vestibular sensitivity.

First-line: Metoclopramide (Maxolon®) 10 mg PO/SC/IV TDS — prokinetic + antiemetic. Limit duration to 5 days (risk of extrapyramidal side effects). ✔ PBS
Alternative: Haloperidol 0.5–1 mg PO/SC nocte or BD — effective CTZ antagonist. ✔ PBS
Vestibular component: Prochlorperazine (Stemetil®) 5 mg PO/IM TDS or cyclizine 50 mg PO/SC/IV TDS. ✔ PBS
Refractory: Ondansetron (Zofran®) 4–8 mg PO/IV BD–TDS. ✔ PBS. Consider switching opioid if nausea persists >7 days.

Opioid-Induced Sedation

Sedation commonly occurs at opioid initiation and with dose increases, typically resolving within 48–72 hours. Persistent sedation suggests excessive dosing, drug interactions (benzodiazepines, antihistamines), delirium, or metabolic causes (hypercalcaemia, uraemia).

Reduce opioid dose by 25% if excessive.
Review co-prescribed sedating medications (benzodiazepines, antipsychotics, antihistamines).
Consider opioid switch — hydromorphone or fentanyl may cause less sedation in some patients.
Methylphenidate 2.5–5 mg mane (specialist use) for persistent sedation — not PBS-listed for this indication.

Opioid-Induced Neurotoxicity (OIN)

A spectrum of neuropsychiatric effects associated with opioid accumulation, particularly morphine in renal impairment. Manifests as:

Myoclonus — involuntary jerking; may progress to generalised. Dose-reduce, switch opioid, or add clonazepam 0.5 mg PO/SC BD–TDS.
Delirium / hallucinations — confusion, agitation, visual hallucinations. Rule out other causes (infection, metabolic, medications). Switch opioid and reduce dose.
Hyperalgesia (opioid-induced) — paradoxical increased pain sensitivity with dose escalation. Stop dose increases; switch opioid (methadone may help via NMDA antagonism). Consider ketamine adjuvant (specialist supervision).
Allodynia — pain from normally non-painful stimuli. Manage as per hyperalgesia.

Respiratory Depression

ℹ️

True respiratory depression is rare at standard palliative doses titrated to effect. Fear of respiratory depression should NEVER prevent adequate opioid titration. The risk is highest in opioid-naïve patients receiving parenteral boluses, patients with obstructive sleep apnoea, and those receiving concurrent sedatives. At end of life, opioids titrated for breathlessness do not hasten death when used appropriately (double effect doctrine).

Other Adverse Effects

Adverse Effect	Management
Pruritus (esp. morphine, codeine)	Switch opioid; low-dose naloxone infusion; antihistamines (limited efficacy)
Urinary retention	Assess with bladder scan; catheterise if needed. May resolve with opioid switch.
Dry mouth	Oral hygiene, saliva substitutes, pilocarpine drops (specialist use)
Sweating (hyperhidrosis)	Switch opioid; consider low-dose clonidine or oxybutynin
Endocrine (hypogonadism)	Relevant with chronic use; rarely needs intervention in palliative setting

Monitoring

Monitoring in palliative care balances safety with patient comfort. The focus shifts from rigid protocol-driven monitoring to patient-centred assessment.

Clinical Monitoring

Pain assessment — use validated tools at each review: Numerical Rating Scale (NRS 0–10), Abbey Pain Scale (for non-verbal patients), or patient self-report. Document and trend over time.
Adverse effects assessment — screen for constipation (bowel diary), nausea, sedation, confusion, myoclonus at every contact.
Respiratory rate and sedation score — particularly after initiation and dose increases. Use the Pasero Opioid-Induced Sedation Scale (POSS) or equivalent.
Functional impact — assess how pain and opioid effects impact quality of life, sleep, mood, and social participation.

Laboratory Monitoring

Renal function (eGFR, creatinine) — essential at initiation and periodically, especially in patients with declining renal function. Guides opioid choice.
Liver function tests — at initiation if hepatic disease suspected; guides dose adjustment.
Calcium — hypercalcaemia (common in malignancy) can cause confusion and reduce pain threshold; may be mistaken for opioid toxicity.
Routine drug levels (opioid serum levels) are NOT recommended — titration is guided by clinical response, not serum concentrations.

Syringe Driver (SC Infusion) Monitoring

Check the CADD-MS 3 or Graseby syringe driver site every 4–8 hours — look for erythema, swelling, leakage, or catheter displacement.
Rotate SC site every 48–72 hours (or sooner if problems arise).
Common sites: anterior thigh, anterior abdominal wall, upper arm. Avoid oedematous, irradiated, or diseased areas.
Document drug compatibility — morphine, hydromorphone, fentanyl, haloperidol, cyclizine, metoclopramide, dexamethasone, and midazolam are commonly co-infused. Check with pharmacist for specific combinations.

Special Populations

🫘

Renal Impairment

Morphine

Avoid if eGFR <30 mL/min. Active metabolites (M6G, M3G) accumulate — risk of prolonged sedation, respiratory depression, myoclonus, seizures.

Hydromorphone

Preferred second-line. H3G metabolite less clinically active. Start low, extend interval.

Fentanyl

Safest choice in significant renal impairment. No active metabolites. Use transdermal for stable dosing or SC for titration/syringe driver.

Methadone

Use with extreme caution; metabolites accumulate. Specialist-only prescribing.

🫁

Hepatic Impairment

All opioids

Reduce dose by 25–50% in Child-Pugh B–C. Morphine clearance reduced due to reduced hepatic blood flow and first-pass metabolism.

Codeine

Avoid — reduced conversion to active morphine (reduced efficacy).

Fentanyl

Preferred in severe hepatic impairment — hepatic extraction ratio is high but single-organ clearance makes it more predictable with dose reduction.

👶

Paediatric Palliative Care

Morphine

First-line in paediatric palliative care. IR morphine 0.2–0.4 mg/kg PO every 4 hours (opioid-naïve); titrate. SC morphine = 50% of 24-hr oral dose for syringe driver.

Fentanyl

Useful for syringe driver (1–2 mcg/kg/hr SC) and transdermal patches in older children with stable requirements.

Constipation

Co-prescribe laxatives from initiation — paediatric patients are equally susceptible. Macrogol preferred.

👴

Elderly Patients

General principle

"Start low, go slow, but go." Start at 50% of standard adult dose. Elderly have increased sensitivity to opioids (reduced renal clearance, altered receptor sensitivity, reduced protein binding).

Delirium risk

Higher risk of opioid-induced delirium in elderly. Monitor closely; consider haloperidol 0.5–1 mg SC/PO nocte if delirium develops. Review polypharmacy.

Fall risk

Opioids increase fall risk. Implement falls prevention strategies; consider physiotherapy review.

🛡️

Immunocompromised Patients

Drug interactions

Review CYP3A4 interactions — azole antifungals (fluconazole, voriconazole) and some antiretrovirals may increase opioid levels. Reduce dose and monitor. Fentanyl and methadone are particularly affected.

Infection masking

Opioid-induced sedation and sedation may mask signs of sepsis. Maintain vigilance for new fever, confusion, or haemodynamic instability.

🤰

Pregnancy

General

Palliative care in pregnancy is rare but opioids may be needed. Morphine is preferred. Avoid methadone unless already prescribed. Neonatal abstinence syndrome is a risk with chronic use. Involve obstetric and neonatal teams early.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Australians experience a disproportionate burden of cancer and chronic disease, yet access to palliative care is significantly lower than for non-Indigenous Australians. The AIHW reports that Indigenous Australians are 1.3 times more likely to die from cancer and are less likely to receive specialist palliative care or adequate pain management. Opioid prescribing in this context requires cultural safety, recognition of historical trauma related to government-controlled medication, and practical strategies to overcome access barriers.

Cultural safety

Engage Aboriginal and Torres Strait Islander health practitioners and liaison officers early. Understand that the concept of "palliative care" may not translate directly — frame discussions around "keeping comfortable" and "walking together." Respect that some patients may wish to return to Country for end of life.

