MORPHINE: GOD’S MEDICINE, DEVIL’S IMAGE
“The very earliest Christians, when celebrating the Eucharist, would send a fragment to the sick and the dying people who were unable to be present. Records dating back to AD 100 also tell us that a portion of the Eucharist would be carefully preserved in a safe place to be given to those in danger of death as viaticum or ‘food for the journey’. In the twelfth century, the Church legislated that the Blessed Sacrament was to be reserved in a “skillfully constructed and safely locked tabernacle.”
(From 'The Corpus Christi Sunday bulletin', Nairobi, 7th June 2015).
Morphine, like the Blessed Sacrament, can be the best medicine for those suffering from severe pain due to acute or chronic or terminal painful conditions. Like the Blessed Sacrament, it must be kept in a locked container, and several rules and regulations restrain its manufacture and distribution, with a view to preventing “diversion and abuse”. Oral Morphine is perhaps the only medicine which is procured in the name of the doctor holding the 'Morphine Licence', who is directly responsible for its safe storage, dispensing and maintenance of records and necessary documentation.
India has been the land of Marijuana (Cannabis). Mention of Marijuana can be found in the Vedas (ancient Hindu sacred text, 2000 to 1400 BC). It was already in use as 'chillum' to be smoked or as 'bhang' (mixed with sweetened milk) to be drunk. Various scientific studies have established that cannabis is good for pain relief and is in many ways, better for chronic pain management as there is low risk for addiction and fatal overdose compared to opioids. However, medical use of cannabis is not legal in most parts of the world, including India.
Opium was brought to India in the 15th century, probably through Arab traders. In India, poppy seeds (khus khus) were mainly used as an ingredient in the food and beverage industry and opium (a black gummy resin from the poppy plant) as a medicine in the Ayurveda system. Its euphoric properties were known, but it did not gain much popularity, perhaps because marijuana was already widely available.
Opium achieved the status as commodity during the Mughal era, when cultivation of poppy took place at the fertile Gangetic plains, producing some of the best quality poppy crop. Soon, the European traders noted its commercial value in the international market. Their chief market was China, an opium smoking country, and not India. 18th century saw the phenomenal growth of opium as a global commodity and by mid-18th century, the British, through the East India Company, established their monopoly in cultivation and international opium trade with the high-quality poppy cultivated in India.
Despite the Chinese emperor Qing’s edicts, the British traders continued the illegal trade (trafficking) of opium for profit. When the emperor took strong measures against the traffickers, the British went to war against China (The Opium Wars - AD 1838-1858). After the victory of the British, the trade was legalized. A large proportion of the income of the imperial government in Britain came through this trade.
Meanwhile, the British in India brought in many regulations on opium to maintain and increase their monopoly on this enormous source of income through its cultivation and trade. These regulations which were intended to protect the British monopoly, later became the basis for the Narcotic Laws that emerged later.
In the 20th century when the world woke up against opium trade, several conventions - Shanghai 1906, Hague 1912 and Geneva 1925 - were organized to help form a consensus on national and international regulations to curb the usage of opioids. It was in this climate of early 20th century, that the British government in India shaped its narcotic laws based on the earlier laws of 19th century designed for monopoly, and retained the same language of restrictions.
By late 20th century, the effectiveness of opioids as pain medications for the persistent severe forms of pain as seen in cancer, HIV and many other chronic conditions became well known. But, for most of the world which had seen the addictive dimension of opioids, this was difficult to acknowledge.
The Single Convention on Narcotic Drugs, promulgated at the United Nations in 1961 is seen by many as the cornerstone of ‘drug war’ treaty. Morphine and other opioid analgesics were classified as ‘scheduled drug’. UN member countries were required to pass domestic laws prohibiting the manufacture, distribution and consumption of narcotic drugs “except for medical and scientific purposes.” Criminal laws were put in place to prevent diversion and misuse. The unintended consequence of this was that Morphine, an essential medicine for adults and children, as per the World Health Organization Model List of Essential Medicines, became virtually unavailable in almost 140 countries.
After gaining independence from the British in 1947, the Government of India formed the Narcotic Drugs and Psychotropic Substances (NDPS) Act in 1985. The legislation was so draconian that even a clerical error could invite stiff penalties including rigorous imprisonment. Pharmacies and institutions gradually stopped stocking morphine. By 1997 (within 13 years), India's annual consumption of Morphine fell from 600 kg to 48kg, an alarming drop of 92%. India's per capita consumption of morphine ranked among the lowest in the world (113th among 131 countries).
Fear leads to stigma and translates into cultural and legal barriers that interfere with the use of opioid medicines for pain relief. When Morphine became unavailable, only a few medical schools and even fewer countries trained doctors and nurses to use this essential medication for severe pain. Generations of doctors have passed out of Medical schools without ever having seen what a tablet of Morphine looked like.
A global system set up to punish ‘illicit use’ of narcotics and to ‘ensure adequate access’ for medical and scientific purposes, has failed at both ends, as these continue to be easily available on the streets and almost unavailable in the hospitals, especially in poor and developing countries.
