Why is worldwide access to morphine so poor?
Morphine is deemed an essential medication for a basic healthcare system to function (WHO Model List of Essential Medicines) but it is effectively unavailable in almost 150 countries. Just a handful of Western countries consume 90% of the global opioids; Australia, Canada, New Zealand, the United States of America and several European countries.
Prohibition, intended to curb drug abuse, has been the focus of international and national laws (1961 the UN Single Convention on Narcotic Drugs). The inadvertant consequence is that millions of people are denied morphine and suffer unnecessarily, dying in pain. In 1971 Richard Nixon launched the ‘war on drugs’; one of the most influential political and public health campaigns shaping public opinion. We now have evidence that prohibition fails to stop drug abuse, instead it results in thriving criminal markets.
Powerful political campaigns and prohibitive drug laws seep into the public psyche. People are scared of morphine – they know it as a ‘street drug’; a drug of abuse, addiction and social decline. Doctors who have little experience in prescribing it are scared of side effects such as reduced consciousness and respiratory depression, as well as addiction and abuse. When the person using morphine is not in pain, the effect on the neurological system causes euphoria, and can lead to psychological and physical dependence. In palliative care when morphine is used appropriately, addiction is very unlikely. Even in countries like the UK, this fear and ignorance can create a cultural barrier to the use of opioids as medicines.
Law in India
Morphine is classified as a narcotic under the Narcotic Drugs and Psychotropic Substances Act (NDPS) 1985. The central government controls the cultivation of the poppy, collection of opium and manufacture of morphine. The sale and distribution of morphine is controlled by the state government. Kerala, the state at the forefront of palliative care with over 80% of India’s palliative care programmes, has relatively relaxed regulations so the supply of morphine is reasonable. In states such as West Bengal, the access is much more limited.
Many committed individuals, including Dr Rajagopal, have campaigned for decades for new legislation to improve access to morphine. There was a breakthrough at the beginning of 2014 when an Amendment to the Narcotic Drugs and Psychotropic Substances (NDPS) Act was passed by Parliament. The amendment enables medical institutes to procure morphine by obtaining a single licence from the State Drugs Controller rather than five. In theory this should make access to morphine easier. We are yet to see the benefits in West Bengal.
It is easier to find men who will volunteer to die, than to find those who are willing to endure pain with patience
Improving Opioid Availability
Improving government legislation and policy is just the beginning. More hurdles exist, including the lack of medical expertise. Most doctors in India have not been trained in how to use morphine. Even in countries such as the UK, where doctors are trained and access is well established, prescribing is often suboptimal. And even if prescribed well, cultural barriers and stigma mean that patients may be reluctant to take morphine. To overcome these interrelated problems the WHO recommends a three-pronged approach addressing;
- drug availability; production and guaranteed accessibility at low cost by pharmaceutical companies
- government policy
- education; of healthcare professionals and the public
EIPC has information kiosks about Palliative Care in busy government hospitals
Proponents of palliative care in India work tirelessly to address the above three recommendations, recognising that morphine is essential to pain relief and pain relief is the cornerstone of successful Palliative Care Programmes.