An Epidemic of Pain in India

“Death does not scare me; this unbearable pain does. I just pull my hair apart and wish I could die,” Dipti Vij told me last August. She struggled to prop up her weak frame during a break from intravenous therapy; she could no longer swallow food, and she was tethered to a bag of solution for most of the day. Dipti, a thirty-year-old manager at a call center for a software company in New Delhi, was diagnosed with throat cancer in 2011. Within a year, the cancer had spread throughout her body. In a cycle that repeated itself every few hours, when the agony was especially severe, she fell on her knees and screamed; when it was unbearable, she collapsed. Doctors at various hospitals in New Delhi sent her home with a prescription for paracetamol, a mild, over-the-counter pain reliever.

After enduring several months of misery, Dipti was brought to the All India Institute of Medical Sciences (AIIMS), in New Delhi. When she arrived, Sushma Bhatnagar, the institute’s head of anesthesiology, pain, and palliative care, immediately put Dipti on a continuous and regulated dose of oral morphine pills. Palliative care is an area of medicine that focusses on relieving and preventing pain, especially for people who have incurable terminal diseases. According to Bhatnagar, the institute is one of very few hospitals in the country that stores and prescribes opioid drugs for treating chronic pain in terminally ill cancer and AIDS patients, and the only one in Delhi to do so. “Now there is no pain,” Dipti said at the time, when she still had hope of going back to work.

The World Health Organization considers morphine, an alkaloid found in the opium poppy plant, the “gold standard” for pain relief. (Morphine is extracted from poppy straw or from the plant’s dried latex, which is what is commonly referred to as opium.) It works by attaching to specific proteins called opioid receptors, found in the brain and other parts of the nervous system, blocking pain signals, and promoting the release of endorphins. Other well-known opioids include codeine, oxycodone, and hydrocodone. Though morphine can be highly addictive, it has been used by doctors all over the world since it was discovered, more than two hundred years ago, and is commonly used to treat the postoperative pain and acute pain caused by cancer, myocardial infractions, and other severe illnesses.

While many countries consider morphine to be central to palliative care, India does not. Less than four per cent of the one million people in India who suffer from the chronic pain caused by cancer have access to medicinal morphine. Counting other life-limiting diseases, a 2009 Human Rights Watch report noted that experts estimate that at least seven million people in India need morphine for pain relief. According to the World Health Organization, in 2003 six developed countries accounted for seventy-nine per cent of global morphine consumption; developing countries, just six per cent. But unlike many developing countries, which must import morphine for pain treatment, according to the International Narcotics Control Broad, India has been “the leading licit producer of opium for several decades, accounting for over 90 per cent of global production.” In 2010, according to the I.N.C.B., ninety-nine per cent of the global production of licit opium—five hundred and eighty tons—occurred in India, which exported the majority of it. Morphine is not expensive: a ten-milligram tablet of costs between one and ten cents. The problem is not supply or cost; rather, it is Indian legal restrictions, which so tightly control opioids that they have strangled access to pain medication for those who need it most.

In November, 1985, India enacted the Narcotic Drugs and Psychotropic Substances Act, superseding the previous laws under which the country regulated narcotics and its longstanding opium trade—the Opium Acts of 1857 and 1878 and the Dangerous Drugs Act of 1930. The resulting string of procedures to acquire opioids and narcotics for scientific or medicinal purposes is dizzyingly complex: up to six licenses are required for every consignment of morphine. If a doctor’s possession license expires, an individual could be fined or worse, subject to a non-bailable arrest and a jail term between six months and twenty years long, depending on the amount of the opioid in possession. In some states, when morphine is prescribed only one member of a family can pick it up, and the family is required to return pills to the consulting doctor if a patient dies in the course of treatment. It’s “a draconian act,” Nagesh Simha, the president of the Indian Association of Palliative Care, said. “How can a doctor be arrested for prescribing a drug?”

Many hospitals and medical schools have reacted by simply not stocking morphine. Most manufacturers, which are subject to the same legal restrictions, in turn have stopped producing it, and over the years, since the N.D.P.S. Act came into force, treatment for acute pain in India has greatly diminished. Even some doctors are unaware of the merits of morphine because many have graduated from medical schools without learning about it: of more than three hundred medical colleges in the country, fewer than twenty per cent of them educate doctors about palliative care. Unsurprisingly, data from the International Narcotics Control Board and World Health Organization shows that medicinal use of morphine dropped by ninety-seven per cent in the country after the law was enacted, from seven hundred kilograms in 1985 to a low of eighteen kilograms in 1997.

The fear of addiction has been cited as one of the leading concerns by the government in its hesitance to drastically increase access to legal morphine. An International Narcotics Control Board report, from 2012, notes that after cannabis, opioids (which include heroin) are the most abused drugs in India. And among those treated for drug-related problems in 2010, sixty-six per cent abused opioids, nineteen per cent of which were prescription medications. M. R. Rajagopal, the director of W.H.O.’s Collaborating Centre for Training and Policy on Access to Pain Relief, says that “the N.D.P.S. Act created by Government of India was concerned only with preventing abuse and diversion; it did not give attention to facilitating medical use.”

An amended N.D.P.S. Act, its third iteration in two decades, could become the new law if it passes by both houses of parliament in the legislative sessions that began this week. It would greatly simplify the process of obtaining morphine by providing a uniform set of regulations for every state to follow. However, if the amended act doesn’t come up for a vote before December 20th, when the final session before the new year’s national elections ends, the bill will effectively die.

If it fails and morphine restrictions continue, it would jeopardize the government’s initiatives to introduce palliative care throughout India. A few medical schools have begun to offer training in pain management for medical students and doctors, with, for instance, workshops on prescribing morphine. But “if the N.D.P.S. bill is not passed, the palliative-care policy will fail,” Dr. Nagesh Simha said. “How can you have a law that forbids use of morphine and then have a policy to educate medical practitioners about using it in pain treatment?”

Dipti died a few days after the interview. During her brief stay at the hospital, Dipti’s family was relieved to see her smile, talk, and even speak with me. But a deep sense of guilt weighs them down now, as they wish they had brought Dipti to AIIMS earlier, or perhaps had just known about morphine. “I cried and begged doctors for a stronger pain killer,” Dipti said. “They said it did not exist.”

Um-e-Kulsoom Shariff is a graduate of Columbia Journalism School and a reporter and anchor for India’s N.D.T.V.

Photograph by Prashanth Vishwanathan/Bloomberg/Getty.