Indian Journal of Palliative Care
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Table of Contents 
Year : 2020  |  Volume : 26  |  Issue : 1  |  Page : 70-71

Judicious usage of who step III opioids in palliative care in India

Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Submission05-Sep-2019
Date of Acceptance10-Sep-2019
Date of Web Publication28-Jan-2020

Correspondence Address:
Dr. Arunangshu Ghoshal
Department of Palliative Medicine, Tata Memorial Hospital, Mumbai - 400 012, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJPC.IJPC_158_19

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How to cite this article:
Ghoshal A. Judicious usage of who step III opioids in palliative care in India. Indian J Palliat Care 2020;26:70-1

How to cite this URL:
Ghoshal A. Judicious usage of who step III opioids in palliative care in India. Indian J Palliat Care [serial online] 2020 [cited 2020 Jul 10];26:70-1. Available from:

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.


I would like to acknowledge the authors of “Factors influencing the initiation of strong opioids in cancer patients on palliative care: An audit from a tertiary cancer center in India.”

  References Top

The World Bank. Data: World Bank Country and Lending Groups. World Bank Ctry Lend Groups; 2018.  Back to cited text no. 1
Dureja GP, Jain PN, Joshi M, Saxena A, Das G, Ahdal J, et al. Addressing the barriers related with opioid therapy for management of chronic pain in India. Pain Manag 2017;7:311-30.  Back to cited text no. 2
Johnson M, Collett B, Castro-Lopes JM. The challenges of pain management in primary care: A pan-European survey. J Pain Res 2013;6:393-401.  Back to cited text no. 3
Ripamonti CI, Santini D, Maranzano E, Berti M, Roila F; ESMO Guidelines Working Group. Management of cancer pain: ESMO clinical practice guidelines. Ann Oncol 2012;23 Suppl 7:vii139-54.  Back to cited text no. 4
Kwon JH. Overcoming barriers in cancer pain management. J Clin Oncol 2014;32:1727-33.  Back to cited text no. 5
The Lancet. The opioid crisis in the USA: A public health emergency. Lancet 2017;390:2016.  Back to cited text no. 6
Belzak L, Halverson J. The opioid crisis in Canada: A national perspective. Health Promot Chronic Dis Prev Can 2018;38:224-33.  Back to cited text no. 7
Nielsen S, Dietze PM. What can Australia learn from the North American opioid crisis? The role of opioid regulation and other evidence-based responses. Drug Alcohol Rev 2019;38:223-5.  Back to cited text no. 8
Vokinger KN. Opioid crisis in the US – Lessons from Western Europe. J Law Med Ethics 2018;46:189-90.  Back to cited text no. 9
Bendix J. Opioid crisis. Med Econ 2016;93:28-32, 35-6.  Back to cited text no. 10
Jones MR, Viswanath O, Peck J, Kaye AD, Gill JS, Simopoulos TT, et al. A brief history of the opioid epidemic and strategies for pain medicine. Pain Ther 2018;7:13-21.  Back to cited text no. 11
Berterame S, Erthal J, Thomas J, Fellner S, Vosse B, Clare P, et al. Use of and barriers to access to opioid analgesics: A worldwide, regional, and national study. Lancet 2016;387:1644-56.  Back to cited text no. 12
Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain – United States, 2016. MMWR Recomm Rep 2016;65:1-49.  Back to cited text no. 13
Nuckols TK, Anderson L, Popescu I, Diamant AL, Doyle B, Di Capua P, et al. Opioid prescribing: A systematic review and critical appraisal of guidelines for chronic pain. Ann Intern Med 2014;160:38-47.  Back to cited text no. 14
Saloner B, McGinty EE, Beletsky L, Bluthenthal R, Beyrer C, Botticelli M, et al. A public health strategy for the opioid crisis. Public Health Rep 2018;133:24S-34S.  Back to cited text no. 15


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