Pain in the Last Days of Life

Last updated 1 Jun 2026 · Palliative care

📋 Key Information Summary

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Pain in the last days of life (typically the final 48–72 hours) requires anticipatory prescribing and rapid titration, as patients are often unable to self-report.
Nonverbal pain assessment is essential — use validated tools such as the Abbey Pain Scale or FLACC scale; observe for grimacing, guarding, moaning, restlessness, and physiological signs (tachycardia, hypertension).
There is no maximum dose of morphine — titrate to effect, increasing by 30–50% of the current dose every 24 hours if pain persists, with more frequent adjustments in the last days.
Subcutaneous (SC) infusion is the preferred route when oral intake is no longer possible; convert the current 24-hour oral morphine dose to SC using a ratio of 1:2 (oral:SC) or 1:3 depending on local guidelines.
If opioid-naïve, start morphine SC 2.5–5 mg with 2.5–5 mg available as needed every 1–2 hours via syringe driver (over 24 hours) plus PRN boluses equivalent to 1/6th to 1/10th of the total 24-hour dose.
Existing opioid therapy should be continued — convert the current 24-hour opioid dose to SC morphine equivalent; do not abruptly stop transdermal fentanyl patches (they provide residual analgesia for 12–24 hours after removal).
Breakthrough (rescue) doses should be prescribed as PRN SC boluses at 1/6th to 1/10th of the total 24-hour opioid dose, available every 1–2 hours.
Adjuvant analgesics — consider dexamethasone for bone metastases or raised intracranial pressure, and midazolam for muscle spasm or anticipatory distress alongside morphine.
Anticipatory prescribing of subcutaneous medications (opioid, antiemetic, sedative) into the home or bedside is best practice and recommended by Palliative Care Australia.
Renal impairment is common at end of life — morphine-6-glucuronide accumulates; consider hydromorphone or fentanyl in significant renal failure (eGFR <15 mL/min).
Ethical principle: the doctrine of double effect protects clinicians who titrate opioids to relieve pain even if respiratory depression is a foreseeable consequence — intent to relieve suffering is paramount.
Non-pharmacological strategies remain important: positioning, gentle massage, music therapy, and caregiver presence reduce distress at end of life.
ATSI patients may have cultural and spiritual dimensions to pain; involve family, Aboriginal health practitioners, and culturally appropriate palliative care services early.

Introduction & Australian Epidemiology

Pain management in the last days of life is a critical component of end-of-life care. During this period — typically defined as the final 48–72 hours before death — patients may lose the ability to communicate verbally, swallow medications, or participate actively in their own care. The transition from oral to parenteral analgesia, combined with vigilant nonverbal pain assessment, is essential to ensure comfort and dignity.

In Australia, approximately 160,000 people die each year, with around 70% of deaths occurring in hospital or residential aged-care settings (AIHW 2023). Palliative Care Australia estimates that 50–70% of patients experience pain in the final weeks of life, and undertreated pain remains one of the most common concerns reported by families and carers. The National Palliative Care Strategy (2018) emphasises that all Australians should have access to high-quality palliative care regardless of location, including those dying in regional and remote areas.

This article focuses specifically on the pharmacological and non-pharmacological management of pain when patients are no longer able to swallow or communicate reliably. It covers nonverbal assessment techniques, morphine infusion regimens, conversion from existing opioids, and management of breakthrough pain. All recommendations are consistent with the Palliative Care Therapeutic Guidelines and the Australian and New Zealand Society of Palliative Medicine (ANZSPM) consensus statements.

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Key principle: The goal of opioid titration in the last days of life is comfort, not cure. Dose escalation should be guided by signs of pain, not arbitrary dose ceilings. Clinicians should document their clinical reasoning and intent clearly.

Nonverbal Pain Assessment

As patients approach the final days of life, verbal self-report of pain becomes unreliable or impossible. Clinicians must rely on validated nonverbal assessment tools and systematic observational skills. Failure to detect pain in nonverbal patients is a significant source of undertreated suffering and is a key quality indicator in palliative care.

