The NDPS act has been amended after much struggle by a dedicated group of palliative care specialists. Their consistent effort, culminating in the amendment of the act, would undoubtedly benefit millions of cancer pain sufferers. If we are to be a nation which makes meaning in compassionate, constructive and just ways, we should be proud of their efforts. The uniform system of licensing of morphine, wherein the single window clearance comes into effect, would make morphine available and accessible for the many. In five to seven years time, with the entry of private manufacturers, the production of morphine in India is expected to surge from 250kg/year to 30,000kg/year. This increased production and easy availability, we all wish, should reach people who are truly in need. But, there is no guarantee that this would be the case.
For every single cancer pain sufferer there are at least fifty persistent non-cancer pain sufferers in India. At least in metros, according to recent estimates, the prevalence of pain is 20%. These pains are mostly managed in the community by the primary care physician and, when complex in nature, by the secondary and tertiary care specialists. Pain is still seen as a symptom of a disease than an entity in its own right which needs managing. The biological model of managing persistent pain – a failed model but still ingrained in the physicians psyche – would make it tempting for the physicians, particularly the ones practicing in resource poor settings, to prescribe morphine for persistent non-cancer pain. It may be done with the best of intentions or under pressure, but what are the consequences?
When there are no guidelines or policies for prescribing and monitoring opioids in India, it would be unfair to blame the primary care practitioner. There is, in addition, nothing to deter someone who has been misusing the opioid to move to the next physician, in the next building, to get his opioid prescription. Not in the distant future such a scenario may unfold, which would be disturbing and exasperating in equal measure. It would be pointless thereafter to rush for regulatory changes when we could actually learn from someone else’s mistake now. Not in the distant past, in America, a group of palliative care physicians went to town encouraging the use of opioids in persistent non-cancer pain. Iatrogenic drug abuse and accidental prescription drug related death is now one of the major killers in the USA. The practice standards in America are now changing for the second time in a generation – a fine mess indeed.
Morphine is one tool in the management of pain, not the only tool. It is imperative for the pain medicine physicians to emphasize that while morphine has stood the test of time in cancer pain, it has a very minimal or no role in persistent non-cancer pain. In the past few years, due to the rise in addiction and deaths, the pain societies of various countries have rushed to produce guidelines on safe opioid use. The following are some of the recommendations of the British Pain Society on opioids in persistent non-cancer pain
- Data demonstrating sustained analgesic efficacy of opioids in the long term are lacking
- Complete relief of pain is rarely achieved with opioids
- 80% of patients taking opioids will experience at least one adverse effect
- Patients must be aware of uncertainty regarding the long term effects of opioids, particularly in relation to endocrine and immune function
- Opioids should not be used as first line pain therapy if other evidence-based interventions are available for the condition being treated
Pain medicine and palliative medicine are different. The ethos might be the same, but the practice is different. The training is different. The learned societies are different. A case in point is that pain medicine is cautious about opioid use, whereas palliative medicine encourages it. Vouching for Pain Medicine as a specialty, therefore, should be the goal. In addition to implementing pain medicine training at a national level among undergraduates and postgraduates, we should also be important stake holders in any opioid policy the government may introduce, so that the indications for opioid use are clearly laid out. We should, furthermore, advocate a national database of opioids which records who prescribes what, and to whom. Not impossible with the Aadhar number.
An inter-professional approach to pain is highly desirable. The dialogue between learned societies should stem from the foundations of knowledge and team work. As pain physicians we should not be timid to highlight the point that while the amendment to the NDPS act is a wonderful thing for cancer pain sufferers, the same might not be true for persistent non-cancer pain. In fact, the pain physicians should be one step ahead in anticipating the potential challenges of misuse, abuse and death, and start formulating guidelines. Otherwise, in addition to facing a backlash from the press and public in the future, we will also be left with holding someone else’s baby.
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