While amendment to this act was meant to make access to morphine and other such opioids easier for those suffering from pain, stringent jail terms and fear of addiction means that few doctors prescribe them
By Shobha John
When Nidhi Gupta*, a media professional, was diagnosed with breast cancer a few years back, she kept her spirits up. A pleasant woman, she was well liked by her friends and neighbors. As the disease progressed, Nidhi first had to get rid of one breast and undergo regular sessions of chemotherapy and radiation. But as the rampaging cancer took a hold of her lithe frame, she had a relapse. She had excruciating pain which was eased by small doses of morphine. Yet, she would get irritated at her care-givers, leaving them hurt and befuddled. Doctors slowly increased the morphine until they couldn’t give any more. She finally passed away in peace a few months back.
Nidhi’s family was glad that they got morphine to ease her last days. This and other opioids ease severe pain in diseases such as cancer, myocardial infarctions and postoperative pain. According to a UN report last year, some 5.5 billion people have limited or no access to proper pain relief treatment. It is believed that less than four per cent of the 10 lakh in India who suffer from chronic pain due to cancer have access to morphine. In many cases, patients have begged their doctors for relief as they scream and thrash about in pain, so much so that death ultimately comes as a relief.
While earlier it was difficult to procure these opioids, amendment in the Narcotic Drugs and Psychotropic Substances Act in 2014 has made things easier. Registered agencies can procure opioids for scientific or medicinal purposes by obtaining a single licence from the Drugs Controller in place of the four or five needed earlier.
Also, once the new amendment and regulations are implemented, hospitals and clinics would be able to stock it. But despite this Act, the ground reality is that there are still lacunae before patients can get these drugs easily. Experts say that implementation of the new law will be successful only if state governments don’t bring in additional procedural restrictions. While the drugs controller of the state is now the single agency for approval of Recognized Medical Institutions, if as part of his normal enquiry he starts seeking concurrence from other government departments, the Act will lose its efficacy.
Firstly, there are very few institutes which offer palliative care or store morphine and other strong opioids such as methadone. No one wants to take the responsibility for a patient who has got addicted to them. But can it lead to addiction? Experts say that the risk of addiction in the case of cancer is next to nothing. However, when used for non-cancer pain, which can go on to decades, there is a risk. One estimate says it could be as much as 10 percent. But guidelines recommend opioids for non-cancer pain only as a third-line measure. For short-term use of less than three weeks, there is no risk of addiction, they say.
FEAR OF ADDICTION
Nonetheless, the fear of opioid addiction has led to a plethora of laws in various countries to contain their use even for medical purposes. But the International Narcotics Control Board says that about 92 percent of the world’s morphine is consumed by only 17 percent of the world population, namely those living in the US, Canada, Western Europe, Australia, and New Zealand.
In the US, the use of painkillers has, in fact, reached epidemic proportions with many patients hooked to them. Centers for Disease Control and Prevention have even cautioned about prescribing opioids to non-cancer patients. US doctors also check databases to ensure that patients have not already been prescribed opioids elsewhere.
As for the developing world, most of its poor people simply learn to live with the pain due. Ukraine, for example, allows patients to take home only a 15-day supply of morphine. In Russia, access to morphine is riddled with a lot of paperwork. In Armenia, cancer patients have to make numerous rounds to oncologists and expert committees before some morphine is given to them. In Nigeria, said The Economist, while morphine started being imported from 2012, pharmacists from hospitals have to physically travel through its bad roads to Lagos, its capital. Colombia, on the other hand, produces its own opioid painkillers, but here again the problem is of procuring them, especially for those from rural areas. Nepal, on the other hand, didn’t use 50 percent of its supply of morphine tablets due to the fear of addiction. But when it can ease mind-numbing pain, it seems inhumane not to give it to such patients.
This is the principle of balance—while we have a duty to curb the abuse of these drugs, we also have a duty to provide it for those who need them desperately.
But one reason for the morbid fear of keeping or prescribing these opioids in India is stringent punishment, leading to doctors and hospitals having a hands-off approach. The amended law has not done away with the mandatory imprisonment of 10 years. Experts say this is a grossly unfair situation as even clerical errors can lead to that situation.
On top of that, doctors are hardly given any training in how to prescribe morphine or the correct doses to do so. It is essential that the fundamentals of pain management and principles of palliative care be taught to medical students and as advised by the World Health Assembly in 2014.
Morphine, incidentally, is extracted from the poppy plant’s latex. And ironically, India not only produces it but also exports it in huge quantities for medical use in other countries. Yet, against the 329 kg of morphine used presently, the requirement is said to be more than 30,000 kg if everybody here got access to pain relief, said Dr MR Rajagopal, chairman, Pallium India.
Kerala, incidentally, has a good mechanism in palliative care with about 200 NGOs working even in small towns and villages so that the local community will take responsibility to look after the needy there. In addition, based on a proposal submitted by Pallium India in 2005, Kerala declared a palliative care policy in 2008. A growing number of government hospitals is helping out now.
So even as the business of living and dying goes on in a matter-of-fact way in India, some institutions are making a difference and spreading some cheer.
—Mary Mitzy, advocate