title: A comparison of the resources used in advanced cancer care between two different strong opioids: an analysis of naturalistic practice in the UK.
abstract: OBJECTIVE
  To assess the resource implications of using strong opioids in patients with advanced cancer in the UK, based on naturalistic practice, in order to develop the evidence base supporting better management.
  
  
  METHODS
  A modelling study performed from the perspective of the UK's National Health Service (NHS). Study participants and interventions: A data set was created from the DIN-link database comprising 986 patients with advanced cancer who were prescribed either 12-hourly sustained release morphine (SR morphine; MST Continuous) ( n = 784) or transdermal fentanyl (Durogesic) (n = 202) as their first strong opioid between 1st January 1998 and 30th September 2000 and died during that period.
  
  
  METHODS
  Palliative care-related resource use data were obtained from the DIN-link database. Unit costs at 2000/2001 prices were applied to the resource use values to determine the mean NHS cost of palliative care from the start of treatment until death.
  
  
  RESULTS
  Patients initially treated with transdermal fentanyl started their strong opioid regime 8.5 years after diagnosis compared to 6.4 years after diagnosis in those who started SR morphine. This equates to an overall survival period from diagnosis of 8.8 years and 7.4 years respectively. Nevertheless, the total NHS cost of palliative care was similar between treatment groups, ranging from a mean 3087-3462 pounds per patient. Hospitalisation accounted for up to 71% of the total cost and opioids accounted for up to a further 17%. Less than one-third of patients received 4-hourly morphine as part of their initial opioid treatment despite UK guidelines recommending that moderate-to-severe pain should always be managed initially with an immediate-release preparation. Additionally, patients who received transdermal fentanyl as part of their initial treatment received significantly more laxative prescriptions than patients who started with SR morphine.
  
  
  CONCLUSIONS
  SR morphine and transdermal fentanyl seem to be used in different situations. The results also confirm previous findings that pain management in cancer patients is often sub-optimal. The low contribution of opioids to the overall costs indicates that this should not be an obstacle to starting this aspect of palliative care earlier in disease progression. This characterisation of the resource implications of using SR morphine and transdermal fentanyl should enable purchasers and providers to optimise the availability of strong opioids for cancer patients on medical, economic and humanitarian grounds.
authors.affiliation: CATALYST Health Economics Consultants, Northwood, Middx, UK. julian.guest@catalyst-health.co.uk
authors.forename: Julian F
authors.initials: JF
authors.lastname: Guest
authors.forename: Francis J
authors.initials: FJ
authors.lastname: Ruiz
authors.forename: Jo
authors.initials: J
authors.lastname: Russ
authors.forename: Roben Das
authors.initials: RD
authors.lastname: Gupta
authors.forename: Adela
authors.initials: A
authors.lastname: Mihai
authors.forename: Mark
authors.initials: M
authors.lastname: Greener
mesh_terms: D000279:Administration, Cutaneous; D000293:Adolescent; D000328:Adult; D000368:Aged; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000493:pharmacokinetics; D002648:Child; D002675:Child, Preschool; D003692:Delayed-Action Preparations; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage* / Q000191:economics; D017048:Health Care Costs; D006295:Health Resources / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage* / Q000191:economics / Q000493:pharmacokinetics; D009369:Neoplasms / Q000191:economics* / Q000503:physiopathology; D010146:Pain / Q000188:drug therapy* / Q000191:economics / Q000209:etiology; D010166:Palliative Care / Q000191:economics*; D012189:Retrospective Studies; D013222:State Medicine / Q000191:economics / Q000706:statistics & numerical data; D006113:United Kingdom
chemical_list: D000701:Analgesics, Opioid; D003692:Delayed-Action Preparations; D009020:Morphine; D005283:Fentanyl