Behavioural and Physiological Indicators of Pain

Facial expression: grimacing, frowning, clenched teeth, furrowed brow, tearing
Body movements: guarding, bracing, rigidity, restless agitation, withdrawal from stimulus
Vocalisation: moaning, groaning, crying, sighing, calling out
Physiological signs: tachycardia, hypertension, diaphoresis, tachypnoea (note: these may be absent in the actively dying)
Changes in behaviour: new-onset confusion or agitation, social withdrawal, resistance to care, altered sleep patterns

Validated Nonverbal Pain Assessment Tools

Tool	Population	Components	Scoring
Abbey Pain Scale	Adults unable to self-report (end of life, dementia)	Vocalisation, facial expression, body language, behavioural change, physiological change, bodily change	0–2 = no pain; 3–7 = mild; 8–13 = moderate; 14+ = severe
FLACC Scale	Children; adults with cognitive impairment	Face, Legs, Activity, Cry, Consolability	0 = relaxed; 1–3 = mild; 4–6 = moderate; 7–10 = severe
PAINAD	Patients with dementia	Breathing, negative vocalisation, facial expression, body language, consolability	0–10 scale
Critical-Care Pain Observation Tool (CPOT)	Critically ill intubated adults	Facial expression, body movements, muscle tension, compliance with ventilator	0–8; ≥3 suggests pain
Comfort-B Scale	Neonates and infants	Alertness, calmness, respiratory response, movement, muscle tone, facial tension, blood pressure, heart rate	6–30; higher = more distress

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Practice tip: The Abbey Pain Scale is recommended by the Australian Commission on Safety and Quality in Health Care (ACSQHC) for use in residential aged care and palliative care settings. Reassess pain at least every 4 hours using the same tool to allow comparison.

Differentiating Pain from Other Causes of Distress

Not all agitation or restlessness in the last days of life is due to pain. Differential causes include:

Delirium — fluctuating consciousness, disorientation, hallucinations (consider haloperidol 0.5–1 mg SC)
Urinary retention — palpable bladder, restlessness (catheterise if confirmed)
Constipation/faecal impaction — abdominal distension (consider rectal examination; microenema or manual evacuation if appropriate)
Dyspnoea — air hunger, nasal flaring, accessory muscle use (low-dose morphine 2.5–5 mg SC and/or midazolam 2.5–5 mg SC)
Spiritual or existential distress — may require pastoral care or psychosocial support

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Do not assume all restlessness is pain. Administering escalating doses of opioids for non-pain causes of agitation may worsen the clinical picture. Systematic assessment must precede dose escalation.

Morphine Regimens in the Last Days of Life

Subcutaneous morphine delivered via continuous syringe driver (e.g., CADD-MS 3 or equivalent) is the standard approach for opioid delivery in the last days of life when the oral route is no longer feasible. The syringe driver runs over 24 hours and is supplemented by PRN breakthrough doses.

Starting Morphine — Opioid-Naïve Patients

For patients not previously receiving opioids, the initial subcutaneous regimen should be conservative with rapid titration based on clinical response.

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Morphine Sulfate (SC Infusion)

Ordine® · Sevre-Long® · Opioid analgesic

Adult dose (opioid-naïve) 2.5–5 mg SC over 24 hours via syringe driver

PRN bolus dose 2.5–5 mg SC every 1–2 hours PRN (equal to or less than the 24-hour infusion dose)

Titration If ≥2 PRN doses used in 24 hours, increase the syringe driver dose by 30–50% and recalculate PRN dose as 1/6th of new 24-hour total

Route Subcutaneous via butterfly needle or PICC line

Diluent Normal saline 0.9% — compatible in the same syringe with most common palliative care co-infusions

Renal adjustment eGFR 15–30: reduce dose by 25–50%, extend interval; eGFR <15: switch to hydromorphone or fentanyl

PBS status ✔ PBS General Benefit

Titration Protocol

Assess pain using nonverbal tools

Abbey Pain Scale or equivalent every 4 hours; document findings

Review PRN use in the preceding 24 hours

If ≥2 PRN bolus doses required, pain is inadequately controlled by the infusion

Increase the syringe driver dose by 30–50%

Add the total PRN doses used to the 24-hour total, then increase by 30–50%

Recalculate breakthrough dose

New PRN dose = 1/6th of the new total 24-hour opioid dose, available SC every 1–2 hours

Reassess at 4–6 hours

Reassess pain after dose increase; repeat titration as needed. In the last days, more rapid adjustments (every 4–6 hours) may be necessary.

