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Stress on making palliative care affordable

By C. Maya

THIRUVANANTHAPURAM, MARCH 6. Increasing non-availability of cheap and inexpensive analgesic drugs is making palliative care unaffordable to a large section of poor patients, M.R. Rajagopal, Board member of International Association for Hospice and Palliative Care, who is also the Head of Anaesthesiology and Palliative Medicine, Amrita Institute of Medical Sciences, said.

Talking on the sidelines of a workshop on Palliative Care organised by the Palliative Care Division of the Regional Cancer Centre here on Sunday, Dr. Rajagopal pointed out that pharmaceutical firms were interested only in promoting expensive drugs, while most of those patients who require pain relief and anti-cancer drugs could not afford expensive medicines.

A regular supply of inexpensive morphine would solve the problem for doctors working in the area of palliative care but there was none out there selling it to doctors, he said.

Ethical dilemmas

He pointed out that the emergence of new and expensive drugs that offer marginal advantages over inexpensive drugs were posing new ethical dilemmas before doctors.

"In our social set up, where the majority of cancer patients are extremely poor, should we prescribe expensive drugs to patients knowing fully well that he cannot afford it?" Dr. Rajagopal said.

"The inexpensive drugs now used for pain relief might have some disadvantages. But these are certainly manageable," according to him. Proxyvon (dextropropoxyphene) is a second-stage drug that is widely used in palliative care because it is inexpensive. However, many doctors are now prescribing Tramadol because the pharmaceutical companies have been pushing its `advantages'. The difference is that a day's dose of Proxyvon costs about Rs. 11, while Tramadol costs Rs. 60, he said.

Most of the drug research is done by the pharmaceutical industry itself and no effort is going into making inexpensive drugs available for poor patients. "The U.K. has now decided to phase out the drug Proxyvon within ten months. Soon, there could be an outcry that a drug banned by the U.K. is being sold in India. Ultimately, patients will have no choice but to opt for expensive drugs," he said.

Another major hurdle before palliative care is the stringent drug regulations that make the availability of cheap oral morphine a difficult proposition for patients. There is also the misconception or fear among doctors regarding morphine addiction.

Only nine States in the country today, including Kerala, have implemented rules where in Recognised Medical Institutions (RMIs) have been allowed by the Drugs Controller to have an annual quota of morphine. Kerala has about 60 RMIs while in States like Delhi, Haryana, Sikkim and Tripura, there are none.

"Even today, oral morphine reaches only 19 per cent of the needy patients, while thousands are forced to live with the excruciating pain of cancer," Dr. Rajagopal said.

A large number of institutions with cancer treatment facilities do not have a palliative care division, primarily because the medical and nursing profession is yet to accept palliative care as an essential part of healthcare.

Earlier, patients were referred to palliative care division after it was found that their disease was incurable.

"Palliative care is not just terminal care, it is required all through curative treatment. The patient's family also needs support through out and after the patient's death. Rehabilitation should become an essential part of palliative care and this is where NGOs can help," he pointed out.

Novel programme

Home visits for delivering palliative care is being successfully implemented in North Kerala through the Neighbourhood Network programme. "At Manjeri bus stand, money boxes have been kept where every bus driver and conductor drops Re. 1 daily towards this programme. That is more than what we have been doing for the suffering poor," Dr. Rajagopal said.

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