High Opioid Costs in Argentina: An Availability Barrier That Can Be Overcome

Abstract

To the Editor: The World Health Organization (WHO) has concluded that opioid analgesics are insufficiently available in developing countries due to a variety of reasons, including high costs.1Organizaciòn Mundial de al Salud Alivio del dolor en el cancer; con une guia sobre la disponsibilidad de opioides. Segunda edicion. OMS, Ginebra1996Google Scholar This issue becomes a barrier for the adequate treatment of cancer patients with low incomes.2Mercadante S. Costs are a further barrier to cancer pain management.J Pain Symptom Manage. 1999; 18: 3-4Abstract Full Text PDF PubMed Scopus (7) Google Scholar The problem of expensive opioids has been discussed at different WHO-sponsored Latin American meetings, and probable solutions to this problem have been elaborated.3De Lima L. Bruera E. Joranson D. Vanegas G. Cepeda S. Quesada L. Opioid availability in Latin America The Santo Domingo Report, Progress Since the Declaration of Florianopolis.J Pain Symptom Manage. 1997; 13: 213-219Abstract Full Text PDF PubMed Scopus (32) Google Scholar We describe this situation in Argentina, how it changed with time, and the possible reasons for the change. In 1982, opioids unsuitable for chronic cancer treatment such as buprenorphine, nalbuphine, meperidine, and propoxyphene, were available. Presently, there are 12 different analgesic opioids available (Table 1), but the high price of most of them place an economic restriction on their use (Table 2). Although some health systems cover the cost in full, or partially, the cost of commercial preparations is very high compared to the average monthly income of US$400.Table 1Opioid Availability in Argentina in 2000BuprenorphineMeperidineCodeineMorphineDextropropoxypheneMethadoneFentanylNalbuphineHydrocodoneOxycodoneHydromorphoneTramadol Open table in a new tab Table 2Monthly Cost of Treatment with Commercial Opioids in ArgentinaCost of quantity = 180 mg of oral morphine.IR morphine (product #2)$ 72Methadone$ 89IR morphine (product #1)$131Hydromorphone$324Fentanyl$400SR morphine$582SR oxycodone$702IR morphine #2: wholesale cost (>500 pills).1 US$ = 1 $. IR, immediate release. SR, sustained release.Source: Manual Farmacéutico (ISSN 0329-06389), # 000, Jan. 2000. Open table in a new tab This situation has undergone a positive change that has improved the availability of opioids. To understand this change, it is useful to analyze the evolution of the monthly cost of treatment with oral morphine at 180 mg daily (Figure 1). Between the start of a movement to control cancer pain according to WHO guidelines (circa 1982) and the appearance of the first morphine commercial preparation (1990), the only option for oral opioids were the magistral preparations. These had varying prices, but initally they were inexpensive, with prices close to those suggested by the pharmaceutical colleges' standards. The first commercial morphine product was high-priced, sustained release (SR) preparation. This fact favored the continued use of a magistral formulation. The growth of the market for magistral drugs and the non-existence of immediate-release (IR) morphine commercial products possibly facilitated a negative outcome, namely the increase in price of the magistral preparations. As a result, there was greater availability of expensive magistral preparations in many cases with higher prices than those of the commercial products. It was more difficult to obtain less expensive drugs. When the first immediate-release morphine appeared, its price was similar to that of the SR morphine preparation. The price was significantly reduced, probably to distinguish it from the SR preparation and also to compete with the magistral preparations. This may have been the first positive result of the competitiveness in the opioid market. The second positive result of this competitiveness might have been the sharp and significant decrease in price of a second commercial IR morphine. The price of this drug was initially high and was recently set at a similar level as the international price and lower than the average cost of magistral prescriptions. This price reduction was probably induced by the appearance of methadone in the Argentine market, which was the least expensive analgesic option. We hope that this last change will generate a third positive fact in the near future: the reduction of the price of methadone to its international value. These analyses indicates that quality products can become available, and also favor the more inexpensive one. The search for the best cost/benefit ratio, its promotion and diffusion, is an ethical responsibility for all of us who are in clinical and teaching positions and wish the most convenient treatments for our patients. In Argentina, the efforts to disseminate this concept, the implementation of clinical and teaching programs based on WHO and Pan-American Health Organization recommendations, and the free competitiveness of the pharmaceutical companies in a liberal market have achieved substantial changes in the availability of low cost opioids.