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There is no maximum dose of morphine. Dose ceilings are a myth in palliative care. Titrate to analgesic effect, monitoring for adverse effects (sedation, respiratory depression, myoclonus). The doctrine of double effect applies — intent to relieve suffering is the ethical and legal standard.

Common Co-Infusions in the Syringe Driver

Medication	Indication	Typical SC dose / 24 hours	Compatibility with morphine
Metoclopramide	Nausea, vomiting, gastroparesis	30–60 mg	Compatible in same syringe
Haloperidol	Nausea, delirium, agitation	2.5–5 mg (up to 10 mg for delirium)	Compatible
Midazolam	Anxiety, seizures, refractory dyspnoea	10–30 mg (up to 60 mg for refractory agitation)	Compatible
Hyoscine butylbromide	Secretions, colic	60–120 mg	Compatible
Dexamethasone	Bone pain, raised ICP, nausea from obstruction	8–16 mg	Separate syringe recommended (pH incompatibility)
Levomepromazine	Refractory nausea, sedation	25–50 mg	Separate syringe recommended

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Syringe driver change intervals: Most subcutaneous infusions should be changed every 24 hours. Some combinations may require earlier change — consult your local palliative care pharmacist or the Palliative Care Therapeutic Guidelines for specific stability data.

Managing Patients on Existing Opioid Therapy

Many patients approaching the last days of life will already be receiving regular opioid therapy. The key principle is continuity — do not abruptly stop existing opioids. Convert the current 24-hour opioid dose to an equivalent subcutaneous morphine regimen.

Oral-to-Subcutaneous Morphine Conversion

Current Route	Conversion Ratio (Oral:SC)	Method
Oral morphine → SC morphine	2:1 (i.e., divide total 24-hour oral dose by 2)	Total oral morphine in 24 hours ÷ 2 = SC morphine over 24 hours
Oral oxycodone → SC morphine	Oral oxycodone × 1.5 = oral morphine equivalent, then ÷ 2	Use 1:1.5 ratio for oxycodone:morphine (oral), then convert to SC
Transdermal fentanyl patch → SC morphine	See Fentanyl Patch Conversion table below	Remove patch; start SC morphine 12 hours after patch removal
Oral hydromorphone → SC morphine	Oral hydromorphone × 5 = oral morphine equivalent, then ÷ 2	Hydromorphone is approximately 5× more potent than morphine (oral)

Fentanyl Patch Conversion

Fentanyl Patch (mcg/hr)	Approximate 24-Hour Oral Morphine Equivalent	Equivalent SC Morphine / 24 hours
12 mcg/hr	30 mg	15 mg
25 mcg/hr	60 mg	30 mg
50 mcg/hr	120 mg	60 mg
75 mcg/hr	180 mg	90 mg
100 mcg/hr	240 mg	120 mg

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Fentanyl patches in the last days of life: Transdermal fentanyl has a prolonged absorption and elimination half-life (12–24 hours after patch removal). When converting to SC morphine, do not start the SC infusion until 12 hours after patch removal to avoid opioid toxicity. In some cases, a small "rescue dose" of SC morphine (2.5–5 mg) may be given before the 12-hour interval if breakthrough pain is severe.

Buprenorphine Patch Conversion

Buprenorphine patches (Norspan®) are less commonly used in the last days of life due to complex pharmacokinetics and ceiling effects. Conversion is as follows:

Norspan 5 mcg/hr ≈ 12 mg oral morphine / 24 hours ≈ 6 mg SC morphine / 24 hours
Norspan 10 mcg/hr ≈ 24 mg oral morphine / 24 hours ≈ 12 mg SC morphine / 24 hours
Norspan 20 mcg/hr ≈ 48 mg oral morphine / 24 hours ≈ 24 mg SC morphine / 24 hours
Remove the patch and allow a washout period of 12–24 hours before starting SC morphine; use PRN SC morphine 2.5–5 mg during the transition if needed

Methadone Conversion

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Methadone conversion is complex and non-linear. Due to variable half-life, NMDA receptor antagonism, and QTc prolongation risk, conversion from methadone to SC morphine should only be undertaken with specialist palliative care or pain medicine guidance. As a rough guide, methadone 10–20 mg/day oral ≈ morphine 30–60 mg/day oral, but significant individual variation exists.

