It’s available, it’s not addictive, it’s dirt cheap — morphine is used globally to treat pain. So why do Indian doctors refuse to prescribe it — even in terminal cases, asks Rohini Mohan
If Sunita Pal could have her way, she’d just go home and never come back to the damn hospital. It had robbed her of her hair, energy, and third attempt at her 10th standard exam. “What stage am I at?” she asked the deadpan oncologist in Delhi’s Safdarjung hospital for the fourth time during the 20-minute-long medical examination, and according to her, for the “hundredth time in seven months”. Once again, he simply ignored the waif-thin 18-year-old.
Later that evening, limping slowly towards the bus stand to go home to Patel Nagar with her father, Sunita’s knees suddenly buckled. She grabbed her thighs, and fell onto the road straight on her face. Here it was again. That deep, squeezing pain swirling from her right foot up to her hip. She shook her head from side to side, as if possessed, her mouth open in a scream that wouldn’t release itself. She started to vomit. People gathered. Her father lay on the road next to her, hugging her tight, shouting “Auto! Auto!”. A baffled man in the crowd asked, “But I can’t see, where is the blood? Where is she hurt?” Sunita stared at the man. “I don’t know,” she sobbed. “I don’t know.”
Ever since Sunita was diagnosed with bone cancer, she had been walking around with a dull ache that, every few days, seemed to expand and thrash through her body, like it was beating the insides into submission. She was unrecognisable in her pain. Worse, no one had told her there was an easy cure.
Every year, five million people suffering with cancer, tuberculosis or HIV in India endure unbearable pain. The cheapest, most effective treatment for this sort of intractable pain is morphine. But only 0.4 percent of cancer patients in the country get access to it. That means the rest of them, while receiving treatment for a disease with no known cure, are left suffering with a pain for which safe and full relief exists.
Morphine is an opium-based drug that is globally prescribed to treat pain, especially for terminally ill patients. When administered orally or through injections, it blocks the perception of pain. When a patient is given morphine, it doesn’t treat the cause of pain, which is cancer, or AIDS. It simply blocks the nerve receptors that recognise pain.
But it’s not just about dulling the senses. Neurobiologist Allan Basbaum of the University of California, San Francisco, found in a scientific study in the late eighties that morphine not only relieves pain, but also prevents its occurrence. “Nerves actually remember the body’s past travails, causing permanent changes that are recorded in their molecular structure,” writes Basbaum. This means the more pain you endure, the more sensitive the spinal nerves get, and the more painful the pain will be. “You can end this mailbox effect by reducing the occurrences of pain in the first place.”
Morphine does this. Which is why it is the mainstay of palliative care, a field of medicine that seeks to eliminate pain, and improve the quality of life of patients whose illnesses curb their ability to live normally. It is prescribed based on the intensity and continuity of pain. And the side effects of constipation and dryness of the mouth are easy to overcome.
However, in India, the painkiller is hardly ever prescribed. Is it too expensive? No, a 5mg tablet of morphine costs only Re. 1. Is it not available? No, India is one of the highest producers of legal morphine in the world. Morphine is taboo in the country for a bunch of unscientific and uneconomic ideas.
When I asked Sunita’s Safdarjung doctor why he didn’t give her morphine, he said, “I didn’t want to create an addict. Also, it involves too much paperwork.” He’d given her a Brufen instead, a caffeine-based paracetamol to treat mild aches. In that dismissive wave, the doctor sums up the two reasons morphine is such a bad word in India. Myths about addiction. And a prohibitively strict narcotics policy.
The Indian law to regulate production and sale of narcotics is one of the harshest in the world. Passed in 1985, the core of the Narcotic Drugs and Psychotropic Substances Act is to crack down on drug trafficking. It introduced a long, complex, bureaucratic procedure to obtain permission even for medical use of narcotics. In the process of curbing drug trafficking, the availability of opiates for medical purposes has plummeted. Immediately after the law was passed, legal morphine use fell 97 percent.
Only government-approved hospitals can obtain morphine after registering and submitting an application. Each hospital is allowed only a fixed quota, and each shipment requires five licenses. The morphine pills must be locked in a two-key cabinet, and usually, a separate pharmacist must be hired to maintain records for every pill prescribed by the doctor. The doctor too, must make out the prescription in a form exclusively for morphine. When patients die, families must return unused pills.
No more than 90 pills can be given to a patient at a time. “For patients that come from remote villages, we need to prescribe for a month or at least 15 days,” says Dr Anjay Babu, who studied pain management in Kerala, one of the few states with impressive infrastructure for palliative care. Dr. Anjay now practises in Delhi hospitals and some NGOs helping children with cancer. “Since one tablet relieves pain for four hours, that’s six pills a day, or 180 pills a month. The quota is meaningless.”
It’s not just about relieving the pain. Morphine also prevents its very occurrence
Due to this bureaucratic nightmare, clinics dispensing morphine are scarce. The entire state of Uttar Pradesh however currently has 4 lakh people with cancer, but only one pain clinic. Haryana has close to 60,000 people with cancer, but not a single pain center.
