Opiates for All, Opiates for None
By Ramya Sampath
Imagine having a tumor so large on your leg that you can no longer walk without excruciating pain. It has caused you to lose your job as a farmer, the only source of livelihood where you live. You have exhausted your meager savings to afford costly chemotherapy and without it, your doctor, whose clinic is 250 miles away, grimly informs you that you will die. Even more, your pain will grow significantly through the coming days. After lengthy discussion, he may be willing to give you a prescription for pain medication, but no pharmacy within your township has the appropriate state-issued licenses to fill the prescription. This is a familiar story for over 99% of the Indian population that lives out of reach of pharmaceutical palliation.
The United States’ opioid overdose epidemic has garnered nation-wide calls for action resounding from Washington to local emergency rooms. Researchers and journalists have explored extensively how pharmaceutical companies underplayed data on opiate addictiveness to quickly ramp up sales, creating the present crisis of over-prescription and over-use. The Centers for Disease Control (CDC) estimates that a staggering 91 Americans die every day due to opioid overdose, a figure that includes deaths from prescription opiates and illegal opiates, like heroin.
Roughly 8,000 miles away, India suffers from an opiate crisis as well. Yet there, under 1% of India’s population has access to opiates for pain relief in advanced illness, despite India being the largest global producer of opium. This asymmetry of opiate usage characterizes the divide between high-income countries, such as the U.S., and low- and middle-income countries (LMICs), such as India. It is estimated that 83% of the world’s population lacks access to opiates for controlling pain. Meanwhile the U.S., at under 5% of the global population, consumes nearly 80% of all opiates produced. Within India itself there is marked disparity in access between the wealthy and the poor. Both globally and nationally the burden of this disparity is not distributed equally.
Health care access is often discussed in terms of resource availability per capita, but in this case, we must draw a distinction between availability and access. Although India produces over 90% of the world’s licit supply of opium, little of that supply stays within the country for use by its own population.
The contemporary structure of the global licit opium market has in large part been determined by the 1961 United Nations’ Single Convention on Narcotic Drugs. Initiated by the U.S., the convention created goals for the global management of narcotic production and use, establishing the International Narcotics Control Board (INCB). This international body is simultaneously responsible for ensuring availability of opioids for medical use while also restricting access to opiates by enforcing regulations to curtail illegal trafficking. Each year member countries are required to estimate their populations’ annual medical opiate needs and report fastidiously on any use in the previous year.
This process is not necessarily intended to hamper access to opiates for medical use. Yet in countries like India, poor application of regulations to local legal frameworks has led to the over-bureaucratization of medical opiate use. National, state, and local authorities restrict access to opiates by creating a web of regulation and licensure. These mandates have effectively deterred medical acquisition, prescription, and use of opiates.
India’s restrictive opioid policy originates in the 1985 Narcotic Drugs and Psychotropic Substances Act (NDPS), which was passed after pressure from the United States to join its global cry for its “War on Drugs.” The NDPS Act has since been heavily criticized for failing its original goal to curtail the illegal trade of narcotics, which has only continued to rise since the Act was passed. Indian policymakers, palliative care activists, and international monitors also regard the NDPS Act as a deeply flawed law whose unintended consequence has been a drastic decline in biomedical palliation available for those who suffer from extreme pain due to chronic and advanced illnesses. National data show that medical use of morphine in India dropped by 97% after the passage of NDPS Act.
Although an amendment to the NDPS Act passed in 2014, simplifying the licensing process for medical opiate prescription, access to opiates for medical use has not increased dramatically. Dr. M.R. Rajagopal, a prominent palliative care advocate and lobbyist for Indian drug policy reform, believes that negative attitudes toward opiate prescription pose major roadblocks toward delivering effective pain management to Indian patients. Many doctors and patients still fear legal entanglement given the harsh penalties for unsanctioned opiate use. Further, social stigma around pain medication and addiction may prevent access to opiates for those who could benefit greatly from seeking treatment.
Indian activist groups and physician advocacy organizations, such as Can Kids, the Indian Association of Palliative Care, and Pallium India, are dedicating great effort to proposing alternative legislation that will streamline drug regulatory processes. We also ought to remember that the NDPS Act did not originate in isolation from global discourses on opiates, but rather took shape due to political pressure from the U.S. which sought multilateral support in its War on Drugs.
India, in turn, has spent the last thirty years waging its own war on drugs. Although both countries use this turn of phrase as part of their political rhetoric, the term encodes disparate political and social realities that have drastically different implications for their populations. For India’s population, the result has been an epidemic of pain whose remission is still not in sight.
Ramya Sampath is a post-baccalaureate pre-medical student at Harvard University. She studied Anthropology as an undergraduate at the University of Chicago, and she is interested in medical anthropology, correctional health care, and end-of-life care in the US and abroad.
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