Easing Unbearable Pain

The passage of the Narcotic Drugs and Psychotropic Substances (NDPS) (Amendment) Act, 2013 means that for the first time since 1985, cancer, HIV/AIDS patients and others suffering excruciating pain will have proper access to opioid medicines. Among the most effective and inexpensive of these is morphine that can make a humongous difference not only to the estimated 24 lakh cancer sufferers (15 lakhs at the unbearable pain stage) but also to the terminally ill among the 16 lakh HIV/AIDS patients in India. Barely 1% of these sufferers are getting the palliative medicines that they desperately need at present. This situation is a classic example of how a regulatory law and its rules applied rigidly can lead to large-scale human suffering. Even now, after the Act has been passed, there are areas that will need urgent attention. Apart from the procedural andimplementation aspects, medical courses which shied away from teaching/discussing about use of morphine since the mid-1980s will have to include this aspect. More importantly, the mindset engendered by the excessive caution of doctors in the past three decades in prescribing the opioids and the cumbersome bureaucratic requirements to stock and sell them will also have to change quickly if the law has to have any effect.

Actually, it is not only the suffering patients who are affected by regulatory laws involving palliative care medicines. One should include their families too and those who have to see them suffer the mind-numbing pain day in and day out. Patients in severe pain also often suffer from depression and suicidal thoughts accompanied by extreme anxiety, resulting in further deterioration in their quality of life. Introduced in the face of real and speculative fears about the misuse of narcotics and psychotropic substances, the 1985 law saw hospitals and medical colleges preferring not to stock narcotics meant for medical use. Since the law asked for obtaining licences for stocking, transporting and dispensing, involving five different departments like health, excise, drugs control, etc, and violations meant harsh punitive measures, doctors and medical institutions thought it wiser to steer clear of the entire process, thus damning lakhs to pain which could have been manageable. These decades also saw the prejudices and misconceptions associated with morphine, especially in regard to “addiction” continuing to proliferate. This situation fed into another that has been peculiar to this country and which is now changing albeit too slowly. It is the lack of focused attention to palliative care or pain management and the training of medical and paramedicalpersonnel in how to use it effectively.

Health activists consider access to palliative care to be an issue of fundamental human rights. Thanks to the unrelenting pressure by doctors appalled by the sufferings of their patients, and M Rajagopal of the Indian Association of Palliative Care, in particular, the central government directed all state governments to follow modified rules from 1998 onwards. A number of states amended the regulations but a majority continued with the old regime. The activists’ efforts also led to the NDPS Bill 2011 being introduced in Parliament. Despite the centre’s directives, the situation at the ground level continued to be the same. Kerala has been a major honourable exception and a couple of other states including Delhi and Tamil Nadu have implemented the eased regulations to improve the lot of patients. The plight of cancer patients from rural areas coming to cities for treatment and those in the regional cancer centres was the worst among this section.

Now the newly amended NDPS Act will ensure that the different regulations in each state and union territory will become uniform regarding opioids. The central government will hold the right to amend these rules, and, more importantly, instead of a number of departments and bodies giving the licensing nod, it will now only come from the drug controller. The centre will also be able to ensure that the opioid drugs are available in the required amount by coordinating the activities of the various departments and agencies. No longer will the patient using narcotics or psychotropic drugs for medicinal purposes be categorised as an “addict”. Doctors involved in pushing for the amendment have pointed out that not only are the fears about addiction to morphine baseless but also that there are enough mechanisms in place to deal with misuse, if the political will is present.

As with all laws, it is the aftermath involving implementation that is crucial. Medical institutions will have to focus on training personnel in the use of morphine, and, more importantly, pay special attention to pain-care management. This means that state governments too will have to ensure that palliative care becomes part of the public health system. As mentioned earlier this will require undoing the paralysis that had set in since the mid-1980s. The fruits of these efforts, however, will mean the alleviation of pain for lakhs of Indians and an improvement in the quality of their physical and mental well-being, including that of their families and care-givers.