IV crisis as morphine supplies are now low

Supplies of several crucial medicines are running short around the nation, such as liquid morphine products vital to ease the suffering of palliative care patients, including children.

Australian & New Zealand Society for Palliative Medicine president Michelle Gold.

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Supplies of several crucial medicines are running short around the nation, including morphine products vital to ease the suffering of palliative care patients, as some medical specialists reject claims by the nation’s health ministers that the shortage of IV fluids – which has thrown hospitals into chaos – is easing.

The IV fluids crisis has exposed major supply shortages in other critical areas of medical practice, including palliative care, where a lack of oral liquid morphine is causing distress to some patients, particularly for children who cannot swallow tablets.

The Australian has obtained correspondence showing Health Minister Mark Butler was warned nine months ago that palliative care patients were in danger of losing access to vital opioid analgesic medicines, particularly liquid morphine, but it appears no effective action was taken.

Australian & New Zealand Society for Palliative Medicine CEO Joe Hooper says the shortage is a “government policy failure which has hit us hard in that patients at the end of their life cannot access vital liquid-based morphine medications to relieve pain”.

Mr Hooper said Mr Butler had “flicked it off to various departments and we got a response via the TGA (Therapeutic Goods Administration) which wasn’t exactly a call to arms or an action list”.

Other countries such as the UK had no issues of supply of the drugs, Mr Hooper said.

“The current government is failing because, first, we have no manufacturing and second, you’re relying on sponsors – the drug companies – to apply for approvals,” he said. “The government is telling us it’s really at the behest of the commercial interests to decide which medicines are available to the Australian public. So there’s a flaw in the process.”

ANZSPM president Michelle Gold said: “Oral liquid morphine is such a basic medication for pain management in palliative care, especially for children and other people who can’t swallow tablets.

“It’s flexible, it’s safe, it’s basic pain relief and not to have access to it, in 2024, is just extraordinary.”

In October last year manufacturer Mundipharma announced it intended to remove its Ordine morphine oral liquid and other products from Australia, even though the company knew it was likely to discontinue the product up to three years before.

“Despite the company making us aware of it six months ago, there is not a reliable, consistent supply of a PBS-subsidised product currently available”, said Dr Gold, who is also director of palliative medicine at the Alfred Hospital in Melbourne.

“These are people who are frail or who are in pain and they don’t need to be going backwards and forwards to different pharmacies and different hospitals.

“Parents of a child who is dying are often giving these things through feeding tubes which you can’t do as easily with the tablets, and with the liquid version you can finetune a very tiny dose for a very tiny patient.”

The ANZSPM wrote to Mr Butler in November 2023, warning that discontinuation of vital opioid medicines – often with little notice – and sustained shortages would cause great distress to patients at the end of life.

“This is a serious risk for all Australians requiring quality pain management, including those receiving palliative care,” ANZSPM’s then-president Christine Mott wrote in a letter asking Mr Butler to take urgent action to ensure opioid supply and access.

“We now regard (the shortages) as a looming crisis for palliative care patients of all ages as well as those with chronic pain, cancer and other conditions requiring effective pain control.”

Morphine oral liquid is an extremely critical medicine in Australia for management of severe pain in adults and children, and a range of products is needed to take into account an individual patient’s ability to swallow, need to use feeding tubes, kidney or liver issues, and how they respond to one medicine over another.

“Some palliative care patients are already using the only opioid analgesic medicine they can tolerate,” Dr Mott said.

The present minimum reporting period for the pharmaceutical industry to inform the market of medication discontinuation is six months. That should be extended to at least 12 months for opioid analgesic medicines, Dr Mott recommended, and the process for TGA registration reviewed to ensure a fast-track pathway for critical medicines.

A TGA spokesman said it was working to manage and improve supply of the medicines as a priority. To facilitate ongoing access to oral morphine products, the TGA had approved access to several alternative overseas-registered medicines, some of which were included on the PBS.

“The TGA is also continuing to investigate the registration and/or supply of new Australian products,” the spokesman said.

“Medicine sponsors are private businesses and make their own decisions regarding if and how to market a product in Australia.”

Meanwhile, some anaesthetists and obstetricians have hit out at the claim made by federal and state health ministers after a joint meeting on Friday that shortages of IV fluid bags “while easing, are expected to continue through 2024”, saying they had seen no sign of improvement.

Australian Society of Anaesthetists president Mark Sinclair said: “We’re not seeing that yet at the coalface, all we’re hearing from our hospitals who supply this is: be judicious please, be careful please. We haven’t seen any change in that directive.

“We’re not hearing from the hospitals that it’s OK, we’re certainly not hearing that.”

IV fluids were particularly vital for anaesthetists in certain emergency situations, Dr Sinclair said, such as an anaphylactic reaction to anaesthesia drugs. “You might need a very large amount of IV fluids as part of the management of that sort of life-threatening scenario, so it’s a critical component that, until this year, we’ve never had to really think about.”

Some anaesthetists in private hospitals have already faced a choice between cancelling procedures because of lack of IV fluid or going ahead but knowing that patients will come out of the surgery “feeling like crap” because they didn’t get IV fluids.

Patients often go into surgery already dehydrated from fasting or because they’ve taken preparations, and rehydrating them during anaesthesia can help them feel better afterwards.

“It’s a difficult decision I have to make every day now when I go to work”, said one anaesthetist, who said he did 10 procedures in a private hospital last week but could not use IV fluids on any of them because of the need to quarantine supplies for bigger and more urgent cases.

“What is the point of having all these desk jockeys sitting in airconditioned offices in the various departments of health or TGA, when they can’t predict or prevent something like this occurring?” he said. “The current federal Health Minister’s position is untenable, given he has let this occur on his watch. This is a public health policy failure on a much grander scale than anything that happened during the Covid-19 pandemic.”

The situation with the IV fluid shortage varies across the country. Some hospitals have sufficient supply, and patients who need IV fluids are being prioritised.

However, National Association of Specialist Obstetricians and Gynaecologists president Gino Pecoraro said on Monday that the situation in private maternity wards was still critical.

“An easing of the shortage is not at all what I am seeing,” said Dr Pecoraro, an obstetrician who works across private hospitals in Queensland. “The government’s representation that the shortage is easing is absolutely contrary to what I’m seeing and hearing.

“I’ve just finished a small operating list this morning, and the anaesthetist tells me it is far from over, that there are cases that are being cancelled, and I’ve heard around the country that there are people who have had their inductions of labour cancelled.”

Inductions were now being done according to prioritisation of need, but by delaying inductions the small amount of risk to the baby may increase depending on circumstances, Dr Pecoraro said.

“If something unexpected happens, which is the nature of obstetrics, then you can’t guarantee that there won’t be an adverse outcome,” he said.

“This IV fluid shortage is just a symptom of how bad our mismanagement of health is. They’re still trying to say that it’s a worldwide issue, and it isn’t a worldwide issue. It’s a lack of proper planning. It’s just horrific. I can tell you, the feeling and the morale in operating theatres today is just awful.”