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.
*Name changed to protect patients identity