Costs and Cost-Effectiveness
This section describes the costs and benefits of providing oral morphine and essential adjuvant drugs to terminally ill cancer and AIDS patients who require it. It assumes the drugs are used according to the WHO analgesic ladder. We recognize that other analgesics can also contribute significantly to patients' costs and pain relief, but at least some such drugs (acetaminophen, for example) are available relatively cheaply in most places. Although not everyone has access to such drugs, we are unaware of any data that could be used to estimate that proportion. Costs are estimated for three countries at differing income levels and with different patterns of cancer and AIDS deaths: Chile, Romania, and Uganda (see box 52.3).
[Box 52.3]
Costs Included in the Estimates
The quantitative analysis presented here is restricted to the costs, before such drugs reach the patient, of oral morphine and the adjuvant drugs needed to treat its side effects. We mention other costs associated with delivering oral morphine to terminal AIDS and cancer patients later in this section, but for reasons we discuss, we have not assigned dollar values to them.
Costs of Oral Morphine
The appropriate measure of drug cost is the sum of costs to all payers—governments, insurers, charities, and patients—for the drug itself, but that sum does not include the costs of personnel to administer the drug or otherwise care for the patient.
Oral morphine can be purchased in bulk powder or finished form and administered as a tablet or liquid (De Lima and others 2004; Rajagopal and Venkateswaran 2003). The cost to the final payer is influenced by import taxes, if any; requirements to document the chain of custody of the product; costs to local manufacturers of excipients, salts, diluents, and other materials required to produce finished forms; and price markups. The actual cost of oral morphine in LMICs is difficult to document because it is unavailable in so many places or is manufactured for finished use at different points in the distribution chain. The price of a 30-day supply of immediate-release oral morphine in 2003 ranged from US$10 in India to US$254 in Argentina, among the few countries for which prices were reported (De Lima and others 2004).
Morphine is likely to cost less where it is produced locally and used in easy-to-reach, urban locations. Liquid preparations made by mixing morphine powder will cost less than tablets. Even with these variations, if barriers to access to oral morphine are removed, a total drug cost of 1 cent per milligram or less for immediate-release oral morphine should be achievable for most countries. A realistic and conservative estimate of the cost of oral morphine is 0.5 cent to 1.0 cent per milligram in the countries in our analysis.
The cost of morphine per patient depends on the number of days that opioids are required and the average daily dose, recognizing that the required dosage typically increases with increasing pain nearer to death. An average daily dose in palliative care programs in developing countries is roughly 60 to 75 mg per day, and patients require this dose for an average of three months. (Merriman 2002; personal communication, L. De Lima, International Association for Hospice and Palliative Care, June 2004; personal communication, M. R. Rajagopal, Amrita Institute of Medical Sciences, Kochi, Kerala, India, June 2004).
Using the inputs above, we estimate the cost of oral morphine for a cancer or AIDS patient with severe pain near the end of life at about 30 to 75 cents per day, or US$9.00 to US$22.50 per month, which is needed for an average of three months.
Costs of Other Necessary Drugs
Morphine's most common side effects are constipation, nausea, and (less frequently) psychosis. Representative drugs to treat these conditions are senna, a laxative, available to some government purchasers for about 3 cents per day; prochlorperazine, an antiemetic, about 8 cents per day; and haloperidol, an antipsychotic, about 15 cents per day (Management Sciences for Health 2003). Retail prices after markups would add 20 to 30 percent.
Under the assumptions of this analysis, oral morphine for all dying cancer and AIDS patients would cost between 3 cents and 21 cents per capita per year (table 52.3) in Chile, Romania, and Uganda. The cost per pain day avoided by oral morphine is the same in all three countries, assuming that each country can acquire and dispense morphine equally efficiently.
[Table .]
Cost-Effectiveness
The analysis indicates that the drug costs of oral morphine come to about US$216 to US$420 per year of pain-free life gained in the three sample countries. The next question is whether the pain relief that could be achieved would be worth the cost. We know that patients value pain-free days highly. A day lived with the certainty of experiencing severe pain is of very low value, perhaps even lower than death itself (Furlong and others 2001; Le Gales and others 2002). Bryce and others (2004) find that people are willing to give up several months of healthy life for access to good end-of-life care. Patients in low-income countries place as great or even greater value on pain relief as patients in high-income countries (Cleeland and others 1988; Murray and others 2003).
Costs Not Included in the Analysis
The analysis presented includes only the most basic costs—the costs of oral opioids and associated drugs—that would be incurred in a pain control program. Clearly, there are many other costs, ranging from the costs of services at the individual patient level to the costs of changing drug laws and policies at the national level. The most significant additional costs are discussed below.
Incremental Costs of Care Delivery
In addition to requiring the drugs themselves, implementation of the three-step ladder requires trained individuals to assess and monitor patients. Where health care systems are well developed, the incremental cost of adding oral morphine will be low. If it involved one additional health center visit, the cost per patient would increase by about US$8 in Chile, US$6 in Romania, and US$4 in Uganda, amounting to less than 1 cent per capita in all three countries.
Where primary health care is weak, widespread access to oral opioids depends on the development of new systems, such as community- or hospital-based palliative care networks. Clearly, allocating the full cost of upgrading the health care system, or even the development of new palliative care programs, to oral morphine alone, would be inappropriate.
Other Costs
Security and recordkeeping related to stocking and distributing opioids, required by the Single Convention, entail additional fixed and ongoing costs. Because most hospitals handle injectable opioids (for example, pethidine), these costs would be less for hospital-based programs than for community-based programs.
Professional training and education is required for all personnel involved in the use of opioids for dying patients, in part to overcome fears and in part to ensure proper use. These costs are likely to be highest where the health care system is most deficient.
The costs of changing national policy toward opioids is substantial in terms of cost, time, expertise, and leadership (see, for example, Pain and Policy Studies Group 2003 and 2004 and other annual reports at http://www.medsch.wisc.edu/painpolicy/publicat/annrepts.htm). The time expended is an opportunity cost, but it may be amortized over a long time if the effort succeeds.
Potential Cost Savings
In some circumstances, making oral morphine available through a palliative care system could actually save money—for example, if it enabled some terminally ill patients who would otherwise be admitted to the hospital for pain control to die at home, or if it shortened their period of hospitalization. This outcome is more likely in places with good medical infrastructure, but even in low-income countries, patients in unbearable pain are often brought to hospitals by distressed relatives who are willing to go into debt to ease the suffering.
