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

2. 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. Total market size now: 74 kg Potential market size: >651 kg 9-fold growth potential in the near term Demand in morphine equivalents (ME) versus minimum need

3. Growth beyond this minimum need is unlikely in the near-term Minimum need 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

4. Region Total market size (kg NMME) East Asia & Pacific 12, 961 Europe & Central Asia 77, 227 Latin America & Caribbean 3,0 22 Middle East & North Africa 1,0 91 North America 17 2,461 South Asia 33 9 Sub-Saharan Africa 1,3 21 Grand Total 26 8,422 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 Kyrgyzstan Pop – 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) 2014 2.19 kg (1.64 kg oral,.55 kg injectable) 2015 2.74 kg (2.05 kg oral,.69 injectable)

13. Need in Armenia Pop – 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 Ukraine Pop - 45,706,100 Morphine need = 515.68 Kg 32.086 kg current 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 Kazakhstan Pop – 16,558,459 118.61 kg needed 3.63 kg current usage all injectable =8.52 Kg Adjusted 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 Tajikistan Pop: 7,708,500 17.74 Kg needed.817 kg current usage all injectable =2.04 Kg Adjusted 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