Editor’s Note: Dr. Chadha has been following the National Pain Report in India. We had a virtual conversation recently and thought that giving our readers a sense of how the chronic pain issue in the world’s second largest country would be interesting. As you’ll read it’s different and the same, all at once.
Every country has its own story, history and its own jaunt that it has undertaken over centuries. It suffers, it celebrates it evolves; akin to it is the story of pain, peculiar to each, as it varies according to ethnic, social, cultural, religious concepts and environment. In a country like India acculturation can be seen all across, in its own sphere there are multiple culturally diverse universes fueling in different concept of pain perception and behaviors for both acute and persistent chronic pain.
We are a country where koovagam (a transgender festival) is celebrated in southern part of India since ages when the western world was totally intolerant for such public transgressions. This festival tests the psychobiology of pain to its hilt, as they seek spiritual healing for their psychological pains. Tolerance to pain has been inbred in Indian society thru ages. The art and science of meditation & yoga which is now recognized world over as an effective management modality for chronic pain patients was practiced in this land for centuries, sadly in Indian medical teaching, the concept of mind-body-soul or as we like to call it the biopsychosocial approach got lost to miniscule approach of organic and biologic causes for treatment of pain. We strayed into the obvious and lost tract of an ancient self management technique. Most clinicians in India view chronic pain as a symptom and not as a disease and sadly the biological model of managing persistent pain – a failed model is still ingrained in the psyche of majority of physicians.
A report by Joshi M1 on prevalence and practice of Chronic Pain suggested a point prevalence of chronic pain in the range of 13% in metros of India and almost 95% persistent pain were still managed by over the counter NSAIDS. Unlike USA where opioids are causing a ripple and dependency, in Indian scenario it’s the anti-inflammatory the known devil. Indian markets are already flushed with over the counter, fixed dose combinations of NSAIDS, they also are available as FDC with weaker opioids (like tramadol). A recent study2 showed almost 73% FDC (fixed dose combinations) for NSAID are not centrally approved in INDIA, this is a major issue, there is no standardized monitoring in place for this as to who is using or abusing these drugs. The problem stems from lack of awareness of chronic pain as a disease, secondly dearth of clinical training at all levels for chronic pain, a damning Human Rights Watch report in 2009 said, the curricula for undergraduates and postgraduate medical studies do not provide for any specific education on palliative and pain management, as a result vast majority of medical doctors in India are unfamiliar with the most basic of pain and palliative management. Since then there have been strides in pain education though at a snail pace, Indian government has come up with MD palliative care (a three year course) whose first batch will be out soon. One year Fellowship programs in pain medicine both in private and government sectors have been launched.
Indian Society for the Study of Pain is in process of forming an Indian academy of pain for a standardized pain education and training. It has already formulated guidelines for the Medical council of India to integrate pain education at both undergraduate and post graduate level. What we lack is a National Pain strategy which needs to be worked upon.
In terms of Cancer pain there is good news, government of India has amended the NDPS (National drug and psychotropic substance act), a uniform system of licensing of morphine with single window of clearance, this will definitely ease up and increase the domestic consumption, the paradox being India is the world’s largest licit supplier of opium, it contributed almost 420 tone3 (42 tons of Morphine equivalent) in 2011 but has a consumption of only 0.1079mg/capita4. This act should benefit cancer pain patients as it will ease the availability of morphine in the market, cancer in India kills close to 5 hundred thousand patients/ year – bigger than any other disease a report recently published by Indian council of medical research Cancer registry 5.
The only problem is that this can work as a double edge sword, we have seen the pit falls and damage it caused to the American system where opioid use and abuse is at its pinnacle compared to India – USA consumes a whooping 78.6245mg/capita of Morphine4, the problem is grave. Taking a cue from this, training, opioid monitoring, formulation of guidelines and stringent checks need be formalized before we flood our markets with various brands of opioids. We have a mammoth task in our hands and the need of the hour is an interdisciplinary approach to pain. A dialogue needs to be established between various learned bodies in order to devise strategies for a comprehensive pain management for cancer and non-cancer pain, involving allied sciences on the same platform to help devise a National pain strategy further. India is a young nation, a growing economy, an average Indian is working more, the ergonomics are incorrect, lifestyle issues are burning up and he/she is adapting more sedentary lifestyle, this in turn is going to increase the burden of chronic pain. The need of the hour is preventive pain management strategies. Pain advocacy, education and integration of pain management services and allied health at one platform may help us devise “Pain Free India”. The elephant of Indian pain is out in the open, it needs nurturing, safe keeping – only then it can roar.
About the Author – Dr. Chadha is a Consultant in Pain Medicine: My basic specialization is in Anesthesiology from National Board OF Examinations India, I further specialized in chronic pain and completed my MMED (Masters of Medicine in Pain Management (UST/AUS) and advanced interventional fellowship in Pain from Axon associates Hyderabad . I am a Trainer for EPM (Essential pain Management) and EPM lite India Wing which is a brain child of Faculty of Pain Medicine Australia. Area of Interest- Chronic Musculoskeletal Pain & Psychobiology of Chronic Pain.
Here are the References cited in his blog:
- Joshi M (2014). Prevalence of chronic pain, impact on daily life, and treatment practices in India. Pain Pract. Feb:14(2):E51-62
- Patricia Mcgettigan (2015). Use of Fixed Dose Cominabtion Drugs in India. Central Regulator Approval and Sales of FDCs containing non-steroidal Antiinflammatory , Metformin, or Pyschotropic Drugs. PLOSmedicine. Journals.plos.org. DOI: 10.1371/journal.pmed.1001826.
- www.incb.org/documents/Narcotic-Drugs/Technical Publications/2012/NDR_2012_Part2_Comments_E.pdf
- Cancer now India’s biggest killer. Article DNA. Www.dnaindia.com. May 2015.
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