Opioids are among the top-most choices for palliative caregivers as well as in-pain management using pharmaceuticals. It is well-known that India is the world's largest manufacturer of legal opium for the pharmaceutical industry. However, opioids are a double-edged sword. Under supervised conditions, small doses of the drugs can provide essential relief from acute pain. But it often comes with the risk of addiction or over-prescription.
"Opioids are used to treat pain, but with long term use, the pain might worsen as the efficacy of the drug on the body reduces, dependency sinks in, and it begins to hamper one's day to day life if the drug is not consumed. Larger than prescribed doses for longer durations might even lead to death," Dr.Vighnesh Naidu Y, Consultant General Medicine, Yashoda Hospitals, Hyderabad told Sputnik.
Dr. Naidu also informed that India has about 4 million illicit opioid users, out of these 232,000 are from Punjab state alone. "India's numbers are twice the global average for Opioids usage, with the easing of the Narcotic Drugs and Psychotropic Substances (NDPS) Act there is fear of a further spike in these numbers," Dr. Naidu said.
According to the 'Magnitude of Substance Abuse in India' 2019 report by India's Ministry of Social Justice and Welfare, after alcohol and Cannabis, Opioids are the next-most commonly used substances in India. About 2.1% of the country’s population (22.6 million individuals) use opioids including Opium (or its variants like poppy husk, known as Doda/phukki), Heroin (or its impure form, 'smack' or 'brown sugar'), and a variety of pharmaceutical opioids. Nationally, the most common opioid used is Heroin (1.14%) followed by pharmaceutical opioids (0.96%) and Opium (0.52%). Sikkim, Arunachal Pradesh, Nagaland, Manipur, and Mizoram have the highest prevalence of opioid use in the general population (more than 10%).
"Usually this is seen among patients from older age groups and younger age groups. People in the 30-40 age group do not usually have such issues. It usually starts off as a prescription that is given by the doctor to get relief from certain pain. Patients experience good results and then they continue, without realising that they are on an opioid drug. One of the things which is very important is that the doctors should inform the patients that they are putting them on opioids, which have a very high chance of causing addiction. It should be written on the prescription--do not refill. These patients take the prescription to the pharmacies, get the drugs and they keep giving the drugs," Dr. Rohan Sequeira, an Internal Medicine-Physician told Sputnik.
Older adults are at higher risk of accidental misuse or abuse as they have multiple prescriptions and chronic diseases, increasing the risk of drug-drug and drug-disease interactions. This can also lead to slowed metabolism that affects the breakdown of drugs.
Opioids are generally prescribed as they contain chemicals that relax the body and can relieve pain. Prescription opioids are mostly used to treat moderate to severe pain and sometimes they can be used to treat coughing and diarrhoea.
"Dependency on these drugs is easy to identify clinically, if they adhere to a single physician or a clinic, but upon refusal they do tend to hop from one centre to another, making it difficult for the new physician to ascertain the facts of prior drug use; upon discontinuation they do tend to face withdrawal symptoms akin to those of non-medical addicts, but to a slightly lesser degree, they might not even realise that they are addicted to the pain killers until the matter is discussed with them," Dr. Naidu said.
According to a report of the Indian Journal of Medical Research, prescription opioid abuse has become a major clinical and public health concern. According to experts, while opioids are useful for chronic cancer pain, their use in non-cancer pain management should be exercised with caution. Some experts pointed out that there is a lack of training in the management of pain and psychiatric illnesses among most undergraduate medical trainees in India, which has resulted in the over- or-under-prescription of opioids. According to a study of the National Medical Journal of India, the growing misuse of pentazocine in India is a matter of concern. Some doctors have also stressed that 25-26 percent of patients on long-term opioids have opioid dependence that is unrecognised.
"When we talk about opioid addiction, the problem in India has always been the weakest link, which is at the pharmacy level. There are many drugs or opioid painkillers which are available on the market today. Patients are always able to get these drugs from the pharmacy, sometimes even without a prescription. Of course, certain medicines like morphine are not available without a prescription. However, other opioid-category drugs are readily available. As per statistical differences, India is presumed to have twice or thrice the number of addicts compared to the global average," Dr. Rohan said.
After they're consumed, opioids bind and activate receptors on cells located in many areas of the brain, spinal cord, and other organs in the body. When opioids are attached to these receptors, they block pain signals sent from the brain to the body and release huge amounts of dopamine throughout the body. This release can strongly reinforce the act of taking the drug, making the user want to repeat the experience.
"Patients who have chronic conditions like a lot of back pain or fibromyalgia find a lot of relief through opioids. These are the patients who are highly prone to get addicted. The diagnosis is very difficult as the patients don't know they are addicted. Phasing out is generally recommended," Dr. Rohan added.
Global Scenario
However, this scenario is not just prevalent in India but in other parts of the world too. According to a report by the National Survey on Drug Abuse, opioid dependence affects nearly 5 million people in the United States and leads to approximately 17,000 deaths annually. A report by the Society For The Study of Addiction has revealed that Opioid misuse and dependence among prescription opioid patients in the United States may be higher than expected. Another US-based study revealed that patients receiving higher doses of prescribed opioids are at increased risk for overdose. However, the extent to which overdose risks are elevated among patients receiving medically prescribed long-term opioid therapy is unknown.
Fortunately, there are several signs of dependence that can be observed by physicians. "A patient requesting the same prescribed meds, asking for an increase in the dose of the medicine or increased frequency of the drugs, refusal of newer safer substitutes or complaints that the new substitutes are not as efficacious as the ones prescribed before, mood disturbances and erratic behaviour, as well as the inability to be productive in one's day-to-day routine are the most common red flags we come across," Dr. Naidu said.
He also suggested that keeping in mind the addictive nature of these opioids, safer substitutes should be used right from the onset of the disease.