Judicious usage of WHO Step III Opioids in Palliative Care in India

The article entitled, “Factors influencing the initiation of strong opioids in cancer patients on palliative care: An audit from a tertiary cancer center in India,” raises many important issues about the use of WHO Step III opioids in cancer patients in a lower-middle-income country[1] like India. Managing cancer pain requires a multimodal approach. In developing countries, it is likely to be related to geography and limited resources. Legal restrictions also present barriers.[2] In developed countries, it is usually related to a “disease” rather than a “symptom” model of care, which minimizes symptom management. Other factors include the lack of physician education and failure to follow the existing guidelines. Patients fear addiction, drug tolerance, and side effects.[3] The establishment of effective pain management requires comprehensive assessment, competency with analgesics, and communication wth patients and families. Hence, optimal utilization of adjunctive analgesic modalities coupled with good supportive care can minimize the requirement of strong opioids.[4] This can be particularly useful in places with limited opioid availability and palliative care services.[5]

Increased opioid prescribing has led to a growing crisis of misuse, addiction, and overdose in the United States,[6] Canada,[7] Australia,[8] and Western Europe[9] with even deaths occurring from prescription or illicit opioid-related overdose. Most of these cases are seen in noncancer conditions.[10] Many patients experiencing opioid-related harms, including misuse, opioid use disorder, and overdose, may have been initially exposed to opioids through a prescription for the treatment of acute or chronic pain. To address this crisis when preserving access to appropriate pain treatment, stakeholders across the health system, particularly in the United States, are attempting to implement strategies to ensure that opioids are safely and appropriately prescribed.[11] Supporting safe and appropriate prescribing is only one component of a comprehensive public health approach to the opioid crisis that also includes evidence-based prevention, support for treatment and recovery from substance use disorders (SUDs), and overdose prevention.

Opioid overdose deaths could well be the current major problem in the regions mentioned above, but the bigger crisis in the world is the pain burden and serious health-related suffering caused by the lack of access to opioids to treat pain.[12] In this context, paramount is to remember the principle of balance: we have a duty to contain the current problem of nonmedical use of opioids; just as we have a duty to make opioids available for those who need them desperately.[13] However, that does not take away the onus on the stakeholders in developing countries, including policymakers, health system leaders, health-care payers, and health-care providers to try and mitigate risks through more judicious prescribing of opioids vulnerable to misuse. A useful step in such direction would be to periodically assess the impact of safe opioid-prescribing practices on patient health outcomes and public health. This would prevent stigmatization, barriers to appropriate treatment for both acute and chronic pain, and other adverse consequences for patients currently prescribed opioids for the treatment of chronic pain. Strategies and tools that can be potentially useful in such assessments include prescribing guidelines, prescription drug monitoring programs, screening and risk-assessment tools for opioids, other interventions designed to change the prescriber behavior and manage access to prescribed opioid analgesics, and improved patient care. While coordinated safe prescribing strategies often involve a combination of these tools, a framework for understanding well-balanced approaches to supporting the safe use and appropriate prescribing of opioid analgesics includes (1) establishing goals for safe opioid analgesic prescribing and appropriate pain management; (2) enhancing provider tools for screening, monitoring, and mitigating risks of opioid analgesic therapies; (3) developing system approaches for changing prescriber behavior; and (4) expanding patient access to coordinated pain management and SUD treatment. In order to reduce potential barriers to access to appropriate therapies, comprehensive approaches to safe use and appropriate prescribing must include expansion of alternative nonopioid therapies, coordinated multimodal pain management, and evidence-based SUD treatment.[14]

Moving forward, Indian health system leaders must learn to balance the competing demands of rapidly responding to an evolving public health crisis with the need to collect the data, rigorously evaluate efforts, and developing best practices for future implementation. Policymakers, health system leaders, and payers must also balance the need to preserve access to opioids as a part of appropriate pain management. Overall, strategies to support the safe use and appropriate prescribing of opioid analgesics are an essential component of a comprehensive public health approach to the opioid crisis,[15] but one that must be met with commensurate effort within the health system to expand access to SUD treatment and overdose prevention.