Freedom from Pain – Part Two
Why is worldwide access to morphine so poor?
Morphine is deemed an essential medication for a basic healthcare system to function (WHO Model List of Essential Medicines) but it is effectively unavailable in almost 150 countries.  Just a handful of Western countries consume 90% of the global opioids; Australia, Canada, New Zealand, the United States of America and several European countries.
Prohibition, intended to curb drug abuse, has been the focus of international and national laws  (1961 the UN Single Convention on Narcotic Drugs).  The inadvertant consequence is that millions of people are denied morphine and suffer unnecessarily, dying in pain.  In 1971 Richard Nixon launched the ‘war on drugs’; one of the most influential political and public health campaigns shaping public opinion. We now have evidence that prohibition fails to stop drug abuse, instead it results in thriving criminal markets.
Powerful political campaigns and prohibitive drug laws seep into the public psyche. People are scared of morphine – they know it as a ‘street drug’; a drug of abuse, addiction and social decline. Doctors who have little experience in prescribing it are scared of side effects such as reduced consciousness and respiratory depression, as well as addiction and abuse. When the person using morphine is not in pain, the effect on the neurological system causes euphoria, and can lead to psychological and physical dependence. In palliative care when morphine is used appropriately, addiction is very unlikely. Even in countries like the UK, this fear and ignorance can create a cultural barrier to the use of opioids as medicines.
Law in India
Morphine is classified as a narcotic under the Narcotic Drugs and Psychotropic Substances Act (NDPS) 1985. The central government controls the cultivation of the poppy, collection of opium and manufacture of morphine. The sale and distribution of morphine is controlled by the state government. Kerala, the state at the forefront of palliative care with over 80% of India’s palliative care programmes, has relatively relaxed regulations so the supply of morphine is reasonable. In states such as West Bengal, the access is much more limited.

Patient in Kerala who benefits from palliative care at home
Many committed individuals, including Dr Rajagopal, have campaigned for decades for new legislation to improve access to morphine. There was a breakthrough at the beginning of 2014 when an Amendment to the Narcotic Drugs and Psychotropic Substances (NDPS) Act was passed by 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. We are yet to see the benefits in West Bengal.
It is easier to find men who will volunteer to die, than to find those who are willing to endure pain with patience
Julius Caesar
Improving Opioid Availability
Improving government legislation and policy is just the beginning. More hurdles exist, including the lack of medical expertise.  Most doctors in India have not been trained in how to use morphine. Even in countries such as the UK, where doctors are trained  and access is well established, prescribing is often suboptimal. And even if prescribed well, cultural barriers and stigma mean that patients may be reluctant to take morphine. To overcome these interrelated problems the WHO recommends a three-pronged approach addressing;
1 drug availability; production and guaranteed accessibility at low cost by pharmaceutical companies
2 government policy
3 education; of healthcare professionals and the public

EIPC has information kiosks about Palliative Care in busy government hospitals
Proponents of palliative care in India work tirelessly to address the above three recommendations, recognising that morphine is essential to pain relief and pain relief is the cornerstone of successful Palliative Care Programmes.
If you are interested to find out more about access to morphine worldwide, I recommend this excellent film:
Freedom from Pain – Part One
Morphine is produced in abundance in India and is one of the cheapest and most effective pain killers known to man.  It is regarded as the gold standard of analgesics to relieve intense pain in the World Health Organisation (WHO) pain treatment ladder.  Yet due to stringent drug enforcement laws only 1-2% of patients in India with severe pain, including cancer pain, receive morphine.  Availability and access to morphine is a global problem.  Freedom from pain must be regarded as a human rights issue.
Daily, morphine can alleviate pain and suffering for just 7 pence. Tramadol (the next best painkiller available in my hospital) costs 72 pence per day – more than ten times the amount of morphine. Given the fact that almost a quarter of people in Kolkata live on less than 27 pence a day, morphine is affordable where weaker painkillers are not.
It is not just a painkiller; it has other helpful properties such as relieving breathlessness. Breathlessness can be an extremely distressing symptom at the end of life for cancer patients as well as palliative patients with lung disease, heart failure and renal failure.

Papaver Somniferum Poppy
Morphine sulphate, an opioid medication and narcotic drug is grown in large quantities in poppy fields in the states of Uttar Pradesh, Madhya Pradesh and Rajasthan.  India is one of the world’s largest exporters of morphine, yet prohibitive laws make access to morphine for medical purposes near impossible.  A morphine licence (or five) can be obtained, however the paperwork involved is insurmountable for many medical institutes in India. 
The Situation in my hospital
Miss Dutta* was diagnosed with sarcoma (bone cancer) when she was just 28 years old. Five years on and the cancer had spread throughout her body with secondary deposits in her bones, lungs and spinal cord. Her legs were paralysed, she was no longer able to walk and she required a urinary catheter. The symptoms that were most distressing for her were the pain in her chest and intermittent breathlessness that worsened towards the end of her life – she had very little functioning lung left due to the cancer. She required an increasing dose of morphine to alleviate the pain and the breathlessness, but thankfully it worked well for her. Well enough to ensure she was comfortable, mostly pain free and able to talk with us and more importantly spend time with her family in the last few weeks and days of her life. Without morphine it is difficult to know how Miss Dutta or her family would have coped with the last stages of her debilitating illness.
The hospital I work in has stocked morphine for the past two decades, but this is not an easy process. Although the law has recently been amended on a national level to improve access to morphine, the implementation of this is yet to be seen. At present, a total of five different licenses are required to procure morphine.
When trying to explain the difficulties medical institutes face in applying for a morphine licence, a wise Indian doctor said to me “the British brought bureaucracy to India, and we took it to a whole new level”. Most people who have travelled in India will have some insight into the bureaucratic mazes faced, whether that be trying to register a visa, or simply booking a train ticket as a foreigner.   Imagine the frustration of trying to apply for multiple licences to supply an ‘illegal’ substance on medical grounds. Understandably, most institutes do not apply.
One licence is required to stock the medication under lock and key. This licence used to last only six months but it has recently been extended to twelve months. A separate licence is required to stock the liquid or injectable form of the medicine. A further three permits are required to transport the morphine from the state that produces it to the hospital: an export permit, a transport permit and an import permit. And each of these permits only lasts for six months.
Not too long ago my hospital faced a situation where the transport permit application had been delayed and the export permit was nearing the end. When the transport permit was eventually issued, there was only a small window of time where all three permits overlapped. There was a problem with the lorry transporting the morphine; it got held up long enough for the export permit to expire. Thus the protracted application process had to start over again, and the hospital ran out of morphine.
Lean patches, where the morphine stock is running low, are not uncommon.  Doctors have to think carefully about who they prescribe morphine to. The worst case scenario is when they run out and patients who were stable on morphine can no longer have it, resulting in a deterioration in their pain control. The stock is never plentiful as the amount the hospital procures must be based on evidence of how much they use.

A patient receiving morphine from the home care team
Morphine is essential for good pain control, and pain control is central to palliative care.  In the Part Two of this blog I will address the political and cultural aspects of opioid availability, and how access to morphine can be improved.


Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: