Morphine painkillers for the dying still rare in IndiaThe regulations became stringent

CHENNAI: Bridha Raghunathan lay still on the frail wooden cot in her house in Chennai. She could not move her arms and legs anymore. Her eyes, devoid of expressions, were fixed on an empty spot in the ceiling, but tears rolled out of them. A few days before, she twisted her ankle and fell twice in the span of just a few hours, the second fall severely injuring her head and back. Her organs were failing one after the other. She couldn’t walk straight after her brain’s functions slowed, and she couldn’t control her limbs anymore.

Brindha, terminally ill from cardiac complications, was sent back home for the last time by doctors, after she frequented them for over a decade with different sets of health complications. The fall was merely catalysing the dying victim’s impending end. After involuntarily chewing repeatedly on empty words for minutes, she mustered a sentence.

“My back hurts badly, turn my body around please. I fell down,” she said without emoting. More tears rolled out of her eyes. A few hours of silence and tears later, she involuntarily chewed for a while again and said, “My back hurts. Are you hitting me? Don’t! Turn my body please!” Neither Brindha, nor her family was aware that they could make her death less painful. She bore traumatic episodes of pain she couldn’t fully express, threw up a dozen times and succumbed to death the next day. She is among the 96 per cent of people from low and middle income countries who are either unaware or did not have access to palliative health care that offers morphine as an alternative to excruciating pain.

Purview of the rich

Globally, some 61 million people suffer serious physical and psychological suffering and pain each year. Of this total, some 83 percent live in low and middle-income countries where access to low-cost, off-patent morphine is rare or completely unavailable, even though the cost should be pennies a tablet, according to a recent study by the Lancet Commission on Global Access to Palliative Care and Pain Relief.

“Of the 298.5 metric tons of oral morphine distributed worldwide, only 10.8 metric tons, or 3.6 percent, go to low and middle-income countries,” the report observed. Morphines are drugs that bind to the opioid receptors, which are on the surfaces of nerve cells in the brain and spinal cord. This triggers a chain of chemical signals within the cell making the cell membrane less excitable. This means that pain-sensing nerve cells become electrically ‘sluggish’ and don’t fire so many impulses.

“The annual burden in days of severe physical and psychological suffering is huge — 6 billion days worldwide, 80 per cent in the low and middle-income countries,” the study pointed. India grows opium poppy under license in Uttar Pradesh, Madhya Pradesh, and Rajasthan. Under strict supervision of the government, opium is extracted from these poppies and then exported, before being used to manufacture opioid analgesics around the world. Only a tiny fraction of the raw material is converted to morphine for domestic medical use.

How use of painkiller declined

India is one of the world’s largest exporters of morphine, yet prohibitive laws make access to morphine for medical purposes near-impossible. There are only about 250 medical centres that have permission to prescribe morphine pain killers in India, of which 117 are in Kerala. Tamil Nadu features in the top three despite having only 20 centres.

Morphine is classified as a narcotic under the Narcotic Drugs and Psychotropic Substances Act (NDPS) 1985. The cultivation of the poppy, collection of opium and manufacture of morphine is controlled by the central government, while sale and distribution is controlled by the State government. “The regulations became stringent and penalties tougher. Certification became extremely tedious for medical institutions. During this period, the use of morphine as painkiller became virtually negligible,” said MR Rajagopalan, the managing director of Pallium India, a leading organisation in palliative care, based in Kerala.

This was the same time when World Health Organisation (WHO) was advocating the use of morphine for end-of-life care and listed it as an ‘essential drug’. While more countries in the world were inducting the use of these drugs into palliative care, India saw a reverse trend. Between 1985 and 1997, morphine consumption decreased by 97 per cent, reaching a low of 18 kilograms in 1997 and India’s per capita consumption of morphine ranked 113th of 131 countries. During the same period, global consumption of morphine increased by 437 per cent.

With the government breathing hot air on all transactions, medical use of morphine and pain management started slipping out of academic medical training. This created a whole generation of doctors in the country who did not know how to prescribe or administer the drug correctly. After years of campaigning, in 2014, an Amendment to the Narcotic Drugs and Psychotropic Substances (NDPS) Act was passed by the parliament.

The amendment enables medical institutes to procure morphine by obtaining a single licence from the State Drugs Controller rather than five. In theory this should make access to morphine easier. Reality is however very different. Human Rights Watch estimated that the amount of morphine India used in 2008 was sufficient for just 4 per cent of patients with advanced cancer. Rajagopalan estimated that the scenario has not changed much since.

Fear of addiction

Through decades of strict regulation, medical professionals have developed a fear for morphine; they do not use it and teach students to avoid it. There are exaggerated fears of addiction and overdose reinforced by an unbalanced regulatory environment. This also means most pharmacies don’t have stock. “Tamil Nadu has been extremely welcoming to new palliative care centres opting for morphine.

However, there is a large moral block against the use of the drug,” said Deepa Muthaiya, the founder of Dean Foundation, a palliative health care centre in Chennai. Although very limited, cities still have little basic access and awareness about medical use of painkillers for end-of-life treatment. “Freeing a dying person from pain dignifies their death,” added Muthaiya. Pain is all around end-of-life treatment. Pain management can, however ,be enforced with awareness.

Global use rose by 437%

Between 1985 and 1997, morphine consumption decreased by 97 per cent, reaching a low of 18 kilograms in 1997 and India’s per capita consumption of morphine ranked 113th of 131 countries. During the same period, global consumption increased by 437 per cent.