Getting High: India shows the way to better Opioid use
Unleashing an overdose epidemic upon western nations like USA and Canada, opioids often get a bad rep in healthcare discussions. However, in many poor and developing countries, millions who are agonized by unbearable pain are in dire need of proper opioid prescriptions. As one part of the world struggles to limit its opioid use, the other is witnessing painful horror each day as people in dire need of pain management die pathetic deaths. What are Opioids? Opioids are a class of drugs that are mainly used in pain relief i.e. palliatives. Simply put, they enter the body and slow down the communication of pain to the brain, hence allowing patients to feel better and manage their lives without needless pain. Opioids also tend to create feelings of euphoria as they tend to boost the production of dopamine – often called a “feel-good” hormone - in the brain. It is because of this euphoric “high” that opioids, improperly consumed, can lead to addiction, overdose and even death. Opioids in the west are consumed both legally and illegally. Legally produced, they come in the form of pills and are prescribed by doctors – aka prescription drugs. Illegally consumed, they usually take the form of drugs like heroine, but heroine consumption is in most cases preceded by overdosing on prescription drugs. Addicts usually make the switch to heroine because it is more easily available in the black market at cheaper rates than prescription drugs. Opioid consumption and prescription is higher in western nations than it is in developing nations like India – although it cannot be denied that there does exist a substantial addiction problem in such countries as well.
Why are Opioids important? The chances are pretty high that if you are reading this, are a human being – and not an AI program. And as humans, some of us are unfortunate enough to deal with agonizing diseases which may not be curable, or the cure itself may be prolonged and painful. Such illnesses can cause continuous and unbearable physical pain that can destabilize daily lives of the victim, alongside their loved ones. Such needless suffering can destroy whole families, as is the case when, say breadwinners of the family are left shackled to their pain.
Dr. MR Rajgopal, a Padma Shri awardee – one of India’s highest civilian honors - has been campaigning for an increased use of opioids as palliatives to reduce such suffering. Dr. Rajgopal believes that healthcare as it exists today, lacks the compassion necessary to treat patients as real, living human beings, adding that,
“…there is a tendency for doctors to be human machines, [only] diagnosing the disease[s] and attacking the disease[s]. Somewhere, medical practice lost a bit of [its] heart.”
Hailed as a humanitarian in the field of healthcare, he believes in “holistic treatment” - treating the patient as a person, rather than treating patients merely as a container of disease. Hence, opioids like morphine become important in order to empower people. Minimizing a patient’s pain can significantly prevent the downfall of the quality of their lives as well as the quality of their deaths.
As desirable as opioids seem in such deplorable healthcare conditions, their use is a tricky act to balance. Contrasted with the West, a peculiar situation emerges. 92% of the Opioids worldwide are consumed in the Global North (western, developed nations), a large section of which, presumably, feed the demand from the 2.6 million (2015 figures) suffers of opioid addiction.
On the other hand, the Global South (developing nations like India) suffer from a severe lack of opioids – even for medicinal prescription. The blame – Opiophobia - an exaggerated fear of opioids and their potential of unleashing mass addiction epidemics. Opiophobia leads to major barriers of entry for opioids in developing nations. Those against the introduction of opioids in developing countries use the addiction epidemic in the West, particularly in the US, to drive home their point. The argument makes intuitive sense, despite better state apparatus to control prescriptions and delivery of drugs, the US has failed to control the epidemic. If the world’s richest and most institutionalized country can be brought to its needs, one can only presume what would happen in developing nations like India, which are still plagued by quacks in the healthcare system.
A study published in the Journal of Global Oncology explained that barriers to entry for opioids in India and other Low Income Countries included requirements for physicians to receive licenses to prescribe opioids; requirements for duplicate or special prescription forms; prescription limit of 30 days; inability to prescribe opioids in an emergency situation by fax or telephone; and, pharmacists not having the authority to correct a prescription with a technical error. Compounding these structural barriers was the fact that even when opioids were included in a hospital or clinic’s pharmacy, they were often not available.
The study also found that, although morphine was more readily available at the surveyed hospital than at many other sites in India, access was limited and that there were significant gaps in supply. Other key barriers to prescription and use included,
Limited involvement of nurses in evaluating pain;
Lack of basic knowledge in pain control - incorrectly identifying antiemetic or sedative medications as analgesics;
Misconceptions among trained staff that cancer pain was inevitable and unmanageable; and,
Structural barriers (family members would need to return to the clinic from far distances to obtain refills).
Solution (?) This raises a problem for those in need of palliatives – and the Indian state of Kerala seems to be leading the change in this regard. Although largely absent, opioid use is not unheard of in India. Over the past few years, the state has begun progressively introducing opioids like morphine into its healthcare system to ease patients’ pain. This has, until now not led to any significant increase in cases of addiction or overdose among people.
The aforementioned study also found that, at 1.56 mg/capita, Kerala has a significantly lower consumption of opioids when compared with the global average of 6.27 mg/capita (2). For a state with a population roughly equaling that of Monaco or Lichtenstein, this is no small feat. It is also the main reason why opioids have not blown into a full-fledged epidemic.
Dr. Rajgopal believes that half a century is required in order to bring about necessary reforms in opiates in India and bridge the gap with developing countries. The silver lining though, is that developing countries can learn from the experiences of the developed countries, avoiding pitfalls encountered by the latter. Opiophobia is not unique to LCIMs like India and, until early 1990s, was quite prevalent in the US itself. What blew opioid use out of balance in the US was its unregulated, false marketing by pharmaceutical giants. Opioids were hyper-normalized (used for pain of low severities), and that led to a systemic over-prescription of opioids in the US.
India, given that it is virtually starting fresh, can avoid such a scenario by regulated use. Most importantly, for the millions who suffer needlessly, it needs to overcome the current stringency regarding opioid use through careful crafted policy solutions and regulation. Opioids should not be allowed to become profit-pills for the healthcare giants, or the American story would be repeated. And lastly, India would have to overcome its entrenched attitude to pain as an inevitable part of therapy – no pain is inevitable.
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