India is the second largest producer of opioids, like morphine, globally. However, less than 3 per cent of the morphine produced in India is consumed in the country due to strict regulation by the government, and misconceptions in the medical community contributing to poor access to this cheap and effective medicine, said Dr Sharma, a public health researcher at the Association for Socially Applicable Research.The study, led by Disha Agrawal and Dr Divya Shrinivas from ASAR, found that oral morphine was absent from the national essential medicine list (EMLs) and 17 state EMLs.“How will access to adequate pain relief be possible if the public health system does not dispense oral morphine? Policymakers fear that improving access to oral morphine will lead to a US-like opioid epidemic in India,” Dr Sharma said.However, he said, there is enough evidence to highlight that when prescribed following the WHO pain ladder, prescription morphine does not lead to addiction or misuse.Citing the example of Kerala, which has the best palliative care in the country, he said the state palliative care policy improved access to oral morphine without its abuse.“Kerala’s morphine consumption is nearly 14 times the national average. Kerala highlights how implementation of a balanced policy can improve access to oral morphine without creating an opoid misuse problem.”The study found that no Indian EML had all recommended formulations of morphine as oral solutions, tablets and injectables. Nationally, the Central Government Health Scheme (CGHS) EML and NLEM included morphine injectables and tablets, while the Employees’ State Insurance Scheme (EML) did not include morphine in any form.Nine (33 per cent) state/UT EMLs included injectables and tablets. Twelve (44 per cent) contained only injectable morphine, and one (4 per cent) included only tablets. Morphine was absent in five (16 per cent) EMLs – Gujarat, Karnataka, Manipur, Nagaland and Telangana.Delhi’s EML was the closest to the IAHPC EML and included all required formulations for 17 (52 per cent) drugs. However, Karnataka’s EML included all recommended formulations for only 3 (9 per cent) drugs and some formulations for 6 (18 per cent) drugs, while 24 (73 per cent) drugs were absent.The authors have suggested that the EMLs need to be revised every two years.“All state governments must ensure that their EMLs align with the community’s rising palliative care needs. The addition of oral morphine to all EMLs should be taken up urgently by all state governments,” the study said.EMLs of four states (Arunachal Pradesh, Goa, Sikkim Uttar Pradesh) and five UTs (Andaman and Nicobar Islands, Chandigarh, Dadra and Nagar Haveli and Daman and Diu, Ladakh and Lakshadweep) were unavailable in the public domain, the authors said.“Considering the importance of morphine, both in palliative care symptom management and monitoring of palliative care-related national programs in India, the national and state/UT EMLs should be updated to incorporate oral and injectable formulations of morphine,” the study said.
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