Yesterday, we visited the Kumudini Devi Palliative Care Centre / Hospice in Hyderabad. This center is part of the Pain Relief and Cancer Care Society in Hyderabad, which provides home visits and community outreach to rural areas, outpatient palliative care, in addition to this inpatient center. The inpatient center is a 24-bed inpatient hospice program for those below the poverty line. We met a couple of the physicians managing the place, and yet again I was swept away. These past few days, I have met not one but five physicians who have dedicated their time and skills to the sick and the needy in every sense of the word. Never before have I been so inspired and so humbled. One of the issues brought up during our time there was the access to opioids in India.
Despite the significant and rising number of cancer patients in India, many of whom are terminally ill, morphine continues to be the only oral opioid available here. To make things even more complicated, the Government of India created the Narcotic Drugs and Psychotropic Substances (NDPS) Act in 1985 in an attempt to prevent the misuse of opioids. This mandated stringent licensing procedures, regulated at the state level. In order to be able to prescribe morphine, a provider or a hospital typically needed as many as three or four licenses. Frequently the validity of one license expired by the time another license was obtained. And even if providers were to commit to this and somehow succeed in acquiring all the required licenses, patients continued to have serious difficulty filling these prescriptions as pharmacists out in the community stopped stocking morphine due to fear of imprisonment due to even small inconsistencies in stock.
Due to these complicating licensing procedures, the consumption of morphine in India decreased by 97% between 1985 and 1997. During the same period, global consumption of morphine increased by 437 %. As a result, the Department of Revenue of Government of India, which is responsible for the manufacturing and control of opioids in the country, sent out an instruction to all state governments in the country to amend their narcotic regulations and simplify their licensing requirements. Some 13 states amended their regulations, but many parts of India continued to follow the old regulations. Finally, in 2009, the state of Andhra Pradesh became the 14th state to amend the narcotic regulation.
Yesterday, we learned that despite the amendment in regulations, access to opioids continues to be a real issue. Patients have to travel far once a month to obtain their opioids. Furthermore, morphine continues to be the only oral opioid available. Also of note, pharmacists tend to aggressively favor fentanyl patches over morphine, as they are more expensive. On the other hand buprenorphine patches can be bought over the counter here, which doesn’t quite add up. Another major driver of poor access to opioids, continues to be lack of awareness and an unsubstantiated fear of promoting addiction or even respiratory depression in terminally ill patients, leading to not only avoidance but under-dosing as well. In fact, according to a 2007 article on the subject, while the total opioid consumption in India increased from the year 1998 to 2008, it was still as low as 1569.825 compared to the 36,500 kg (estimated) needed to provide relief to all cancer patients with pain (1). And yet, India remains one of the major exporters of morphine in the world.
1.Rajagopal MR, Joranson DE. India: Opioid availability – An update. J Pain Symptom Manage.2007; 33:615-622.