Sunday, April 24, 2011

Oral Morphine Usage

Awareness to step up usage of oral morphine

With the Directorate General of Health Services writing to the Regional Cancer Centres expressing concern about the ‘under use' of morphine for palliative care, efforts have also been kick-started in Tamil Nadu to spread awareness among health care professionals.

Oral morphine is considered the best analgesic (pain killer) and is recommended by the WHO in cases of excruciating pain, especially those suffered by terminally ill cancer patients. It is an extremely effective drug, with minimal side effects that can be overcome, and is cheap.

However, according to the DGHS, the issue of availability of the drug for needy patients is a matter of great concern. The problem is two-fold – doctors' reluctance to prescribe the drug; and reluctance of chemists/hospitals to stock them.

While the average morphine consumption in the country should be around 900 kg per year, the actual consumption is 120 kg, the DGHS note informed. During the December 2010 visit of the International Narcotics Control Board Mission, the issue of non availability of morphine and its meagre use was discussed. It was then agreed that the government would take necessary steps to sensitise doctors and health workers to prescribe morphine for palliative care.

As far as Tamil Nadu goes, the consensus is that the State is far ahead in terms of both — availability and prescription for palliative care. “Tamil Nadu was the second State to get the narcotics control rules amended, as early as in 2000. In 2007, a Standard Operating Procedure was also evolved to ensure easy availability of oral morphine to treat persons with terminal illness,” said M. Bhaskaran, Director of Drug Control.

The Directorate also processes applications from institutions serving terminally ill cancer patients, oncologists treating terminal illness for licences to prescribe, purchase, store and dispense oral morphine. About 25 institutions in the State are currently licensed; and others are encouraged to apply as well, Mr. Bhaskaran says.

At the Cancer Institute, Adyar, 3.6 kg of morphine is allotted per year, with a provision to up the quota as and when required, its Director T.G. Sagar says. “Currently, supply of oral morphine is not a problem in Tamil Nadu. In fact, the Institute has been at the centre of efforts to facilitate easy availability of morphine for patients, and even to invite a pharmaceutical manufacturer to set up a morphine production unit in Chennai,” he explains.

Mallika Tiruvadanan, of Lakshmi Pain and Palliative Care Clinic, agrees that the licensing and availability of morphine in Tamil Nadu is not a problem. The issue is with awareness – getting doctors to prescribe oral morphine, particularly in rural areas. The WHO has a clear step ladder to treat pain, and at the top of the ladder comes oral morphine. However, if doctors have no knowledge of this, it is going to be difficult to implement. Principal Secretary, Health, V.K. Subburaj says prescription and availability of morphine in rural areas was an issue until recently. However, with the State setting up palliative clinics in all the medical college hospitals, and one hospital in every district, that problem is likely to be a thing of the past. “In fact, we have scheduled a series of awareness camps to spread the message among medical professionals,” he adds.

Part of this awareness message would be facts regarding estimation of pain scale, the dosage of oral morphine to be prescribed, its side effects and how that should be handled. “Even doctors who prescribe morphine give such low doses that the morphine is inadequate; patients continue to feel the pain and stop taking the pills. This is disastrous,” says Deepa Muthiah of Dean Foundation. Part of the reason for this is because medical professionals too mistakenly believe that higher doses of morphine can start an addiction, Dr. Mallika explains.

Oral morphine is not addictive contrary to prevalent opinion. In fact, the dosage must be increased as the pain scale goes up. Injection morphine, on the other hand, could lead to addiction in a normal person, Republica Sridhar of RMD Pain and Palliative care Trust adds.

The side effects – primarily dryness of mouth and constipation —can also be easily handled according to her.

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