The IAHPC has initiated a series of workshops on opioid availability to identify and address barriers to rational palliative care use. Dr. Anjum Khan Joad, a palliative care physician in Rajasthan, India, describes one such workshop held in India 21-22 February 2018, during the 25th Conference of the Indian Association of Palliative Care.
In an intense two-day workshop at the 25th Conference of the Indian Association of Palliative Care, the IAHPC and invited experts interacted with representatives of seven states of the country: Assam, Andhra Pradesh, Gujarat, Orissa, Punjab, Rajasthan, and Uttar Pradesh.
The organizers had meticulously planned the meeting, bringing the ministry/government representative, drug controllers, and palliative care practitioners from each state to one table. Surprising as this may seem, it was the first time that most of us had met the official administration and drug controllers!
We learned that there is a huge gap between what the officials understood and perceived as being true, and on-the-ground reality.
The officials were all well-read, but there were knowledge gaps. Some officials were aware that morphine was important in the treatment of pain, but were under the impression that injectables were enough. One said that it couldn’t be a ‘real’ problem, and that palliative care practitioners were unduly ‘emotional’ about the whole issue. Most officials were genuinely concerned about the risks of diversion and substance use disorders. They were worried that diversion for non-medical uses may increase, as has happened in the past with codeine, dextromethorphan, and alprazolam.
The practitioners shared moving stories of patients’ pain and health-related suffering. There were also disturbing reports of physicians who were wary of prescribing or stocking morphine for fear of harassment from law enforcement agencies. We reiterated that the per capita consumption of morphine or morphine equivalents in one year was 6.5 mg worldwide, 241 mg in the U.K., and 0.11 mg in India.
Clearly, ease of availability must be balanced with prevention of misuse.
Each state drew up its action plan, with SMART (specific, measurable, agreed upon, realistic, and time-based) goals and timelines. Each state inspired and stimulated the others. The interaction with stakeholders should lead to a positive outcome, though it may take time. Lack of availability of morphine is a common theme, there are problems peculiar to each state, such as, heroin abuse in one and social sanction of crude opium at weddings (and funerals!) in another.
We are grateful to IAHPC and Ms. Liliana De Lima, Dr. Jim Cleary, Dr. M.R. Rajagopal, Dr. Lukas Radbruch, Dr. Sushma Bhatnagar, Ms. Tripti Tandon, and Dr. Nandini Vallath for the workshop. We returned home with a host of ideas to address this issue with creativity.
As is often seen in these meetings, there was ‘storming’ (though we didn’t come to blows!) and ‘norming’; we left with the hope of ‘transforming’ the bleak opioid landscape in our states. This workshop has ignited more minds, and I feel sure that we will be able to make a change in opioid policy in our state. Good signs of progress didn’t take long! As we were preparing to leave, Dr. Alok Mathur from the Ministry of Health informed me that the Central government has approved a 25 million rupee grant to my state, Rajasthan, for development of palliative care.
Editor’s note: By the time you read this, another IAHPC-organized opioid availability workshop will have taken place in the Dominican Republic.