India’s opioid paradox

Sick people are dying in pain thanks to the misguided ‘war on drugs’, writes Martin Drewry.

A patient displays a bottle of medicine at an office of HIV/AIDS activists in New Delhi October 13, 2014. Indian companies and global health groups are stepping up efforts to provide a critical medicine for the country's free HIV/AIDS drugs programme after more than 150,000 patients risked going without their dosages this month. Credit: REUTERS/Anindito Mukherjee

‘I have been suffering from severe pain. I travelled to receive treatment and now I travel to a village 280 miles away from here just to get a prescription for morphine,’ explains Nita*, a 37-year-old mother from Gujarat, Western India.

She is dying from advanced mouth cancer. Her husband left his job to care for her in her final months, and, with the added travel costs to get pain relief, took on loans to meet the family’s needs. Their children then had to stop going to school, so they could work as labourers to pay off their growing debts.

Incredibly, Nita is one of the ‘lucky’ ones. At least she is able to access pain relief. Many other patients die in agony due to India’s opioid paradox: the country is one of the world’s leading producers of opioid medicines, yet only four per cent of its palliative care patients receive the morphine they should be getting.

Nita’s story is highlighted in Health Poverty Action’s new briefing ‘The hidden opioid crisis: How the so-called ‘war on drugs’ forces patients to die in pain’. In it we examine how prohibition prevents patients accessing opioid-based pain relief such as morphine.

While our research focusses on three states in India, the story is one that’s repeated again and again across the world. Ninety per cent of the world’s AIDS patients and 50 per cent of cancer patients live in low- and middle-income countries, yet these countries have just six per cent of the morphine used globally for pain relief.

This is, at least in part, a direct consequence of the so called ‘war on drugs’. Prohibition has been so aggressively implemented that heavy-handed restrictions limit access for medical use.

The country is one of the world’s leading producers of opioid medicines, yet only four per cent of its palliative care patients receive the morphine they should be getting

India’s 1985 Narcotic Drugs Act introduced a 10-year mandatory minimum prison term for violations involving narcotic drugs, along with cumbersome licensing procedures of import, export and transport between states. Following the Act, medicinal morphine use in the country dropped by a staggering 97 per cent.

Health workers told us that a combination of harsh penalties for minor clerical mistakes and complex bureaucratic regulations prohibited them from applying or maintaining licences to stock morphine due to the burden of paperwork and fear of being penalised for errors.

This is compounded by the stigma associated with opioids, and the fears they can cause addiction, exacerbated by a lack of training on palliative care. As a result, many practitioners are reluctant to prescribe opioids to relieve their patient’s pain.

The result is that people are dying needlessly painful deaths, whilst others are forced to travel hundreds of miles – and rack up debts – just to access pain relief. One doctor and palliative care expert described it as the ‘collateral damage’ of the war on drugs.

Ironically – and predictably – it’s the legally regulated area of drug use (ie for medical purposes) where it’s been possible for authorities to limit access to them, whereas globally prohibition has had wholly failed to limit the supply of drugs for illicit use.

 People dying in pain is one of many reasons why we urgently need to replace prohibition with healthier drug policies, both in India and across the world. From giving power to criminal gangs, diverting resources away from health and education and damaging the environment, this failed war hurts lives and livelihoods all over the world.

Last month Health Poverty Action published the report Punishing Poverty, showing how this failed war fuels violence, damages the livelihoods of poor communities and locks families into poverty in both India and Brazil.

For myself and Health Poverty Action the solution is legal regulation of the drugs trade. Done with care, and with a pro poor and pro health approach, legal regulation will make products safer, take drug policy out of the hands of criminal gangs, stop the destruction of people’s livelihoods and prevent patients like Nita being the collateral damage of this colossal global policy failure.

All of us concerned with health and poverty have a moral imperative to address the monumental disaster that is prohibition. Like tax, trade and climate change, the failed ‘war on drugs’ demands our urgent attention – for Nita, and for the lives of people across the world.

You can read more about the global case for legalizing and regulating drugs see the September 2012 New Internationalist issue on the topic.

*Names have been changed to protect identities.