Peter Moodie: Pharmac drug decisions based on price and quality

COMMENT

The palliative care movement has made huge strides in the care of patients with incurable cancer in recent years.

It has forced clinicians not only to rethink their attitudes to dying but the way they use pain-relieving medicines. In my own practising career, there has been an amazing change towards a holistic and positive approach to those who were not curable within the medical model.

Pain can be both physically draining and psychologically devastating, and it is the nature of modern palliative care to address both these dimensions. To achieve that, patients need access to medicines that work (and morphine is one of the mainstays of therapy), and a confidence in that therapy. Likewise, a responsible clinician must offer appropriate therapy and at the same time give patients a reassurance that this medicine will work for them.

Pharmac is acutely aware of these issues and they are the sort of things that are carefully considered before any changes are made to medicine subsidies.

This is what has occurred in the case of the long-acting version of morphine sulphate, which is supplied under a number of brand names but which all do the same job in the same manner. In New Zealand, there are four brands approved for use (MST, m-Eslon, Kapanol and LA-Morph), all of which are subsidised to the same level.

The current issue has arisen because the newest entrant into the market, m-Eslon, was offered to Pharmac at a price significantly below that of its competitors and so became the "reference price". This means that if other manufacturers want to charge a higher price, they will impose a manufacturers' surcharge on patients.

I don't want to be an advocate for one brand over another but suffice to say that to be listed on the Pharmaceutical Schedule any drug must be tested by the Ministry of Health (independent of Pharmac and suppliers) and meet strict safety, quality and efficacy standards.

All of the listed products have met those standards and all of them have significant markets overseas - for example, m-Eslon is made in France, is used in 37 other countries and, Pharmac understands, is the market leader in Britain.

Decisions to reference price different brands of drugs are not taken lightly. In the case of morphine sulphate, this involved asking for advice from expert clinical groups, consulting with the palliative care sector and carrying out further independent tests, including a dissolution study performed by scientists at the Institute of Environmental Science and Research.

All the suppliers of morphine sulphate had the opportunity to match the M-Eslon price but the other three initially decided they would withdraw their products from the market, rather than impose a surcharge. This was a decision by the suppliers, not Pharmac.

Following advice from clinicians, we moved to allow terminally ill patients to continue taking their existing brand of morphine sulphate for as long as stocks were available.

Most recently, Pharmac has signed a contract with a second company to continue supply of LA-Morph. Significantly, this will be at the same price as M-Eslon, so will be fully funded for patients from July 1.

We hear comments about New Zealand having Third World systems, but in reality when it comes to medicine subsidies this country is no different to most developed countries and, indeed, is ahead in many respects.

For instance, the United States is often held up as the model for freedom of access to medicines. But in the US more than 40 million people have no access to any subsidised medicines; this in a First World country.

Every country in the Western world, including New Zealand, offers access to any medicine that is approved for use in that country. And it is also true that every country restricts access to subsidised medicines in one way or another.

In New Zealand, we have universal access - the inviolable right for any taxpayer to have access to subsidised medicine regardless of income or status, and that list of pharmaceuticals is long and comprehensive.

The trade-off for providing universal access is that not every medicine is subsidised.

Morphine sulphate continues to be one of a number of medicines that are available. For patients with progressive cancer, their therapy may have to be adjusted or changed daily, and these changes should not be blamed on a simple brand change.

In the final analysis, it is not the drugs that are the key but rather the expertise and the dedication of the people giving them. Good-quality medicines, independently assessed, are widely available here and, even if you have to search them out, the true and caring professionals are there, too.

* Dr Peter Moodie is the medical director of Pharmac and a practising GP in Wellington. He is responding to the view of consulting pharmacist Anne Denton that Pharmac is preventing access to the best medicines just to save money.