M.R.Rajagopal
The repeal of the three farm bills is in the headlines. A little beneath the surface and reportedly all set for the winter session of Parliament are amendments to the Narcotic Drugs and Psychotropic Substances (NDPS) Act. These are causing some worry among medical professionals and palliative care specialists on fears that the “principle of balance” in regulating opioids will be tilted against the interests of patients suffering from intense pain.
The “principle of balance” acknowledges the dual responsibility laid down in the United Nations Single Convention on Narcotic Drugs, 1961. This is the responsibility placed on any government to achieve two ends – prevent inappropriate non-medical use of the medicine while at the same time ensuring its availability for treatment of pain. The lesson is that with reasonable controls, the medicine can be safely used and help relieve pain for patients with cancer and a host of other diseases.
Except for morphine and medicines belonging to that class (opioids), there is no other medicine that can relieve many kinds of pain, particularly about 75% of pains in cancer. It should also be obvious from decades of experience that irrational controls would impact only access to pain relief and have very little impact on non-medical use.
The need for pain relief has been known and clear to health professionals around the world, but the United States recognised this only at the turn of the century. That was when an ill-advised, industry-driven campaign without adequate control measures resulted in the growing abuse of opioids in North America. This became news. The fact that for a quarter of a century prior to that, Western European countries were using opioids effectively and safely, with just enough controls and documentation to prevent it reaching the wrong hands, was not as much reported or emphasised.
It was half a century ago that the growing burden of addiction in the USA resulted in President Nixon announcing the “war on drugs”. India responded to the ensuing ripple effect across the globe, with the Narcotic Drugs and Psychotropic Substances (NDPS) Act of 1985 – a draconian law which effectively paralysed the availability of morphine for pain relief, but had little impact on inappropriate and non-medical use. This law enabled mandatory and harsh punishment for what could even be a clerical error. If a pharmacist or doctor was found in possession of more than 25 grams of unaccounted morphine, the judge would have no alternative but to mete out rigorous imprisonment for a minimum of ten years. The person would not be deemed innocent until proven not guilty, with the onus of proving innocence foisted on the accused.
Hospitals and pharmacies stopped stocking the medicine. State drug controllers stopped issuing necessary licenses. The national consumption of medical morphine came down from more than 600 kgs in 1985 to a meagre 17 kgs by 1998. Rather obviously, that increased the pain burden in the country in inverse proportion.
There should have been a lesson in this for us.
The State of Kerala brought in rational rules in 1998, largely driven by non-government action supported by the government. Morphine and other opioids became at least 15 times more accessible than in the rest of the country, with more than 170 institutions in the State safely stocking and dispensing them for pain relief.
The fact that this has been successfully done in Kerala and demonstrated by another low-income country, Uganda, for decades, has attracted little attention. Contrast this with the attention given to the misuse of drugs and the talk of a “drug epidemic” that we hear globally and now also from parts of India.
Concerted efforts by civil society and medical fraternity advocates eventually bore fruit. Reason prevailed, and in 2014 the Indian Parliament passed an amendment act – which, for the first time, acknowledged the responsibility of the government to provide pain relief. The implementation of the amended law has been incomplete; nevertheless, it was a major step in the right direction.
In recent times, however, there have been unfortunate instances of doctors being jailed and prosecuted on misconceived grounds. This further dissuades them from prescribing controlled medicines or using them in hospitals.
It is essential for enforcement systems to distinguish between licit use and illicit use. Prosecution is warranted in cases of diversion and misuse of opioids, but if arrests happen on misconceived grounds, hospitals and doctors would naturally stop using the medicine. The pharmaceutical industry would be discouraged from manufacturing and distributing them. We will see more and more people with scars around their necks – both successful and unsuccessful attempts – and their children growing up with scars on their psyche. Their numbers will not be in the thousands; they will be in the millions.
Doctors and NGOs working in pain management and palliative care have made a representation to the government, to ensure that professionals and members of the pharmaceutical industry will face prosecution only for illicit use or diversion of controlled medicines and not on misconceived grounds.
The trouble with a campaign for pain relief is that pain and suffering are not very visible till it happens in one’s own family, though there are over a million people with cancer pain in India, and millions more with other diseases. People who have not experienced or borne witness to excruciating pain from diseases like cancer cannot understand the enormity of the suffering – pain like an axe falling on one’s jaw-bone every few seconds or hundreds of needles relentlessly jabbing a foot. These are the experiences that are not usually shared, and when shared, deliberately unheard. A man with cancer in his jaw once asked one of the authors, “Tell me, how can I be strong, when a nail is driven into my ear again and again, through the night and day?”
Similarly, people showing up with a rope burn scar around the neck are not rare in palliative care clinics. The National Crime Records Bureau of India reports that more than 26,000 people die by suicide every year owing to health-related suffering. Having to kill oneself is not the ultimate tragedy. Far worse is not having the strength to do it, and being abandoned to a fate that is worse than death.
India must work to build on the gains painstakingly made over the years, build further on the Kerala experiment and honour the principle of balance – and strike a compassionate balance between the government’s responsibility to control drug misuse and its responsibility to mitigate unnecessary suffering caused by excruciating pain.
(Dr. M R Rajagopal is the Chairman of the non-profit Pallium India and Director, WHO Collaborating Centre for Training and Policy on Access to Pain Relief. Jagdish Rattanani is a journalist and a faculty member at SPJIMR) (Through The Billion Press)