Opioids, including morphine, derived from the poppy flower, are crucial to managing severe pain, particularly in palliative care. These drugs act on the central nervous system and the brain, to block pain signals, providing relief. While concerns about misuse and addiction persist, experts say, and research backs this, that such risks are negligible when opioids are used for medical purposes. In these controlled contexts, the benefits far outweigh the potential for harm, and there is no reason for patients to endure unnecessary suffering, they point out.
Despite successful models in a few parts of India where regulated access to opioids has been implemented safely, there remains a massive lack of access to morphine and other pain relief drugs in the country, a crisis that experts attribute to to overly stringent policies and a colonial-era regulatory framework that remains in place even today.
The history and the law
“Historically, India was a key producer of opium, and post-Independence, the government maintained its cultivation for revenue generation. However, narcotics regulation remains under the purview of the Revenue and Home Ministries rather than the Health Ministry, creating bureaucratic impediments to accessing morphine for medical purposes,” explains Parth Sharma, a community physician and public health researcher.
The Single Convention on Narcotic Drugs, 1961, aimed at curbing illicit opioid use while ensuring medical access, placed a disproportionate emphasis on control rather than patient care, he points out. The Narcotic Drugs and Psychotropic Substances (NDPS) Act of 1985 further tightened these restrictions, resulting in a precipitous decline in opioid availability, even for legitimate medical needs. Although a 2014 amendment sought to rectify this by simplifying procurement procedures, access remains constrained, Dr. Sharma says.
India consumes less than its own morphine production, in stark contrast to the United States, where opioid consumption exceeds its assessed requirement. Canada and Australia, too, register significantly higher consumption rates. Less than 4% of patients requiring pain relief in India receive it, says Dr. Sharma.
The Kerala and Goa models
While national figures remain dismal, Kerala — one of the few States with a strong palliative care focus — has morphine consumption levels that are 14 times higher than the national average.
In Goa too, the government has pushed for better access to morphine. Ira Almeida, Project Director of the South Goa Palliative Care Project, says in South Goa, there is uninterrupted access to opioids for pain relief. “Our jurisdiction covers outpatient, inpatient, and home visits. We also cater to patients who have financial challenges. When we launched our programme in 2023, there was no structured morphine initiative in place, but we have maintained a steady supply of opioids, including morphine, sentinel opioids, and milder variants, without any disruptions,” she says.
Dr. Almeida, who works in collaboration with Goa’s Health Department, highlights the importance of streamlined procurement in the government sector. Earlier, she says, hospitals had to apply separately to procure opioids, but now every district hospital is designated as a registered centre for opioid procurement. This ensures a seamless supply chain, enabling us to maintain a well-regulated inventory while providing essential pain relief to those in need. The government’s Pharmacy department oversees procurement through an integrated model, with support from organisations like the Cipla Foundation,” she explains.
Morphine not included in State essential medicines list
Kerala and Goa however, remain some of the few regions in India where patients have unhindered access to morphine. For most of the rest of the country, the availability of pain relieving medication is scarce, hindering critical palliative care and end-of-life services.
A study published earlier this year, of which Dr. Sharma is a co-author, analysed State Essential Medicine Lists (EMLs) in India, and found that despite the NPPC allowing medical officers at primary health centres to prescribe morphine, 17 state EMLs do not include it. “Without its inclusion, physicians are legally unable to prescribe it, making the policy ineffective,” he says.
“The regulatory oversight of morphine in India has remained under the Narcotics Department, even after its supply and procurement was shifted to the Drug Control Board. Hospitals that are ‘Recognised Medical Institutions or RMIs alone can procure and dispense pain relief medication. This means engaging with the Narcotics Department as well as State authorities to be recognised and licensed,” points out Starlin Vijay Mythri, consultant psychiatrist and palliative care physician at Makunda Christian Leprosy and General Hospital in Sribhumi district, Assam.
