OnCo
ideasIdea

Trials of low-cost opioid alternatives where morphine supply is unreliable

When morphine is unavailable, patients get nothing. Some cheap alternatives, such as methadone or tramadol, may work for cancer pain but have not been properly tested in these settings.

Morphine stock-outs are common in LMICs, leaving patients without analgesia. Methadone is inexpensive, long-acting, and effective for cancer pain but needs careful titration; tramadol is widely available but weaker and not internationally controlled, which affects supply differently. Pragmatic trials of protocolised methadone or tramadol-based regimens delivered by nurses in settings with unreliable morphine would establish safe fallback options and could inform essential medicines lists.

Hypothesis
A protocolised methadone regimen delivered by trained nurses will achieve pain control non-inferior to oral morphine in patients with moderate to severe cancer pain, with acceptable safety.
Rationale
Methadone is already used for cancer pain by specialists in high-income countries and is on the WHO essential medicines list; the question is safe delivery by non-specialists.
What would test it
A randomised non-inferiority trial in three LMIC centres comparing methadone protocol with morphine on pain scores at two weeks, with sedation and QT monitoring as safety endpoints.
Maturity
speculative
Who has to act
research
Cost to try
Medium ($1M to $50M)
Years to first evidence
4
Bottlenecks it attacks

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