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Hydromorphone (SC Infusion)

Jurnista® (PO) · Dilaudid® · Opioid analgesic

Indication Preferred in severe renal impairment (eGFR <15 mL/min) — active metabolites do not accumulate significantly

Conversion from morphine Total 24-hour SC morphine dose ÷ 5 = SC hydromorphone dose over 24 hours (SC hydromorphone is ~5× more potent than SC morphine)

Adult dose (opioid-naïve) 0.2–0.5 mg SC over 24 hours; breakthrough 0.2–0.5 mg SC every 1–2 hours PRN

Renal adjustment Preferred over morphine in eGFR <15; reduce dose by 25–50%

PBS status ⚠️ PBS Authority Required

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Fentanyl (SC Infusion)

Sublimaze® · Opioid analgesic

Indication Alternative to morphine in renal failure or morphine allergy/hypersensitivity

Conversion Total 24-hour SC morphine dose × 10 = total 24-hour SC fentanyl dose in mcg (e.g., 30 mg morphine SC → 300 mcg fentanyl SC over 24 hours)

Adult dose (opioid-naïve) 25–50 mcg SC over 24 hours; breakthrough 25–50 mcg SC every 1–2 hours PRN

Renal adjustment No accumulation of active metabolites — preferred in severe renal impairment

PBS status ✔ PBS General Benefit (injection)

Breakthrough Pain Management

Breakthrough pain — a transient exacerbation of pain occurring against a background of otherwise controlled baseline pain — is common in the last days of life and may be triggered by repositioning, wound care, or bladder/bowel distension. Rapid-onset rescue analgesia is essential.

Principles of Breakthrough Dose Calculation

The breakthrough (rescue) dose = 1/6th of the total 24-hour opioid dose
This dose is available every 1–2 hours as needed via subcutaneous injection
If ≥2 breakthrough doses are required in 24 hours, the regular (syringe driver) dose should be increased
In the last days of life, the breakthrough dose may need to be increased to 1/4 or 1/3 of the 24-hour dose if pain is severe and rapidly escalating

Syringe Driver Dose (24 hours)	Breakthrough Dose (1/6th)	Frequency
5 mg morphine SC/24h	1 mg morphine SC (round to 1–2.5 mg)	Every 1–2 hours PRN
10 mg morphine SC/24h	2 mg morphine SC (round to 2–2.5 mg)	Every 1–2 hours PRN
20 mg morphine SC/24h	3–4 mg morphine SC	Every 1–2 hours PRN
50 mg morphine SC/24h	8–10 mg morphine SC	Every 1–2 hours PRN
100 mg morphine SC/24h	15–20 mg morphine SC	Every 1–2 hours PRN

Procedural Pain at End of Life

Brief painful procedures (wound care, catheterisation, repositioning) may require pre-emptive or co-analgesia:

Pre-procedure: Administer the breakthrough dose 20–30 minutes before the procedure
Severe procedural pain: Consider midazolam 2.5–5 mg SC in addition to the opioid breakthrough dose for anxiolysis and muscle relaxation
Wound care: Topical lidocaine 4% (Emla® cream) to the wound 30 minutes prior may reduce opioid requirements

When Breakthrough Pain Is Refractory

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Refractory breakthrough pain despite adequate opioid titration suggests a neuropathic or bony pain component. Consider adding:

Dexamethasone 8–16 mg IV/SC daily for bone metastases, nerve compression, or raised ICP
Ketamine (specialist supervision only) — SC 50–100 mg/24 hours via syringe driver as a third-line adjuvant for neuropathic or opioid-resistant pain
Lidocaine IV infusion 1–2 mg/min (ICU/HDU setting only) for refractory neuropathic pain

Subcutaneous Administration Techniques

In the last days of life, the subcutaneous route is preferred over intramuscular (less painful, easier for carers). Key points:

Butterfly needle: 23–25 gauge, inserted into the subcutaneous tissue of the anterior thigh, upper arm, or anterior abdominal wall; change site every 3–7 days or if signs of inflammation
Maximum volume per SC bolus: 2 mL (ideally ≤1 mL to avoid tissue irritation)
Syringe driver rate: Most drivers deliver at a constant rate over 24 hours (e.g., 1 mL/24h); ensure the medication is soluble at the required concentration
Patient-controlled analgesia (PCA): May be considered in palliative care units for patients who can press the button; otherwise, carer- or nurse-administered PRN doses are standard

Adjuvant Analgesics and Non-Pharmacological Strategies

Adjuvant Analgesics

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Dexamethasone

Dexmethsone® · Corticosteroid

Indications Bone pain from metastases, nerve compression, raised intracranial pressure, hepatomegaly, bowel obstruction-related nausea

Adult dose 8–16 mg IV/SC/PO once daily in the morning

Duration Assess response within 3–5 days; may continue if benefit demonstrated

PBS status ✔ PBS General Benefit

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Midazolam

Hypnovel® · Benzodiazepine

Indications Anxiety, muscle spasm, myoclonus from opioids, seizures, refractory dyspnoea, terminal agitation

Adult dose 2.5–5 mg SC every 1–2 hours PRN; or 10–30 mg SC over 24 hours via syringe driver for continuous sedation

PBS status ✔ PBS General Benefit (injection)

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Haloperidol

Serenace® · Antipsychotic

Indications Opioid-induced nausea, delirium with agitation, terminal restlessness

Adult dose 0.5–5 mg SC/IV every 4–8 hours PRN; or 2.5–10 mg SC over 24 hours via syringe driver

Caution QTc prolongation risk; avoid in Lewy body dementia; monitor ECG if available

PBS status ✔ PBS General Benefit

Non-Pharmacological Strategies

Positioning: Reposition every 2–4 hours; use pressure-relieving mattresses; elevate head of bed to 30° for respiratory comfort
Gentle massage: Light touch massage to limbs and back reduces anxiety and may modulate pain perception
Music therapy: Evidence supports music therapy for reducing pain and anxiety in palliative care (Hole et al. 2015)
Thermal therapy: Warm compresses for musculoskeletal pain; cool cloths for headache
Presence and reassurance: Family presence, holding hands, calm narration of care activities reduces distress
Environmental modifications: Reduce noise, dim lighting, maintain comfortable temperature

Special Populations

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Renal Impairment

Morphine

Active metabolite morphine-6-glucuronide (M6G) accumulates in renal failure, causing prolonged sedation, respiratory depression, and myoclonus. Avoid or use with extreme caution if eGFR <15 mL/min.

Hydromorphone

Preferred opioid in severe renal impairment. Active metabolite (hydromorphone-3-glucuronide) is less clinically significant. Reduce dose by 25–50%.

Fentanyl

No active metabolites. Safe in renal failure. Dose reduction may still be needed in uraemia due to altered protein binding.

Methadone

No dose adjustment required in renal impairment, but complex pharmacokinetics require specialist guidance.

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Hepatic Impairment

All opioids

Reduced hepatic metabolism leads to prolonged half-life. Reduce starting doses by 50% and titrate cautiously. Monitor for excessive sedation.

Morphine

First-pass metabolism is reduced in cirrhosis; oral bioavailability increases. When converting to SC, use a ratio closer to 1:1 rather than 2:1.

Midazolam

Significantly prolonged effect in hepatic failure. Reduce dose and monitor closely.

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Elderly Patients

General principles

Start low, go slow — but do not undertreat. Reduced renal clearance, increased sensitivity to opioids and benzodiazepines, higher risk of delirium. Use 50% of standard starting doses.

Falls risk

Less relevant in the last days of life (bed-bound patients). Focus remains on comfort.

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Paediatric Patients

Morphine (SC)

Neonates: 0.025–0.05 mg/kg/hour SC via syringe driver. Infants and children: 0.02–0.04 mg/kg/hour SC. Breakthrough: 0.1–0.2 mg/kg SC every 1–2 hours PRN.

Assessment

Use FLACC (age 2 months – 7 years) or COMFORT-B (neonates/infants) for nonverbal assessment. Involve paediatric palliative care teams early.