Stigma around opioids

Historical trauma — including government-controlled substance use and punitive approaches — may create deep distrust of opioid medications. Address concerns openly, explain that these are "strong pain medicines" and that the patient is in control. Involve family and Elders in discussions where culturally appropriate.

Remote and very remote access

Opioid availability may be limited in remote communities. Health centres stock limited formularies; morphine IR and MR are generally available, but hydromorphone and fentanyl patches may require Health Department or Remote Area Pharmacy coordination. Plan ahead for medication supply. Royal Flying Doctor Service (RFDS) may assist with urgent supply or retrieval.

Syringe driver availability

CADD-MS 3 or Graseby syringe drivers may not be readily available in all remote communities. Community palliative care nurses and RFDS can support setup and monitoring. Ensure training of local health workers for site checks and medication charting.

After-hours access

After-hours opioid access is a major safety concern. Community pharmacies in remote areas may have limited hours. Ensure sufficient medication supply is dispensed with clear written instructions. Provide PRN breakthrough medication and ensure the patient/carer can administer it. Use My Health Record and medication management plans to support continuity.

Health literacy

Use plain language, visual aids, and teach-back methods. Ensure written instructions are clear and pictorial where possible. Aboriginal health workers can provide culturally appropriate education on opioid use, storage, and when to seek help.

Storage and safety

In shared households, safe storage of opioids (locked box) is essential to prevent accidental ingestion by children. State/territory opioid regulations may apply. Discuss storage as part of initial opioid education.

Social and emotional wellbeing

Palliative care intersects with social and emotional wellbeing frameworks. Loss, grief, and connection to Country are central. Link with Aboriginal Community Controlled Health Organisations (ACCHOs) and social and emotional wellbeing teams for holistic support. Recognise that some patients may choose traditional healing alongside Western pain management.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Palliative care services in Australia. AIHW, Canberra; 2023. Available from: www.aihw.gov.au.
2. Palliative Care Australia. National Palliative Care Standards. 5th ed. Canberra: Palliative Care Australia; 2018.
3. Caraceni A, Hanks G, Kaasa S, et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol. 2012;13(2):e58–e68.
4. Royal Australian College of General Practitioners (RACGP). Prescribing drugs of dependence in general practice. Part B: Benzodiazepines, opioids and beyond. Melbourne: RACGP; 2015 (updated 2020).
5. Davis MP, Walsh D. Methadone for symptom control in advanced cancer. Semin Oncol. 2004;31(6 Suppl 15):32–42.
6. Currow DC, McDonald C, Oaten S, et al. Once-daily opioids for chronic dyspnea: a dose increment and pharmacovigilance study. J Pain Symptom Manage. 2011;42(3):388–399.
7. Abernethy AP, Currow DC, Frith P, et al. Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. BMJ. 2003;327(7414):523–528.
8. Australian and New Zealand Society of Palliative Medicine (ANZSPM). Position statement: Opioid use in palliative care. Sydney: ANZSPM; 2019.
9. King S, Forbes K, Hanks GW, et al. A systematic review of the use of opioid medication for those with moderate to severe cancer pain and renal impairment: a European Palliative Care Research Collaborative opioid guidelines project. Palliat Med. 2011;25(5):525–552.
10. Mercadante S, Bruera E. Opioid switching: a systematic and critical review. Cancer Treat Rev. 2006;32(4):304–315.
11. National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the management of mesothelioma and other thoracic malignancies. Canberra: NHMRC; 2023.
12. Dahan A, Aarts L, Smith TW. Incidence, reversal, and prevention of opioid-induced respiratory depression. Anesthesiology. 2010;112(1):226–238.
13. Australian Government Department of Health and Aged Care. Palliative care under the MBS. MBS Online. Canberra; 2024. Available from: www.mbsonline.gov.au.
14. Pharmaceutical Benefits Scheme (PBS). Schedule of Pharmaceutical Benefits. Australian Government Department of Health and Aged Care; 2024. Available from: www.pbs.gov.au.
15. Cherny NI, Fallon MT, Kaasa S, et al., eds. Oxford Textbook of Palliative Medicine. 5th ed. Oxford: Oxford University Press; 2015.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).