Doctors want the government to improve access to pain-relieving opioids first.
Women and Child Development Minister Maneka Gandhi suggested legalising marijuana for medical purposes at a meeting of a Group of Ministers examining the draft cabinet note on the National Policy for Drug Demand Reduction earlier this week. However, several doctors working in palliative care say that they would rather see the government ensure a better supply of opioid drugs, the medical use of which is already permitted.
Marijuana is a cannabinoid obtained from the cannabis plant. Both cannabinoids and opiods – such as morphine and oxycodone – help in reducing severe pain, such as pain that patients with cancer and multiple sclerosis experience. But opiods and cannabiniods operate differently in the human body and have different receptors in the brain.
“Marijuana is a form of cannabinoids that have tetrahydrocannabinol compounds and other compounds structurally similar to it,” said Dr MR Rajgopal, chairman of Pallium India and Director of the World Health Organisation collaborating centre for access to pain relief for South-East Asia. “These cannabinoids can help only a small number of patients who have specific kind of nerve pain.”
Medical researchers around the world have been investigating the possible role of marijuana to treat chronic pain and acute pain and to prevent addiction to opioids. Some have even looked at using a combination of opioids and cannabiniods to treat pain. Even though there is evidence of marijuana’s role in alleviating pain, the full extent of its benefits and side-effects remains unknown. International institutes like the American Cancer Society Cancer Action Network have not taken positions on legalising marijuana for medical purposes, citing the need for more scientific research on marijuana’s potential.
According to Rajagopal, only opioids can help the majority of patients needing pain relief. “Legalising marijuana is not going to change anything for palliative care in India,” he added. “The demand for legalising marijuana has not come from the palliative community in India.”
Low opioid use
At present, doctors in India are allowed to prescribe six types of opioid drugs known to alleviate pain. However, they say that only three of the six drugs – morphine, methadone and fentanyl – are available at present in India.
Doctors estimate that only 2% of those who need of palliative drugs actually get them. The rest try to battle excruciating pain with less effective non-opioid painkillers.
“What we need is to improve the access to [opioid] drugs first which are already available,” said Dr Mary Ann Muckaden, professor and head, department of palliative medicine at Tata Memorial Centre in Mumbai.
The Narcotic Drugs and Psychotropic Substances Act, 1985, allowed limited access to opioid drugs even for medical use. A hospital would need five different licences each from a different authorities to be able to procure and store opioids. However, an amendment to the Act in 2014 allowed procurement and storage under a single licence, making it easier for doctors to prescribe these drugs.
“Even then the consumption of opioids has not increased in the country,” said Muckaden. “Many patients who can benefit from these drugs are not getting it.”
The problem, according to Muckaden and her colleagues, is that fewer hospitals are willing to procure, store and dispense morphine and other opioids even though their use is permitted for pain management especially in cancer patients. This is because hospitals need to keep detailed records of opioid procurement and use, increasing the amount of paperwork to be done.
Moreover, pain management is not a part of the medical curriculum which has resulted in the poor awareness about opioid drugs in the medical community, according to Dr Sushma Bhatnagar, professor and head of the department of onco-anaesthesia, pain and palliative care at All India Institute of Medical Sciences in New Delhi.
“Most doctors and nurses do not know enough about these drugs,” said Bhatnagar, who feels that India is not ready to legalise marijuana.
Dr Naveen Salins, editor of the Indian Journal of Palliative Care and associate professor at Tata Memorial Centre, said that talking about legalising medical marijuana was “ like talking about euthanasia when you are not able to provide palliative care.”
The demand for medical marijuana
Though illegal, cancer patients in several parts of India confess to have consumed non-processed marijuana, said Salins, who used to practice medicine in Australia where the use of medical marijuana is legal. He has prescribed synthesised marijuana drugs to patients and observed their benefits.
“It is proved that marijuana can help in stimulating appetite and control nausea,” he said, cautioning that the natural form of marijuana can have undesirable side effects because of the psychoactive compounds present in it. “Allowing people to consume it in its natural form could be dangerous.”
Dr Sameer Kaul, a surgical oncologist who runs the non-profit organisaiton Breast Cancer Patients Benefit Foundation, thinks that permitting the use of medical marijuana can be a game changer in oncology. Kaul is against the use of opioids such as morphine. “Marijuana is a far safer and subtle form of agent which can help control pain,” he said, referring to the fewer side-effects and lower addictive capacity of marijuana as compared to opioids.
Sourab Agarwal is the founder of the Medicinal Cannabis Foundation of India in Bhubaneswar, which has applied for permission to conduct a study using cannabis to reduce the side-effects of chemotherapy. “Cannabis has a huge potential in medicine,” he said.
Agarwal pointed out that there cannabis oil continues to be illegally extracted and sold to cancer patients. “By legalising marijuana, we can have better monitoring to know what patients are getting is actually beneficial.”
Kaul knows of cancer patients from India who have traveled to countries such as the United States of America where marijuana consumption in certain American states is legal. Kaul’s non-profit organisation has been considering petitioning with the Indian government to allow the use of medical marijuana.
“I am a strong advocate for this,” said Kaul. “I am not saying that marijuana should be legalised for recreational purpose but patients should get it.”