ECHO Hamrahi 7th session 14 June 2022

Opioids for Cancer Pain

Dr Anil Tandon: Opioids for chronic cancer pain

Dr Mukul Mishra: Opioids and Palliative Care in Mahavir Cancer Sansthan, Patna

This 7^th ECHO Hamrahi session saw us revisit issues of opioid prescribing for severe chronic cancer pain. Dr Tandon shared clinical tips from his experience as a Hamrahi mentor in several sites across India.  

• Avoiding implementing the WHO pain ladder as if it is a stepladder upon which you start at the lowest rung and work up, is an important principle. The ladder was developed to provide clinicians with a simple strategy for prescribing analgesics according to intensity of pain. If pain is severe, then strong opioids plus non-opioids +/- non steroidal anti-inflammatory medications, are indicated as ‘first line’ analgesics. When strong opioids such as morphine are available, then there is little indication for weaker opioids in managing cancer related pain.
• The principle of double effect is over-stated in the textbooks and earlier literature. This ethical principle argues that if an action is morally good and the good effect is the intended effect, if the action also carriers a secondary effect which may involve shortening of life, that is acceptable. However, there is no evidence that patients are dying sooner because of careful effective pain management,  proportionate to their pain severity and in keeping with their renal function and comorbidities.
• Respiratory depression occurs when opioid dose far exceeds the pain threshold or when other conditions (eg. renal failure) intervene.
• There is no ideal opioid for hepatic failure

Dr Mishra shared the story of palliative care development at Mahavir Cancer Sansthan in Patna, Bihar since 2018. The number of patients seen in the Palliative Care OPD has increased from 293 in 2018, to 1,054 in 2021. Opioids have been available at MCS since 2005 but prescribing has now started to increase, rising from 40,838 10mg tabs in 2017, to 98,254 tablets in 2021. However, prescribing of 30mg tablets has not increased greatly.

Statewide, 95% of cancer patients have poorly managed pain, due to lack of available opioids, lack of knowledge of health care professionals, opiophobia and fear of addiction. Bihar does not have a State Palliative Care policy but awareness raising is continuing with multidisciplinary workshops and lectures, community sensitization and recruitment of volunteers. There are plans to establish a training centre for palliative care in Patna, develop home based community services and a Diploma of Palliative Medicine.

Congratulations to the Mahavir team for all these achievements and thank you for sharing your experiences with the Hamrahi community.