The Indian Society for Study of Pain, Cancer Pain Special Interest Group Guidelines on Cancer Pain Management in Adults

Pain is one of the most common and disturbing symptoms in cancer despite the availability of resources and awareness across the world. WHO ladder approach of prescribing analgesics was recommended way back in 1986, however the goal of adequate pain relief to all is far from being realized? Hardly 2-5% patients in moderate to severe cancer pain receive strong opioids. NDPS amendment 2014 came in force due to great efforts undertaken by IAPC and lawyer's community through supreme court pressure, to ease out morphine availability for cancer patients in severe pain. Producers of morphine now just require a single license from respective State Drugs Controller unlike previous times involving prolonged steps and multiple licenses of different validation period. However, the exact impact of NDPS amendment on consumption of morphine for cancer pain in India is not been estimated. What we know that even now our opioid consumption is still very low. Tramadol has also been put under NDPS act since April 2018 due its export and rampant use by ISIS terrorists who used to suppress pain and boost energy. This restriction also came as a big blow to our suffering patients. In current scenario neither WHO step 2 or 3 drugs are available to our needy patients easily in rural and district hospitals. An Indian Face to face survey of 836 patients from 4326 screened general population reported a 19.3% prevalence of chronic pain in India.[1] The study found that 72% patients were taking over the counter (OTC) analgesics. Everdingen MHJB conducted two systematic reviews on prevalence of cancer pain: first one in 2007 and next in 2016[23] and did not find much significant difference in the ensuing decade in the prevalence of cancer pain. He included 117 studies (n = 63333) and pain severity (52 studies, n = 32261) reporting the prevalence as 39.3% after curative treatment, 55% during curative treatment, 66.4% in advanced or metastatic or terminal disease. Pain was found moderate to severe in intensity in 38% patients. Despite all initiatives, a decrease in prevalence rates was not achieved and still many general misconceptions exist ranging from “you don't have to have pain anymore” to “opioids will kill you.”[3] A UK cancer registry data of opioid prescribing during last year of life (n = 6080) analysed the extent and duration of strong opioid treatment, suggesting strategies to be put in place for earlier pain assessment and starting strong opioid treatment to improve pain outcomes.[4] Similarly, a survey of patients and physicians across 10 countries in Asia about current practices in cancer pain management (2015) reported many barriers to adequate pain management e.g. inadequate assessment in 49.7%, fear of addiction (67.2%), adverse events (65%), patients’ reluctance to report pain (52.5%), excessive regulations (48%), reluctance to prescribe opioids (42.8%). Opioid use was only confirmed in 53.2% patients. Pain adversely affected daily activities in almost 81.3% patients.[5] This study highlighted the immediate need for better training and continuing medical education of physicians about cancer pain management. Barriers need to be addressed aggressively to win over the crisis of pain.[6] A study also reported the issue of underdosing of opioids in an Indian cancer hospital.[7] Various initiatives were undertaken in last 5 years in India to enhance pain education. Indian Academy of pain medicine (IAPM) under the Indian society for the study of pain (ISSP) flagship started a fellowship in chronic pain through accredited 10 centers in India in 2016. International association for the study of pain (IASP) conducted many pain schools in south east Asia in last 10 years. ISSP has organized young pain physicians one-day pain CME and later a concept of travelling pain school too became popular to disseminate pain knowledge to MBBS students and general physicians. ISSP formed 9 special interest groups (SIGs) to bring up evidence based best practice pain guidelines for Indian pain practitioners. This issue of IJPC includes 7 articles on cancer pain management covering all aspects from diagnosis to palliative care and end of life based on the evidence-based guidelines. I hope these freshly minted articles will prove to be a torchbearer to young pain physicians during their day to day clinical practice.