Kerala is the odd exception. This is because the first WHO workshop in the country in the eighties was in Kerela. There, WHO introduced a clear step ladder to treat pain, and at the top of the ladder comes oral morphine. It trained doctors on how to treat pain, and some of them still conduct annual workshops to impart that learning to rural doctors. Thanks to this, and the 20-year-long battle waged by hospitals with the Kerala government and Revenue Department of India, narcotics rules were relaxed in the state. Now, for a population of 75,000 people with cancer, there are 140 palliative centers.
The good news is that in 14 states, rules are being similarly relaxed. In Tamil Nadu, narcotics rules were amended in the year 2000. The Cancer Institute in Chennai, Tamil Nadu, is now allotted 3.6 crore kg of morphine per year, with a provision to up the quota when required. Its Director TG Sagar says that the licensing and availability of morphine is not the chief problem today. AIIMS in Delhi, for instance, consumed 8 lakh tablets last year. The real issue is with awareness – getting doctors even in the 14 states with relaxed rules, to prescribe oral morphine.
There is a stunning ignorance about not just morphine, but pain treatment itself. Dr Rajagopal, who runs the Pallium India clinic in Thiruvananthapuram, Kerala, has been lobbying for morphine to become more accessible, but he says the real challenge is for pain management to be taught to doctors. Out of close to 300 medical colleges in the country, only five in the entire country include palliative care or even pain treatment in their curricula. He says there is no real shortage of morphine as is often believed. “It is just that the system fails to get it across to the person who needs it.”
At a rare class on pain and symptom management at the cancer ward in AIIMS, Delhi, Dr Sushma Bhatnagar tries to get a roomful of young anestheologists, oncologists, and nurses to decipher the different types of pain. “If you want to be a pain physician, everything must come from inside,” she says, her face half-lit by the powerpoint slide behind her that shows a table with pain symptoms and the ways in which patients describe it. Cramping, squeezing, thudding: pain in the muscles, bladder, pancreas, or bones. Burning, (‘Mirchi lag rahi hai’), a current going from ear to ear, shooting: neuropathic pain.
“Tell me,” says Dr. Bhatnagar. “How do you relieve them of this pain?” Someone says counselling. Another says paracetamol painkillers. A list of drugs with specific dosages echo through the room. Someone in the back who’s been to the class the previous year triumphantly shouts out the right answer, “Morphine!” Dr. Bhatnagar goes to her next slide, which says Morphine The Wonder Drug. She is immediately attacked with a volley of questions. “Won’t we get arrested?”, “Will the patient not become a drug addict?”, “Children can’t be given narcotics right?!”, “Do we have to sign an agreement on a stamp paper?”, “I hear they’re not giving licenses for narcotics anymore!”
Narcotics. The things teenagers are warned against. The word paints images of the dirty world of shared syringes, skinny addicts, mufti cops, dope peddlers and suitcases full of white-powder filled packets busted at the airport. It means jail, addiction, law- breaking. Even if morphine is by far the most effective and legal painkiller for severe, disabling pain, it remains burdened by its birth in the poppy fields. Doctors don’t prescribe it even when it is known beyond doubt that most cancer patients can take it without becoming addicted. A 2001 Lancet study in India proved that out of 1723 patients, none had misused the oral morphine nor been addicted to it.
Dr Bhatnagar, who is also on the Directorate General of Health Services board that processes applications for morphine, looks around in shock at the young doctors in the pain conference. “It’s amazing how every year, the most experienced oncologists and nurses ask me the same things, hold the same wrong notions,” she says. She spends the next hour banishing the misconceptions.
It is clear that while the supply part of morphine—narcotics law—is getting gradually fixed, the demand from doctors is the greatest barrier to pain relief, and therefore full care of cancer patients. It is why while global consumption of medical morphine has increased 500 percent since the nineties, India remains one of the lowest consumers (113th in 131 countries). Even the amount consumed is largely injectible morphine, which costs about Rs. 500 a shot, and used in private hospitals. Intra-venous morphine is known to be more prone to cause addiction than the oral variety. “If doctors start learning scientific pain treatment, there will be more applications for oral morphine,” says Dr Bhatnagar. “More patients will be painfree, and it will also force the legal process to become simpler.”
Only four in a thousand patients happen to stumble across a palliative clinic, or a doctor well- informed enough to prescribe morphine. These are shameful odds. At the AIIMS pain clinic in Delhi, Dr Anjay points to a toddler with an eye tumour, and a man who said his cheeks felt like knives were being turned into it. Until they came to the pain clinic, most patients just overdosed on any dard ki goli they can find. Some volunteers here say their loved ones even committed suicide from the unbearable pain. “In our eagerness to cure the disease, we often forget to treat the patient,” says Dr Anjay. “Perhaps our government doctors don’t have time for compassion but the least they ought to do is listen to the proof of science.”
Rohini Mohan is a Special Correspondent with Tehelka.