The net result is that millions of patients and their families, irrespective of the socio-economic status, suffer unnecessarily. Moreover, patients and families don’t know they have the right to ask for pain relief, or clinicians the legal obligation to provide it. This is despite the fact that under human rights law, specifically the International Covenant on Economic, Social and Cultural Rights (ESCR), Article 12, governments have the obligation to provide their citizens with “the highest attainable standard of health.” The Committee on ESCR has extrapolated this right to include the right to pain relief and palliative care.
Some of the best quality Morphine in the world, still comes from the legally cultivated poppy crop from the fertile Gangetic plains of India. However, its usage in our country is poor with 96% of adults and 99% of children who need pain relief having no access to this medication. Most of it is exported to the wealthier western countries where more developed medical education and training and better awareness among the public allows higher average Morphine consumption than countries with lower human development scores.
Despite years of efforts by palliative care and human rights organizations to create awareness among medical professionals and public at large, the per capita Morphine consumption in India, as of 2015, was 0.15 mg. China has a huge population but the per capita consumption of Morphine is only slightly better at 1.20 mg.
Compare the figures from wealthier countries with much less population than India and China : UK 22.85 mg; France 27.64 mg; Australia 32.18 mg; USA 60.99 mg and Canada 117.74 mg; you wouldn't fail to realize the sheer tragic irony that in the 21st century, the bulk of humanity still lives in the dark ages of ignorance and suffering.
‘The Principle of Balance’ recognizes that every country has a dual responsibility - ensuring access to opioids for those who need it for pain relief; at the same time preventing non-medical and harmful use as much as possible. The Indian Parliament amended the NDPS Act in 2014 as a result of the untiring efforts of people and organizations championing the cause of pain relief. Through this amendment, the government has accepted its responsibility to ensure easier access of Morphine through simplified rules for medical purposes.
An acknowledgment that it’s not the devil, after all.
· Morphine is an opioid analgesic. It is not a cancer drug. It can be used irrespective of diagnosis or prognosis.
· Morphine is the safest of available analgesics as it can be used in the presence of renal and or hepatic failure. Can be used for acute pain (angina), chronic pain diseases, cancer pain, burns pain, peri and post-operative pain, etc.
· There is no upper therapeutic dose limit.
· Over dose toxicity symptoms like drowsiness, delirium, and myoclonus are what would limit the prescription. Ignoring these warning signs may lead to life-threatening respiratory depression.
· Most common side effects of Morphine (in therapeutic doses) are nausea (usually self-limiting) and constipation (sometimes very severe, leading to the teaching “the hand that writes an opioid, must write a stimulant laxative”).
· Management of constipation is done by means of more stimulant laxatives, not by reducing Morphine. Bulk laxatives are contraindicated when on opioids.
· Morphine is also used to relieve refractory breathlessness as in advanced diseases of the lungs (COPD, ILD), heart (CHF), cancers etc.
· It is also a good cough suppressant, after all, it's the ‘elder brother’ of Codeine.
· Injection of Morphine, to be used inside the hospital, can be prescribed by any doctor with a basic degree of MBBS and above.
· Oral Morphine which can be used for short-term, long-term or life-long period, based on the medical condition, can be prescribed by a doctor with a basic degree of MBBS and above, with an additional certification for Oral Morphine as per the NDPS Act.
· NDPS Act, amended in 2014, is just the beginning of the efforts to bring pain relief to the masses. This has to be implemented by the State governments, further awareness needs to be created among healthcare professionals and lay public at large. There is still a long way to go.
· Meanwhile, NSAIDs (Non-steroidal anti-inflammatory drugs), which are known to have unacceptable multi-organ side effects in therapeutic doses on extended or long-term use even in healthy individuals, are unfortunately easily available over the counter, without any prescription. Easy availability of NSAIDs and its abuse and misuse are things that should worry all of us.
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2. History of Opium: from an addictive substance to pain relieving medication. Dr. Nandini V., National Faculty, Indian Association of Palliative Care. 24/02/2014. E hospice.
3. History of Cannabis in India. Jann Gumbiner.16/06/2011. Psychology today.
4. World Health Organization, 2014. Strengthening of palliative care as a component of integrated treatment within the continuum of care. Http://apps.who.int/gb/ebwha/pdf_files/EB134/B134_RT-en.pdf.
5. Current Status of Palliative Care in India. Dr. M.R.Rajagopal, Director, WHO Collaborating Center for Policy and Training on Access to Pain Relief. Founder -Chairman, Pallium India.
6. Morphine is medicine: the language barrier to opioid availability in more than 83% of the world. Katherine Pettus, Advocacy officer, IAHPC. http://www.ehospice.com/ArticleView/tabid/10686/ArticleId/13179/language/en-GB/View.aspx
7. Global opioid consumption – 2015. University of Wisconsin-Madison Pain and Policy Studies Group.
8. Pallium India. Morphine Consumption in India. 2014. http://palliumindia.org/2014/02/morphine-consumption-in-india.
9. Human Rights Watch:2009. Unbearable pain: India's obligation to ensure palliative care. Http://www.hrw.org/reports/2009/10/28/unbearable-pain-0.
10. Government of Kerala. Pain and Palliative Care Policy for Kerala. Http://www.kerala.gov.in/docs/policies/pain.pdf.