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Offering pain relief

Living without pain is a basic human right but not many with grave illnesses like cancer have access to inexpensive palliative medication. Palliative care is today a distinct discipline and the benefits of oral morphine for pain relief are well recognised. But the public health system in India has not risen to the challenge. That is an irony because a wider availability of oral morphine was declared a priority under the National Cancer Control Programme even in 1992. There was a laudable advance a decade later when a model rule was adopted by many States to make oral morphine available for pain relief through the network of cancer care institutions. Most State governments, however, failed to seize the moment and improve access to oral morphine. The exception has been Kerala. The State has consistently set the gold standard in palliative care and won international recognition for making pain relief a true people’s movement. The World Health Organization has cited Kerala’s community-led initiatives as a model in its recently released guide to palliative care. The efforts of the Neighbourhood Network in Palliative Care in that State are notable for successfully mobilising financial resources through small donations, training a large number of volunteers to work with medical professionals and streamlining morphine availability for home care under prescription.

Kerala’s success in expanding palliative care is the result of a forward-looking approach adopted by the Drugs Controller of India (who exempted palliative care programmes from requiring a drug licence) and the State government’s active support. The State has also provided evidence that fears of misuse and diversion of oral morphine, a medically useful opioid are exaggerated. The Lancet reported more than five years ago that no instance of misuse or diversion was recorded in a follow-up of 1,723 home care patients being treated for pain with oral morphine in Kozhikode. This should sufficiently reassure other States to review bureaucratic obstacles to opioid availability for patients. Although replication of the Kerala model may be difficult in socially less-developed States (eight States did not avail themselves of major cancer care grants from the Centre during 2004-07), the institutional framework to expand morphine availability does exist. Besides specialised cancer care institutions and district hospitals, it is the primary health centres that can play a major role. Doctors trained in palliative care in PHCs and regular monitoring of drug use by Accredited Social Health Activists of the National Rural Health Mission can relieve thousands of patients of their agony.

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