Global Access to Pain Relief Initiative (GAPRI)

1. Global Access to Pain Relief Initiative (GAPRI) Market Forecast in Eastern Europe and Central Asia Meg O’Brien March 2013

2. Demand in morphine equivalents (ME) versus minimum need 9-fold growth potential in the near term Total market size now: 74 kg Potential market size: >651 kg Notes: Current consumption is based on 2010 data reported to the International Narcotics Control Board Minimum need is based on number of deaths from HIV or cancer, assuming 50% of HIV deaths and 80% of cancer deaths require 67.5mg of morphine for approximately 3 months.

3. Growth beyond this minimum need is unlikely in the near-term Consumption relative to minimum need from HIV or cancer deaths On average, consumption does not exceed the minimum need in low or middle-income countries. 651 kg is the maximum growth expected in the near to medium term Minimum need

4. Global market The global market, excluding North America, is about 96,000 kg These five countries represent about 0.1% of it, with near-term growth to about 1% Notes: Total market size is based on 2010 consumption data reported to the International Narcotics Control Board

5. Estimating the near term need for oral morphine by country • Estimate of cancer mortality from WHO Global Burden of Disease estimates, country data, GLOBOCAN estimates & Global Atlas of Palliative Care at the End-of-Life. • INCB morphine consumption data from Univ. Wisconsin Pain and Policy Studies

6. Estimating the near term need for oral morphine by country • Two Methods Used (from INCB) • Morbidity-based Method • Consumption-based Method • The morbidity-based method is used to determine need while the consumption method is used to predict requirements. The market assessment will lie in between these two methods.

7. Need in KyrgyzstanPop – 5,507,000 • Morbidity Calculation Assumptions: • 80% of cancer patients will need palliative care • 80% of 3400* = 2720 • The average cancer patient will use 67.5mg of morphine for 90 days • 6,075 mg per cancer patient • HIV cases are negligible

8. Need in Kyrgyzstan • Morbidity Calculation Assumptions: • Non-cancer patients will also need pain relief and palliative care but we will use a conservative amount for their need that will increase in later years. • Morphine needed for safety stocks, progressive non-malignant disease, and for acute pain treatment will add at least 10%.

9. Need in Kyrgyzstan • Need 2720 pts. x 6075 mg = 16,524,000 mg or 16.524 kg for cancer • + 10% for additional needs • = 18 Kg needed minimum

10. Need in Kyrgyzstan • Consumption based Method • Current consumption is .1048 mg per capita • Population is 5.334 M • 5.334M X .1048mg = 559,000 mg = .56 kg • .56 kg now used, all injectable • .56 x .75 = .42 x 3 = 1.26 + .14 = 1.4 KG Adjusted current usage (we increase the mg converted from IV to oral x3 to equal analgesic conversion)

11. Need in Kyrgyzstan • Assumptions: • 2 new hospice/palliative care teams in Kyrgyzstan • Oncologists in Bishkek & Osh polyclinics begin using oral MS on some patients • 25% annual increase in current morphine use over the next 3 years • 25% Injectable, 40% Slow Release tabs, 35% Immediate Release tabs • Ideal ratio <10% injectable, 60% Slow 30% immediate

12. Projected Need in Kyrgyzstan • Combined Market Estimate • 2013 1.75 kg (1.31 kg oral, .44 kg injectable) • 20142.19 kg (1.64 kg oral, .55 kg injectable) • 2015 2.74 kg (2.05 kg oral, .69 injectable)

13. Need in ArmeniaPop – 3,100,000 • Same assumptions • 80% of cancer patients will need palliative care • 80% of 5,100* = 4,080 • The average cancer patient will use 67.5mg of morphine for 90 days • 6,075 mg per cancer patient • HIV cases are negligible

14. Need in Armenia • 4,080 patients • X 6075 mg = 24,786,000 mg or 24.8 Kg • + 10% for additional needs • = 27.3 Kg needed

15. Need in Armenia • Morphine consumption in Armenia in 2010 is .3904 mg per capita. Add 10% = .42944 mg per capita • Population is 3.09M • 3.09M X .42944 = 1.327 kg current usage, all injectable • 1.327 x .75 = .995 x 3 = 2.99 + .33 = 3.3 KG (we increase the mg converted from IV to oral x3 to equal analgesic conversion)

16. Need in Armenia • Assumptions: • 4 current hospice/palliative care pilot teams in Armenia • Expand to 10 hospitals providing palliative care in next 3 years • 25% annual increase in current morphine use over the next 3 years • 25% Injectable, 50% Slow Release tabs, 25% Immediate Release tabs • Ideal ratio <10% injectable, 60% Slow 30% immediate

17. Projected Need in Armenia • 2013 3.3 kg (2.475 kg oral, 0.825 injectable) • 2014 4.15 kg (3.11 kg oral, 1.04 kg injectable) • 2015 5.19 kg (3.89 kg oral, 1.3 kg injectable)

18. Need in UkrainePop - 45,706,100 • Morphine need = 515.68 Kg • 32.086 kgcurrent MS usage, all injectable • = 80.3 Kg Adjusted current usage (75% oral) • Projected Need (25% annual increase) • 2013 100.4 kg (75.3 kg oral, 21.5 kg injectable) • 2014 125.5 kg (94.1 kg oral, 31.4 kg injectable) • 2015 156.9 kg (117.68 kg oral, 39.22 kg injectable)

19. Need in KazakhstanPop – 16,558,459 • 118.61 kg needed • 3.63 kgcurrent usageall injectable • =8.52 KgAdjusted current usage (75% oral) • Projected need (25% annual increase) • 2013 10.65 kg (7.99 kg oral, 2.66 kg injectable) • 2014 13.31 kg (9.98 kg oral, 3.33 kg injectable) • 2015 16.64 kg (12.48 kg oral, 4.16 kg injectable)

20. Need in TajikistanPop: 7,708,500 • 17.74 Kg needed • .817 kgcurrent usageall injectable • =2.04 KgAdjusted current usage (75% oral) • Projected need (25% annual increase) • 2013 2.55 kg (1.91 kg oral, .64 kg injectable) • 2014 3.19 kg (2.39 kg oral, .8 kg injectable) • 2015 3.99 kg (2.99 kg oral, 1.0 kg injectable)

21. Limitations • Cancer mortality is underreported • Numbers are based on stated assumptions. If assumptions change the numbers change • Assumptions may be incorrect. They are in some cases best guesses. • Increased morphine use dependent on education and change in practice