Published on: February 24, 2020

Dr Namruta, a pain management specialist from Rishikesh who visited Pallium India in January 2020, writes:

Until I worked as a resident in interventional pain medicine, the idea of pain management to me was simply perioperative pain relief. I had no idea that chronic pain is in itself a disabling disease that encompasses physical, emotional, psychological ill effects as well as financial burden.

The following is just one of the many stories of patients/caregivers in smaller cities.

“I am a caregiver who has seen the suffering that cancer brings and the devastation that it brings with it.

“My mother was 70yrs old when she was diagnosed with late stage pancreatic cancer, last June. It all began with severe stomach pain, such that even her routine activities were affected, making her feel incapacitated. As the cancer had progressed to an extent where any definitive treatment was futile, she was advised injection in her back to relieve the pain and improve the quality of life. The injection was helpful and I was relieved to see the relief it provided her, but it lasted only for a month as the cancer still progressed.

“When the pain returned, it came back with a vengeance, making her cry in agony. She was admitted and given care to help with her pain. As the pain drugs started working, she was discharged with pain medication – morphine tablets to take home for pain relief.

“The tablets have been of immense help, they have helped her to maintain a normal routine making her able enough to move around and also to eat. However, the cancer was still progressing and she started feeling weak as it advanced. She became bedridden and expressed her wish to go to her hometown.

“The doctor who was sympathetic to this advised that she can be taken there and gave the reference letter stating the need for morphine to be prescribed and obtained under medical guidance from nearby hospital. I arrived at the cancer OPD I was quite hopeful that the morphine would be issued for my mother’s pain relief, and I was directed to the pain clinic, but to my disappointment I was denied morphine even with a reference letter, due to safety reasons the presence of the patient for the first visit was essential. Bringing my mother to hospital in such a frail condition was impossible for me. I was helpless…”

Almost 20-30% of our patients are referred to us by oncology department. The word cancer in itself brings turmoil in the life of patients and their family members. And as the tumor progresses it affects not only the vital function of that part but it affects the nearby nerves and muscles leading onto severe pain that affects psychosocial and behavioural aspects leading on to suffering that extends up to the nearby family member or a caretaker as they are the ones who feel powerless most of the times. We, as pain physicians, try our best to treat the pain and suffering by various methods including intervention and medication, psychological and psychosocial support on outpatient basis as far as possible but still there are times where we start to feel helpless, like if a patient cannot come to outpatient department the first time for the opioid medication, legally we cannot prescribe them any drug on proxy basis even if they are being referred from a bigger city centre.

Morphine is a cheap and effective drug for the treatment of cancer pain. It helps in relieving pain even when other methods fail. Although it is provided free of cost, sometimes hospitals run out of stock or caregiver/patient fails to come for medication. Finding an authorised shop for morphine outside the hospital setting is still quite difficult in small cities of India. Hospitals in bigger cities with state-of-the-art facilities are over flooded with patients and yet smaller cities are even unable to provide palliative care to such suffering patients.