• Step 1 : It consists in administering a non-opioid (such as paracetamol or non-steroidal anti-inflammatory agent (NSAID), such as aspirin) for mild pain. If pain persists or is moderate at the outset, a weak opioid (such as codeine) and a non-opioid are given.
• Step 2 : If no relief is obtained or pain is severe at the outset a strong opioid such as morphine is combined with a non-opioid.
• Step 3: At each stage adjuvant drugs like antidepressants may be added as deemed necessary. While NSAIDs have a dose ceiling effect, the dose of opioids such as morphine can be increased till the patient gets relief, provided side-effects are not unacceptable. Side-effects such as constipation are manageable and preventable.

Oral morphine is widely used in developed countries to control pain in terminally ill patients. It is safe and effective if used correctly. It is the least expensive oral narcotic agent and the one that is most studied. There is ignorance and a number of myths surrounding the use of opioid analgesics. Continuing education and widespread proper use will help dispel these myths.
At present oral codeine and morphine one available only in a handful of tertiary referral centres scattered far and wide across the country. These are barely sufficient to handle even a fraction of the population with cancer-related pain. Cancer pain is a grossly neglected and undertreated problem in India.
To solve the problem of neglect of cancer pain, oral codeine and morphine should be made available in all district hospitals in the country. This will enable doctors to alleviate unnecessary suffering and pain associated with advanced cancer, rather than abandoning these poor patients. Health care providers are expected to "cure sometimes, relieve often and comfort always". While tightening regulations to prevent drug abuse, simultaneous efforts should be made to make opioids freely available to thousands of patients who waging a desperate war against cancer, for alleviation of their untold suffering and unbearable pain. The enforcement personnel should be made aware of this problem and the Government should take necessary steps to make oral opioids available for legitimate medical use in every district in the country. Success of the crusade against the scourge of drug abuse should not add to the travails of the cancer patient who writhes in pain.
Dr. Rachel C. Koshy is Assistant Professor of Anaesthesiology and Consultant in Palliative Care Service, Regional Cancer Centre (RCC), Thiruvananthapuram.

KERALA CANCER PATIENT'S AGONY: NO PAIN-KILLERS

Thousands of cancer patients in the State are reeling under the impact of an acute shortage of morphine - the most commonly used pain-killer. According to reports, the Regional Cancer Centre (RCC), the premier cancer institute in the State, received only three lakh tablets as against its requirement of eight lakh last year. Consequently, the pain clinic at RCC is left with a stock of less than 200 tablets now. "We have stocks for just three or four days", said Dr Vasudevan Mappat, head of the department. Of the 10,000 new patients registered at the RCC every year, 60 per cent suffer from an advanced stage of cancer. Of these, nearly 70 per cent are in severe pain and require regular medication. "Nearly 90 per cent of the pain can be alleviated through morphine and adjuvants like brufen and voveran", said a specialist. However, according to another doctor the RCC was without morphine tablets from mid-March to April end this year.
The shortage of morphine at RCC has also affected the continuous supply to its early cancer detection centres and pain clinics at Ernakulam, Kottayam and Palakkad. Problems of cancer patients have been compounded by strict enforcement of excise and drug control rules. Only those firms which possess licences from the Excise Department are allowed to manufacture and supply morphine.
Source: Indian Express News Service, 24 June 1998, New Delhi.

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