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Immunocompromised Patients

General principles

No specific opioid dose adjustments. Be aware that pain in immunocompromised patients may have atypical aetiologies (e.g., CMV colitis, fungal osteomyelitis) — consider adjuvant analgesia accordingly.

Drug interactions

Azole antifungals (fluconazole, voriconazole) inhibit CYP3A4 and may increase fentanyl and methadone levels. Monitor closely and reduce doses if co-prescribed.

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander peoples experience a disproportionate burden of chronic disease and cancer, yet access to palliative care services remains significantly lower than for non-Indigenous Australians. The AIHW reports that Indigenous Australians are 1.5 times more likely to die from cancer and often present at more advanced stages. Cultural safety, family-centred care, and connection to Country are essential components of end-of-life care for many Indigenous Australians.

Cultural considerations in pain expression

Pain expression may be influenced by cultural norms — stoicism is valued in some communities, leading to under-reporting. Avoid assuming absence of pain based on verbal report alone. Use nonverbal assessment tools consistently.

Family and community involvement

End-of-life care for Indigenous Australians is typically a community event. Extended family members may wish to be present and involved in care decisions. Allow space for sorry business, cultural ceremonies, and connection to Country where possible.

Remote and regional access

Many Indigenous Australians live in remote areas with limited access to palliative care specialists, syringe drivers, and pharmacy services. Aboriginal Health Practitioners and Remote Area Nurses play a critical role in pain management. Telehealth consultations with specialist palliative care teams (e.g., through the Northern Territory Palliative Care Service) should be utilised.

Opioid hesitancy and stigma

Some communities may have concerns about opioid use due to historical experiences with substance misuse or fear of addiction. Clear, culturally appropriate education about the role of opioids in end-of-life pain management — and reassurance that dependence is not a concern in this context — is essential.

Sorry business and dying on Country

Many Indigenous Australians express a strong preference to die on Country. Facilitate early discharge planning and community-based palliative care where this is the patient's wish. Ensure anticipatory prescribing and community nursing support is in place for home deaths.

Language and health literacy

Provide pain management information in plain English and, where available, in the patient's first language. Use Aboriginal Interpreter Services (available in NT, QLD, WA) for discussions about pain management and end-of-life care goals.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Palliative care services in Australia. Canberra: AIHW; 2023. Available from: https://www.aihw.gov.au
2. Palliative Care Australia. National Palliative Care Strategy 2018. Canberra: Australian Government Department of Health; 2018.
3. Australian and New Zealand Society of Palliative Medicine (ANZSPM). Position statement: Opioid use in palliative care. Sydney: ANZSPM; 2022.
4. CareSearch. Palliative care evidence: Pain management at end of life. Adelaide: Flinders University; 2024. Available from: https://www.caresearch.com.au
5. Abbey J, Piller N, De Bellis A, et al. The Abbey Pain Scale: a 1-minute numerical indicator for people with end-stage dementia. Int J Palliat Nurs. 2004;10(1):6–13.
6. Australian Commission on Safety and Quality in Health Care (ACSQHC). Safety and quality of end-of-life care in acute hospitals: A background paper. Sydney: ACSQHC; 2014.
7. Mercadante S, Portenoy RK. Opioid poorly-responsive cancer pain. Part 3. Clinical strategies to improve opioid responsiveness. J Pain Symptom Manage. 2001;21(4):338–354.
8. Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manage. 2004;28(5):497–504.
9. Hole J, Hirsch M, Ball E, Meads C. Music as an aid for postoperative recovery in adults: a systematic review and meta-analysis. Lancet. 2015;386(10004):1659–1671.
10. Royal Australian College of General Practitioners (RACGP). Palliative care in general practice: Clinical guide. Melbourne: RACGP; 2023.
11. Currow DC, Clark K, Kamal A, et al. Opioid use in the last year of life in Australia: a retrospective cohort study. BMJ Support Palliat Care. 2021;11(2):180–187.
12. Aboriginal and Torres Strait Islander Health Performance Framework. Hospitalisations for palliative care. Canberra: Australian Government; 2023.
13. Cherny NI, Fallon MT, Kaasa S, Portenoy RK, Currow DC (eds). Oxford Textbook of Palliative Medicine. 6th ed. Oxford: Oxford University Press; 2021.

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).