The potent analgesic property of morphine was first isolated in 1804, and after more than 2 centuries morphine is still the gold standard for moderate to severe pain. It is relatively easy to produce, and compared to most pharmaceuticals, morphine is dirt-cheap. Therein lies the cruel conundrum: Morphine is widely available in Western, developed nations, but in resource-constrained countries, comprising about 80% of the world’s population, market conditions have grossly inflated the drug’s price, leaving the majority of the world’s poorer cancer patients suffering in severe pain because they can’t afford analgesic relief.
The Cost Barrier
When governments scale up health-care delivery services in the public sector of a lower-income country, they naturally want a low-cost product. Ironically, even though morphine is a very inexpensive drug, its cost is a major barrier to access in regions such as sub-Saharan Africa, Latin America, and Eastern Europe. However, when we scale up a treatment that’s not in wide use, such as morphine, there is actually a downside. When sale volumes are low and per-dose profits are similarly low, especially in off-patent drugs like morphine, the potential for profit is harder to realize. Naturally, this scenario chills a supplier’s incentive to enter the new drug markets.
Moreover, if a drug supplier does want to sell its product in a new market, it has to pay several thousand dollars in product registration fees. Given the regulatory complexity of many developing nations, that process can take a couple of years. Also, because opioids are regulated products, there is an additional layer of onerous compliance work.
Further complicating the process is that in developing nations there is generally no guaranteed demand for suppliers. Unlike the past 10 years in HIV/AIDS treatment, we actually had guaranteed market demand driven by The Global Fund and The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), so producers knew that certain countries would order therapies for 5 years or more, which was a significant incentive for suppliers to enter the market.
In regions like sub-Saharan Africa we don’t have a set market demand for pain products even though the need for them is great. In order to hedge their investment in an uncertain market, drug suppliers mark up their prices. More importantly, the lack of competition in developing markets is a disincentive for lowering prices. These market inefficiencies have often made morphine more expensive in sub-Saharan African, Eastern European, and Latin American markets than in the United States.
Seeking to maximize their profit, distributors also block certain products. For instance, the fentanyl transdermal patch, a very effective long-acting analgesic, is about 30 times more expensive than morphine. We’ve found that in some developing markets distributors will bring in fentanyl, but not low-cost morphine, simply because fentanyl has a higher profit margin. When you aggregate all these factors, the end result is low market penetration and a more expensive, often cost-prohibitive supply of morphine.
A Ugandan Model
It is important to distinguish between cost and price. The cost of morphine is pennies per dose; the inefficiencies within the market drive the exorbitant prices. In Uganda, what we needed was a way to bypass many of the supply and demand issues that created access barriers to pain medication and left the country without any morphine for more than 6 months in 2010.
For years, a nongovernmental hospice in Uganda, Hospice Africa Uganda, has been producing its own liquid solution morphine. Over the past year, the Global Access to Pain Relief Initiative (GAPRI) has been working with the Ugandan Ministry of Health and local palliative care stakeholders in Uganda (including the Palliative Care Association of Uganda and the African Palliative Care Association) to scale up Hospice Africa Uganda’s production and certify them as a drug manufacturer. The hospice now sells morphine solution to the government at a cost 40% less than the cost of importing the drug from an international supplier.
This process also makes the local market more efficient. Since Hospice Africa Uganda produces its own liquid morphine, they actually manufacture on demand, taking only a week to fill an order. They are able to produce three different incremental dosages in real time; the expiration clock starts ticking at the time they mix it so they can hold the raw powder for much longer, giving more shelf life than an imported finished product. Most importantly, the raw powder does not need to be registered, meaning that they can procure the raw ingredient from the supplier that gives them the best price.
This is one of the newer approaches that can actually produce and deliver morphine to cancer patients in pain for literally pennies a day. The pain treatment costs in the Ugandan model are about $1 per week. And because it resulted in the government getting heavily discounted morphine, in turn, the Ugandan government has agreed to pay for annual orders up front, allowing the hospice to better plan procurements. The government also pays for morphine for all pain patients in the country for free. That includes thousands of patients being treated by hospice programs across the country that previously had to purchase their own morphine out of pocket—an untenable expense for most.
Hospice Africa Uganda used to spend over $40,000 per year on morphine; now they’re making a small profit on every bottle they sell to the government. And all their patients get treated for free. It is a win-win situation—the overall price has gone down across the board, the efficiencies are up, we’re wasting less product, we’re not having to toss expired product, and all the patients are getting their pain medications when they need it.
This is an example of a creative, cooperative approach by a hospice that was willing to take on a risky endeavor for their patients, local partners who supported them, a proactive government that believed in and invested in local solutions, and a small international organization that is helping them both to cut through bureaucratic hurdles. This collaboration is circumventing the challenging market inefficiencies endemic in much of the world’s poorer regions, and by doing so, we have helped relieve unnecessary pain and suffering. Addressing the global tragedy of needless pain is a continued work in progress, and the Ugandan model is continuing to be refined, but it represents a point of light on the horizon—hope for affordable, government-led solutions to unnecessary suffering. ■
Disclosure: Dr. O’Brien reported no potential conflicts of interest.
Dr. O’Brien is Director, Global Access to Pain Relief Initiative, a joint program of the Union for International Cancer Control and the American Cancer Society.