NEW DELHI: A whopping 7 to 10 million Indians need palliative care annually, but only less than four per cent can access it due to various reasons, one of them being restrictive prescription policies for controlled pain medications, like morphine, and limited policy prioritisation, said the latest study.
The study, published in the ecancer journal, said given the rising number of patients needing palliative care in the country, it is essential that drugs, like morphine and other pain relievers, are made available and accessible.
Researchers from Association for Socially Applicable Research (ASAR), Pune, the study evaluated whether Indian national and state essential medicines lists (EMLS) for palliative care medical needs are adequately stocked and found that none of them meet the criteria set by the International Association for Hospice and Palliative Care (IAHPC).
The study said the National List of Essential Medicines (NLEM), which is designed by the Union Health Ministry and was last updated in 2022, had 15 drugs, or 46 per cent of all medicines recommended by the IAHPC for palliative care.
The IAHPC has suggested 22 essential drugs for 16 of the most common palliative care symptoms, like depression, pain, anxiety, and vomiting among others, prevalent in end stage chronic diseases linked to kidney failure, liver failure, and cancer.
According to Dr Parth Sharma, corresponding author of the article, with India rising to the top globally in multiple chronic diseases, like diabetes and cancer, the suffering in the communities is expected to increase significantly in the coming years.
“Access to palliative care, a branch of medicine that holistically deals with a person's suffering, is still abysmal in India. Pain is one of the most common symptoms requiring palliative care. Often, basic medicines like paracetamol and diclofenac are not able to relieve severe pain in people with life-limiting illnesses. Morphine then becomes the drug of choice for relieving pain and suffering," he told TNIE.
India is the second largest producer of opioids, like morphine, globally. However, less than 3 per cent of the morphine produced in India is consumed in the country due to strict regulation by the government, and misconceptions in the medical community contributing to poor access to this cheap and effective medicine, said Dr Sharma, a public health researcher at the Association for Socially Applicable Research.
The study, led by Disha Agrawal and Dr Divya Shrinivas from ASAR, found that oral morphine was absent from the national essential medicine list (EMLs) and 17 state EMLs.
“How will access to adequate pain relief be possible if the public health system does not dispense oral morphine? Policymakers fear that improving access to oral morphine will lead to a US-like opioid epidemic in India,” Dr Sharma said.
However, he said, there is enough evidence to highlight that when prescribed following the WHO pain ladder, prescription morphine does not lead to addiction or misuse.
Citing the example of Kerala, which has the best palliative care in the country, he said the state palliative care policy improved access to oral morphine without its abuse.
“Kerala's morphine consumption is nearly 14 times the national average. Kerala highlights how implementation of a balanced policy can improve access to oral morphine without creating an opoid misuse problem."
The study found that no Indian EML had all recommended formulations of morphine as oral solutions, tablets and injectables. Nationally, the Central Government Health Scheme (CGHS) EML and NLEM included morphine injectables and tablets, while the Employees’ State Insurance Scheme (EML) did not include morphine in any form.
Nine (33 per cent) state/UT EMLs included injectables and tablets. Twelve (44 per cent) contained only injectable morphine, and one (4 per cent) included only tablets. Morphine was absent in five (16 per cent) EMLs - Gujarat, Karnataka, Manipur, Nagaland and Telangana.
Delhi’s EML was the closest to the IAHPC EML and included all required formulations for 17 (52 per cent) drugs. However, Karnataka’s EML included all recommended formulations for only 3 (9 per cent) drugs and some formulations for 6 (18 per cent) drugs, while 24 (73 per cent) drugs were absent.
The authors have suggested that the EMLs need to be revised every two years.
“All state governments must ensure that their EMLs align with the community's rising palliative care needs. The addition of oral morphine to all EMLs should be taken up urgently by all state governments," the study said.
EMLs of four states (Arunachal Pradesh, Goa, Sikkim Uttar Pradesh) and five UTs (Andaman and Nicobar Islands, Chandigarh, Dadra and Nagar Haveli and Daman and Diu, Ladakh and Lakshadweep) were unavailable in the public domain, the authors said.
“Considering the importance of morphine, both in palliative care symptom management and monitoring of palliative care-related national programs in India, the national and state/UT EMLs should be updated to incorporate oral and injectable formulations of morphine,” the study said.