Who cares your PAIN?

Anu Saha, 32, has been travelling to the capital’s Bangbandhu Sheikh Mujib Medical University (BSMMU) from Sirajganj twice a month during the last two years to collect oral morphine for pain management for his dying mother Sebi Saha, 50, a patient of terminal cancer.

“There is no pharmacy that sells oral morphine in Sirajganj. But I can’t let my mother die and go through this severe pain,” Anu Saha told The Daily Star while standing in front of the palliative care unit at BSMMU recently.

BSMMU, the country’s apex and only medical university hospital, is among the very few authorisers and suppliers of the most important pain management drug – oral morphine – to the patients free of cost.

Unlike Sebi Saha, Zillur Rahman, 45, another cancer patient who was a school teacher in Rangpur’s Pirgachha, was not as lucky. He died enduring severe pain during the last days before his death in 2016.

“I still can’t forget how my husband had screamed in pain before dying. We just cried helplessly,” Rumi Begum, wife of Zillur Rahman, told The Daily Star.

Like them, around seven lakh last-stage cancer patients are suffering in pain across the country due to a restricted policy on the use of morphine – a golden drug of choice in pain relief globally.

According to physicians, some 75 to 80 percent of cancer patients, suffer from moderate to severe pain frequently unless opioid sourced drug is administered.

In numeric ratings, pain is measured using the 0-10 scale. Here, scale 4-6 is moderate and scale 7-10 is severe. Moderate pain resembles the feeling of tooth pain.

According to a 2014 NIPORT study, 60 percent of newly diagnosed advanced stage cancer patients require 100 mg morphine every day during the last 100 days of their life.

According to WHO, morphine consumption is an indicator of a country’s situation and progress in cancer pain relief.

Under international law, access to pain treatment medication is a human right under the right to health.

However, numerous myths and misconceptions among professionals as well as among non-professionals have created a stigma over the years, making morphine a sensitive topic among policymakers, experts said.

Modern morphine, an opioid that is naturally found within the opium poppy plant, is the result of centuries of medical development and is the gold standard painkiller in palliative care, especially for cancer patients.

In the Indian subcontinent, opioids were used to heal the wounds of war-injured soldiers of the Mughal Empire (1526-1627).

Morphine acts directly on the central nervous system (CNS) to relieve moderate to severe pain, usually after surgery or traumatic injury.

In 2015, the global average morphine equivalence or consumption was 61.5 mg per capita while countries in South-east Asia, including Bangladesh, consumed just 1.7 mg per capita during the same time period, according to WHO’s South-East Asia journal.

In 2017, patients in low- and middle-income countries, with a share of 84.4 percent of the world’s population, consumed only 13.6 percent of the total amount of morphine used for the management of pain and suffering, according to the United Nations’ International Narcotics Control Board (INCB) report.

On the contrary, a small number of countries located mainly in Europe and North America consumed the remaining 86.4 percent of the total consumption of morphine.

In 2012, the per capita morphine consumption was only 0.05 mg in Bangladesh, according to a 2014 study.

Although there is no latest official estimation for Bangladesh, the annual amount of imported morphine sulphate shows the average consumption is less than one mg per capita, which indicates an extremely grim situation.

The Daily Star collected the latest data from the Department of Narcotics Control (DNC).

The DNC issues permission to the companies for morphine sulphate import as per the authorisation from the Directorate General of Drug Administration (DGDA).

According to the DNC, a total of six pharmaceutical companies have a quota allocation of 70 kg of morphine sulphate in total for import.

In 2014, the palliative care unit at BSMMU estimated that there is a demand of around 1,200 kg morphine annually in Bangladesh.

Of the companies that import and produce drugs from morphine, Gonoshasthaya Pharmaceuticals Ltd has a quota of 20 kg, Popular Pharmaceuticals Ltd 5 kg, Renata Ltd 10 kg, Unimed and Unihealth Manufacturers Ltd 10 kg, Health Care Pharmaceuticals Ltd 20 kg and the only government-run company Essential Drug Company Ltd 5 kg.

In reality, these companies usually import lesser or none at all.

In 2018-19, Gonoshasthaya Pharmaceuticals Ltd imported 17 kg of morphine sulphate and Unimed and Unihealth Manufacturers Ltd imported 10 kg.

Others imported none, according to the latest data from the DNC and DGDA.

Cause for concern

Before the latest Narcotics Control Act came into effect in December 2018, doctors needed written authorisation from the director general of DNC to prescribe morphine drugs. Failure to do so was a punishable offence. Under new law, doctors with a licence from Bangladesh Medical and Dental Council are allowed to prescribe it for pain management.

The ministry of health has included the issue of availability of morphine in its new policy on palliative care, sources said.

Experts, however, said there is need for extra efforts from the government.

The Daily Star contacted the high-ups of the hospital section of the directorate general of health services (DGHS) several times to know how many hospitals have supply of oral morphine. It seemed they are not aware of it.

According to the WHO-SEA journal, only eight medical institutions and four pharmacies in Dhaka city currently have the license to dispense oral morphine.

The Centre for Palliative Care at BSMMU, in the capital city, is the largest prescriber of morphine [free of cost] to the cancer patients in the country, the journal mentioned.

“The longstanding stigma among doctors still exists. The problem is that most of the doctors do not know about the Act. Moreover, you would not get oral morphine outside of Dhaka,” said Dr Farzana Khan, who belongs to a team that conducted a 2014 opioid availability study. The study indicated how physicians are in a misconception about the morphine: Around 85 percent of the physicians preferred to prescribe pethidine, when patients needed opioids for severe pain.

“Unless there is enough supply across the country, changes in rules for doctors would have no effect. The government has to take initiatives in terms of all aspects,” Dr Farzana said.

Dr Bimalangshu Dey, associate professor of medicine at Harvard Medical School in the US, told The Daily Star in an interview in December, “Can you imagine the excruciating pain a patient has to go through?” adding, “There’s inequality in the country.”

“There is every arrangement to cure patients. Society, however, has forgotten about the sufferings of dying people. They are simply abandoned. With no sufficient care management and scarcity of relevant drugs like morphine, they are just waiting to embrace a painful death,” Prof Nezamuddin Ahmed, chairman of the Department of Palliative Medicine at BSMMU, told The Daily Star.

He suggested for a balanced policy towards morphine, rather than the restricted one.

When contacted, health secretary Md Asadul Islam told The Daily Star that the government has a plan to adopt a balanced policy.

“We have a plan. Not only morphine, there are several other drugs like this,” he said.

Pointing to the abuse of morphine as narcotics, the secretary, however, said, “A single perspective cannot be a base [for policymaking], we have to consider other aspects too.”

The reality, according to the 2017 baseline study by the DNC, morphine is not among the 12 most frequently used drug in the country.

The health secretary said that the DGDA would work to make oral morphine available.