In America, the overuse and misuse of opioids is a growing health problem. Morbidity and mortality associated with opioid use has increased substantially over the last decade and a half. Both prescription opioid use and heroin use are contributing to the problem, and the trend is concerning enough to have been coined “the opioid epidemic.” The statistics associated with opioid misuse are quite shocking. Between 2000 and 2014, deaths from from overdoses quadrupled, and emergency room visits related to misuse increased by 153%. In conjunction with this, the number of opioid prescriptions have also increased, from 76 million in 1991 to over 240 million in 2014 (1).
The use of opiates to treat pain dates back to the 19th century. During this time, medical interventions were scarce, and the cause of medical complaints was usually not known. As a result, morphine injections were often given to quickly alleviate discomfort. As medical knowledge progressed and other types of analgesia came about, the use of morphine decreased significantly. It wasn’t until the 1980s that opioids started to be used for chronic pain. In 1995, oxyContin, which is a long-acting opioid, hit the market. Shortly thereafter, pharmaceutical companies started taking a vocal interest in the use of opioids for chronic pain. They were key players in initiating the “Pain is the 5th Vital Sign Campaign,” which encouraged physicians to aggressively treat chronic pain and to assess pain with the “same zeal” as they would with other vital signs. To counter concerns about the safety of opioids, campaign advocates downplayed their potentially negative consequences, using poor quality studies to claim that addiction rates were less than 1%. They also endorsed that the risk of respiratory depression was short-lived (2). The rise in opioid prescription rates and the broader acceptance of opioids stemming from these efforts has led to a greater environmental availability of opioids and a subsequent rise in their nonmedical use. (3)
In India, opioids play a much less prominent role in medical care. In contrast to America, where two years ago there were more than three bottles of opioids prescribed per adult, the availability and administration of opioids is scant. The statistics illustrating this are as equally disturbing as the drastic rise in opioid-related deaths in the states. A review of India’s opiate policies by the Pain and Policies group at Madison, Wisconson estimated that only 0.4% of people in need of opiates for cancer-related pain or chronic pain actually received them (4). During our travels, we visited a rural center for HIV care. The head physician there lamented that when a patient was made CMO, the only pain relief they received was from a combination of NSAIDs, Tylenol, and Tramadol, as anything stronger than tramadol wasn’t allowed.
Unlike many developing countries, India’s dearth of opioids is not related to supply or cost. Three states in northern India produce over 90% of the world’s legal opium. Although most of this is exported, the copious and internally-produced opium supply means that morphine could potentially be manufactured and distributed at a relatively low cost. Instead, it’s the Narcotic Drugs and Psychotropic Substances (NDPS) Act that prevents patients from getting adequate pain control. Instituted in 1985, its main purpose is to prevent drug trafficking and drug abuse. It allows the central government to control morphine production, from the cultivation of poppy seeds to its manufacturing and selling. The most significant upshot has been a depletion of India’s opioid supply, with medicinal use of morphine dropping by 97% in the twelve years following the NDPS (5).
On top of this, physicians and pharmacists face both logistical and cultural barriers to opioid distribution. Doctors have to obtain up to six licenses to prescribe morphine, and even minor offenses of the NDPS’s rules and regulations can lead to harsh punishments, including up to twenty years of imprisonment. Both of these things dissuade offices and pharmacies from even carrying morphine, and many manufacturers have stopped producing it. A secondary consequence of this strict regulation has been a somewhat exaggerated fear among medical professionals of using opioids and a reluctance among the general public to accept them. Moreover, medical trainees aren’t educated on how to safely prescribe them, and palliative care education occurs in fewer than 20% of medical colleges (4, 5).
In America, the overprescription of opioids has led to a crisis of addiction. In India, underpresciption has led to a crisis of pain. What ties these two crises together, though, is that they’ve resulted from marketing and policies that were driven by forces not so scientifically based. In America, economics helped push opioids onto the market. In India, fear of addiction and drug trafficking motivated creation of the NDPS. Each country honed in on only one aspect of opioids rather than emphasizing the medical benefits they have when prescribed judiciously for a specific purpose. Now, both countries face very different problems but are both struggling with populations that are experiencing unnecessary suffering.
- Wilson, et al. Relationship between Nonmedical Prescription-Opioid Use and Heroin Use. New England Journal of Medicine. 2016;374(2):154-163.
- Kolodny, et al. The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction. Annu. Rev. Public Health. 2015. 36:559–74
- The Opioid Epidemic: By the Numbers. Department of Health and Human Services. www.hhs.gov/sites/default/files/Factsheet-opioids-061516.pdf. Published June 2016. Accessed August 2016.
- Rajagopal MR, Joranson DE. India: Opioid availability – An update. J Pain Symptom Manage. 2007;33:615-622.
- Sharif, Ume-e-Kulsoom. An Epidemic of Pain in India. The New Yorker. Published December 5, 2013. Accessed August 2016.