Inside preview of procuring narcotic license.

Sir,

In India, around 555,000 people died of cancer in 2010, representing 8% of estimated cancer deaths globally and 6% of deaths in India.[1] Physical and psychological effects of chronic pain affect the progression of the disease.[2] Opioids are considered as a key component for treatment of moderate to severe pain in cancer patients. Despite the abundant opium availability in India, opioid consumption, as estimated by World Health Organisation Collaborating Centre in 2012, is only 0.24 mg/person [Table 1].[3]

Table 1

Opioid consumption 2010 (Pain and Policy Studies Group, UWCCC/WHO Collaborating Center, 2012)

In India, only 0.4% of the total population have access to the opioids. Complicated rules and regulations along with problems related to attitude and knowledge regarding pain relief and opioids among the medical professionals and the public are major hindrances for poor access to opioids.[4]

According to Narcotic Drugs and Psychotropic Substances (NDPS) Act (1985), to procure opioids, all the medical institutes should possess a license; they should specify the drug, the required quantity and also the formulation of the drug. The procedure to procure the license includes filing an application to the Drug Controller in the capital city; the drug inspector then institutes an inspection. Inspector inspects for adequate storage facilities, security setup, facilities to discard drugs, etc. Approval by the Drug Inspector is transmitted to the Drug Controller. Then the health authority confirms the approval to Drug Controller and License is issued. Frequently, the validity of one licence expires by the time another licence is obtained. Thus, it becomes a tedious job for doctors and hospitals to get all the licences to procure morphine.[5]

Narcotic Drugs and Psychotropic Substances Amendment Bill, 2014 has been passed in 2014 with path-breaking changes for access to narcotics by medical specialty, breaking the various barriers which were included in the 1985 act. Parliament has adopted a new category of essential narcotic drugs in which central government can notify on the basis of expediency in medical practice. Drugs considered as essential will be subjected to central rules and will apply uniformly throughout the country. With the relaxation of rules, chances of misuse may be more and also due to the possibility of pilferage, chances of addiction increase.

Physicians are scared to prescribe narcotic drugs due to unfounded fear of addiction and respiratory depression in patients. Patients who want pain relief are seen as drug addicts and doctors fear prosecution under NDPS Act.[6] Many laws and government policies so far were restrictive, and availability was difficult, without realising their rational medical use in pain management.[78] Next is fear of dependence; for a patient in pain, dependence rarely results and this is not the reason for not prescribing opioids to ailing patients.[9] Studies in palliative care showed that increased use of morphine did not lead to misuse.[10]

Our aim is to update the readers on improved access and awareness of opioids to patients and identify regulatory barriers in the availability of opioids. Physicians and nurses should be educated about the principles of palliative care. Sustained and persistent efforts should be made by the palliative care leaders so that regulatory barriers can be overcome. Awareness can be created by conducting more and more workshops on the proper use of narcotics. Administration also plays a great role as it monitors the administration of narcotics and ensures the accountability of these drugs. It also guides and helps in maintaining the records. License should be issued to the institution or to the panel of physicians rather than on the individual basis and punishment should be harsher. New ampoules are expected to be exchanged for the discarded ones.

According to the the Drug Inspector, the provisions of the NDPS Act, 2014 will allow medical institutes to have uninterrupted supply of narcotics for the patient care and process of getting the different licences is expected to be less tedious. It is better to remember that by simplifying the narcotic regulation, opioid availability cannot be improved to the cancer patients as it needs education of health care professionals in pain management and palliative care along with the integration of the palliative care programmes into the health care system.[4]