Lack of training among medical professionals
The availability of morphine apart, a critical challenge is the lack of adequate training among medical professionals. The medical curriculum in India does not sufficiently cover opioid prescription. The exaggerated fear of respiratory depression and addiction deters doctors from prescribing morphine, despite its established role in palliative care. As a result, India grossly underestimates its morphine requirement, leading to inadequate procurement and distribution, says Nandan Choudhary, Consultant & In-Charge of Palliative Medicine and Supportive Oncology at Karkinos Manipur Cancer Care Institute. “In oncology, morphine is a standard prescription for pain relief, yet a deep-rooted fear of the drug persists within the medical community itself. I have observed cases where, even after obtaining a valid prescription, patients hesitate to use it due to misconceptions. A relative or acquaintance may warn them that morphine is an illicit drug associated with abuse, leading them to endure unnecessary suffering instead,” he says.
To ensure safe and regulated access, Dr. Choudhary follows a structured system at his hospital. “At our facility, pharmacies operate with a double-lock system, accessible only to designated personnel. Each prescription is documented in duplicate – one for the pharmacy and another for the patient – while an online registry tracks the quantity and distribution details,” he says.
Concerns over misuse too, have no basis in ground realities, doctors say. Dr. Mythri emphasises that misuse is not a significant issue in his region due to stringent regulations. While the prevalence of illicit drug use, particularly heroin is high,Dr. Mythri clarifies: “We provide morphine only to terminally ill patients.Morphine is strictly a pain management tool and is not available to anyone outside this subset.” He further points out that patients do not return for more once their pain is alleviated, particularly when they cannot afford it.
The need to strengthen pain relief care and access
Last year, the Supreme Court, in Harish Rana vs Union Of India , questioned the government’s approach to palliative care, particularly in cases where life support withdrawal is not permitted. Although the National Programme for Palliative Care (NPPC) was introduced in 2012, its implementation has remained inconsistent, says Dr. Parth, noting that the programme has not received the necessary political attention.
Dinesh Chandra Goswami, CEO, Guwahati Pain & Palliative Care Society, emphasises the need for additional human resources in palliative care by training both medical professionals and community workers with a foundational understanding of the science behind palliative medicine. Dr. Goswami pointed out that a trained workforce can play an important role in extending care, especially at the community level, where the need for palliative services is most critical.
“Palliative care services are now available across various centres in India, and although the earlier systems operated under outdated regulations, the past five years have witnessed significant improvements in access. However, the availability of morphine remains a persistent issue. It is crucial that such pain relief options be made available at the primary healthcare level, ensuring no one is left without the necessary care,” said Dr. Goswami.
Ishita Gandhi, Medical Director of Palliative Medicine at Cansupport, outlines the challenges faced by the NGO in providing essential palliative care medications, particularly morphine, to patients in need. . “Due to licensing issues, we are compelled to dispatch morphine from our Delhi centre to Punjab, which is an example of the difficulties faced by NGOs like ours to make palliative care available to those in need,” she says.
Dr. Gandhi emphasises the critical role morphine plays in the care of patients with patients with cancer and other terminal illnesses “Morphine helps not just cancer patients but also those suffering from diseases such as chronic obstructive pulmonary disease (COPD) and kidney failure. COPD, which refers to a group of lung diseases that block airflow and make breathing difficult, often causes severe breathlessness, and morphine helps alleviate that distress,” she says.
There is a growing need for mass education on palliative care. “The demand for palliative services is high in Northeast India too, due to the region’s unique challenges, including difficult terrain. Unfortunately, many patients can only seek care when they are in the terminal stages of their illness, which highlights the need for improved access and education about palliative care,” says Dr. Mythri.
While the opioid overdose crisis in the United States is a tragic issue in its own right, says Smriti Rana, Head of The World Health Organisation’s Collaborating Centre for Training and Policy on Access to Pain Relief, it often overshadows another, more widespread opioid crisis affecting 80% of the world: the lack of access to pain relief.
Published – February 18, 2025 05:40 pm IST