International Association for Hospice & Palliative Care

International Association for Hospice & Palliative Care

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Promoting Hospice & Palliative Care Worldwide


2005; Volume 6, No 9, September



Many ways to help support palliative care.

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Article of the Month

Carla Ripamonti, MD

Opioid purchases and expenditure in nine western European countries: “Are we killing off morphine?”

Author(s): F. De Conno, C. Ripamonti, C. Brunelli
Abstract:  Palliative Medicine 2005; 19: 179-184

The primary aim of this study was to evaluate the trend in the amount of sales of four opioid analgesics (codeine, tramadol, morphine, fentanyl) from wholesalers to community pharmacies as an indicator of opioid consumption during 2001, 2002 and 2003 in nine European countries (Belgium, Germany, Ireland, Italy, the Netherlands (NL), Norway, Portugal, Spain and the UK). Particular attention was given to morphine compared to the others. The secondary aims of the study were to compare: a) the amount of each drug purchased by different countries in 2003; b) the average price for each drug in the different countries in 2003; c) and the total expenditure for each opioid from 2001 to 2003.

Data from the Statistical Report on drugs purchased by pharmacies was supplied by IMS Health for our investigation.

In the period 2001-2003, the percentage increase in the purchase of fentanyl and tramadol was considerable, that of morphine was the lowest in all of the countries and was 3 times lower than transdermal fentanyl. In all of the countries considered, there was an observed yearly increase of about 7% in the sales of morphine in both periods. The morphine purchases varied from the maximum increase in Norway (+ 15 % in 2002 vs 2001) to the maximum decrease in Ireland (-11% in 2002 vs 2001). Fentanyl purchases registered a global increases of +25% and +15% in the two periods (all countries together), and reached a maximum in Italy (+70% and +35%), followed by Spain (+37% and + 14%), and the UK (+ 29% and 19%). It could also be observed that the percentage increase of fentanyl purchases was lower in the second period in all countries except the NL.

With regards to the percentage purchase variations of weak opioids in all the countries considered, codeine purchases showed a slight increase similar to morphine in 2003 vs 2002. However, there was a drop in codeine purchases in 2002 vs 2001 and an increase in 2003 vs 2002 in Belgium (-48% and + 7%), in Germany (-8% and + 9%), in Spain (-8% and + 17%). On the other hand, tramadol purchases showed a substantial increase in all the countries together (+11% and +16%) with a marked increase in Norway (+45% and +24%), and moderate increases (from + 15% to + 18%) in Italy , the NL, Spain , the UK . Portugal showed a substantial stability of all opioids purchase data. The largest consumer of codeine was the UK and for tramadol it was Belgium.

There was a high variability in the costs of all the opioids among the different countries. In 2003 the cost of tramadol was highest in Italy (5.95 Euros/g) and lowest in Norway (2.54 Euros/g). Italy was also the country where codeine was the most expensive (14.9 Euros/g) and Norway the country in which the opioids considered were always among the cheapest. Morphine cost ranged from 32.33 Euros/g in Germany to 8.7 Euros/g in Norway ; fentanyl from 2909.00 Euros/g in Germany to 1701.30 Euros/g in Italy.

The trend of expenditure (which depends on both the cost and the quantity consumed) showed a reverse in tendencies. In the year 2001 the highest expenditure was for codeine (69.9 million Euros) followed by fentanyl (55.13 million Euros) and tramadol (54.27 million Euros). In the year 2002, expenditure for codeine and fentanyl are almost equivalent (respectively 70.26 and 70.65 million Euros) whereas tramadol expenditure is about 58.49 million Euros. In the year 2003 expenditure for fentanyl reached the highest level (81.47 million Euros). The expenditure for morphine is the lowest in all the three years considered (from 24.9 to 25.78 million Euros) and corresponds to about 1/3 of expenditure of the other three opioids.

Why I Chose this article

The results of this study open up many questions:

1. Are we killing off morphine?

2. What factors influence opioid purchasing and costs in the European countries?

3. Is it opiophobia or morphinephobia? .

4. What is the role of a more aggressive marketing by the Pharmaceutical Companies?

……for you to find the answers

Carla Ripamonti, MD
Member of the Board of Directors, IAHPC

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