The International Narcotics Control Board has published the following figures for the consumption of narcotic drugs in India for 2003: pholcodine 176 Kg; dextropropoxyphene 78 931 Kg; pethidine 152 Kg; diphenoxylate 3 771Kg. The following figures are based on 2001 statistics because there were no figures available for 2003: codeine 15 346 Kg; morphine 196Kg. The average daily consumption of defined daily doses (for statistical purposes) of morphine per million inhabitants, 2001-2003, for India was 1.⁶⁰ This compares with other Asian countries as follows: Pakistan 1; Bangladesh 1; Sri Lanka 11; China 5; Singapore 31; Japan 178 (Table 8).

Table 8 Average daily consumption of defined daily doses (for statistical purposes) of morphine per million inhabitants, 2001-2003: countries of Asia

 Source: International Narcotics Control Board Narcotic Drugs: Estimated World Requirements for 2005. Statistics for 2003. New York: United Nations, 2005

It is estimated that less than three per cent of India’s cancer patients have access to adequate pain relief^61,62and many states in India have no medical facilities that dispense morphine. In the 16 states/territories with palliative care services we found 14 reported prescribing morphine. However, there are immense difficulties with morphine availability. The licensing of morphine for medical purposes is a state function rather than a central government function. Government regulations are stringent but an individual state/territory can adopt simplified narcotics regulations which make it easier to purchase, store and utilise morphine. There are ten states/territories which have adopted  these simplified regulations^60,63 (Table 9) but availability remains limited.^64-66

Table 9 States/territories which have adopted the simplified narcotics regulations

(* indicates no identified palliative care services in the state/territory):

A sustained initiative to improve the availability and access to opioid analgesics in India is a World Health Organization project which consists of a partnership between David Joranson from the Pain & Policy Studies Group/WHO Collaborating Center at the University of Wisconsin Comprehensive Cancer Center,⁶⁵ The Pain and Palliative Care Society (Calicut), the Indian Association of Palliative Care, agencies of the Central Government of India, and several state government ministries of health. The project was initiated by WHO in 1994⁶³ and is supported with a grant from the United States Cancer Pain Relief Committee. This collaboration has developed guidelines for obtaining morphine and held workshops on opioid availability with healthcare professionals and state officials across India (e.g. Kerala, New Delhi, Chattisgarh, Assam).⁶⁷

Dr Bhatia, Rajasthan Hospital, Ahmedabad, Gujarat, north west India describes the impact of this work:

Getting the hospice care centres started with the help of outside agencies and of course the first focus of David [Joranson] has been always to get the oral morphine released, oral morphine will be shortly I think, at least in Gujarat, available across the counter in big cities and once that experiment works and the drug controller gets confidence that addiction is not a problem then perhaps we’ll go to more to more towns and then perhaps we’ll go to smaller towns and get the drug people to dispense the oral morphine across the counter. But the message that David was conveying to the drug controller is working…The IAPC originally aimed to get the oral morphine liberalised, that is already I think working but the second aim was the training centres, the training of the health workers which has yet to be realised.⁶⁸

There has been some success in improving access to opioids. In Ahmedabad, Gujarat, (since September 2004) morphine can be dispensed by a pharmacy directly to patients. The doctor gives the patient a prescription with their signature and stamp and this can be taken to the pharmacy at a convenient time. The pharmacy works with Global Cancer Concern (an NGO) and there are plans to extend this service to south Gujarat in Surat and Rajkot (300 km and 200 km from Ahmedabad City respectively) which would improve the availability of morphine for patients living beyond the city’s boundaries.⁶⁹

In addition, The Pain and Palliative Care Society (PPCS), Calicut has been designated a WHO Demonstration Project (WHODP) to provide national expertise and leadership in opioid availability, especially in the use and control of morphine (The PPCS is also a WHODP for providing cost-effective community-based home care for late stage cancer patients). In 2004, with the assistance of the WHO Collaborating Center for Policy and Communications in Cancer Care, Dr Rajagopal (AMRITA) secured a grant from the United States Cancer Pain Relief Committee to implement a series of workshop programs which aimed to ensure adoption and implementation of the simplified narcotic regulations by all states and union territories in India. A second grant was awarded to Dr Paleri, Calicut, which aims to train health professionals in India so that there is a body of expertise and training in the proper use of opioids.⁶⁷

Despite some success at improving the availability of morphine, progress is slow and many palliative care services in India have great difficulty obtaining a continuous supply of opioids, which can be frustrating for palliative care practitioners. Tamil Nadu, South India is one of the states which has adopted the simplified narcotics regulations but Dr Mallika Tiruvadanan based at the Lakshami Pain and Palliative Care Clinic, explains how this does not equate to a continuous supply of morphine:

 I don’t have a supply at all. In almost the whole of Tamil Nadu there is just the Regional Cancer Institute in Chennai which has the WHO stock of oral morphine, and only the immediate-release tablets, the 10mg and the 60mg.  So we have got permission from the Director to send our patients to them, so we give our prescription, with our seal and signature and all that, and they can take it to the Institute and get their morphine supply. But, you know, this is difficult for some patients. There were some dealers, just one or two dealers, a year or two ago, but they’ve all shut, closed their doors because they have all complained about constant harassment with going and renewing the licences, obtaining the licence. So they just don’t want to have anything to do with morphine. Now the morphine is being supplied by one or two pharmaceutical companies and it is also given away to one or two of the major hospitals. Now the thing is it’s sometimes available, sometimes it’s not.⁷⁰

Dr Stanley Macaden, Bangalore Baptist Hospital, Karnataka, south India describes some of the problems of morphine availability in India:

All over India the rules have been amended but it has not been adopted by all the States, and health is a State subject, so there are places where they don’t have the rules amended. And even if they are amended the implementation has been a problem, so all those things are there. And also the awareness among the health professionals to prescribe morphine, so the demand also has to be there from the health professional side, and so that’s why the medical education and training of doctors and health professionals, nurses, all this becomes important with regard to palliative care.⁷¹

Barriers to morphine availability in India include:

• Stringent central government legislation
• State government reluctance/ignorance about simplified narcotics regulations
• Difficulties with some state bureaucracy
• Fears about morphine addiction among state officials, health professionals, patients and their families
• Pharmaceutical companies unwilling to produce morphine
• Products prohibitively expensive
• Few dispensing services
• Lack of experience of prescribing morphine among health professionals
• Fear of patient side effects
• Little training/education about morphine for health professionals and the general public