Rajasthan patients' severe pain due to lack of morphine
Thousands of patients in India experience unnecessary pain because access to morphine is restricted.
Morphine, which comes from opium, is one of the most effective painkillers. India grows opium poppies, and produces opium for the international pharmaceutical market.
But patients like Firoj are not getting it.
He is lying on a hospital bed in the SMS Hospital in Jaipur, the capital of the north Indian state of Rajasthan. He is a wasted figure who is never still.
Firoj is in continuous and intense pain. One of his five children sits next to him on a bench, watching but not speaking. His wife, Indira, hovers at his bedside.
"He can't sleep at night, he can't eat anything, and he can't stand on his own," she says. "He has severe pain in his neck and ear."
Firoj is just 40. He has cancer of the tongue.
India has the highest incidence of oral cancers in the world. Dr DP Singh, the head of the Radiotherapy and Oncology Department at the SMS Government Hospital in Jaipur, is treating Firoj.
"His whole tongue is gone - it's a cancer caused by tobacco eating," he explains. "Firoj came to the hospital in the advanced, terminally ill stage when the pain was intolerable."Tough controls
Firoj needs morphine to treat his pain. According to the World Health Organisation, morphine is the "gold standard" for treating moderate to severe pain - especially in cancer patients.
In Western countries, it is available for doctors to prescribe. But the SMS Hospital does not have any stocks of oral morphine, and Dr DP Singh is frustrated.
"There are 20 patients in this ward. Seven or eight of them should be getting morphine because they are in very serious pain, but it isn't available. We have a pain clinic at the hospital, but no morphine."
The dearth of morphine at the SMS Hospital is not due to prohibitive cost. About 7 rupees a day (10p or 15 cents) would buy the morphine to treat Firoj.
It is the controls on the drug that deter under-pressure doctors and administrators from procuring it.
Dr Anjum Khan Joad runs the only department of palliative care in the state of Rajasthan, at the private Bhagvan Mahaveer Cancer Hospital in Jaipur.
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She argues the problem is with bureaucracy: "We do have a licence for morphine, but the procedure is so complicated that every time I run out of stock, I need something like five licences to procure, store and dispense morphine. Because of the multiple government regulations, very few hospitals have oral morphine."
This complex system of regulation in India - involving the state's Excise Department and Drugs Controller - was put in place in the 1980s. It was sparked by fears of illicit drug use and addiction, and is backed by the threat of a custodial sentence for misuse.
But cancer is a growing problem in India.
There are about two-and-a-half million people living with the disease, and a million new cancer cases every year. It has been estimated that only 0.4%, or four in 1000, of those who need opioids for pain have access to them.Desperate measures
Dr Anjum Khan Joad sees the demand on a daily basis: "Something like 75 to 80% of the patients who reach here are in an advanced stage of cancer. Their primary need is treatment of pain. A large proportion of those would need morphine or painkillers of that strength."
A third of India's states and territories have eased restrictions on morphine to make it more readily available.
Rajasthan is not one of them.
In November 2010, there were fewer than 10 hospitals or pharmacies across the state that had oral morphine in stock. And Rajasthan is home to some 56 million people.
The irony of this situation is that Rajasthan is also one of India's three poppy-growing states.
And it seems the lack of oral morphine can force patients in pain in Rajasthan to take desperate measures.
Dr Raj Govind Sharma is a surgical oncologist at the SMS Hospital in Jaipur. "Sometimes patients procure morphine from other sources," he admits. "They say they can get opium in the raw form, and they ask - can we take it? Of course, it is illegal to procure opium like this. And we cannot prescribe raw opium to our patients. "
The Drugs Controller in Rajasthan, DK Shringi, said he was unaware that patients were not getting the morphine they needed. He resolved to rectify the situation, and to make sure the SMS Hospital could get the tablets, and that the state government's pharmacies also had supplies. But they will still need to secure a licence from the Excise Department first.
Mr Shringi may have an impact in Rajasthan, but critics claim it is only a change in the regulations that will ensure people in pain get the morphine they need.
Indira has been at Firoj's bedside at the SMS Hospital in Jaipur for the last month. She is exhausted and distressed.
"He has been suffering with this pain for a year now. It's terrible. "
Firoj is not alone. In many Indian states there are thousands of patients in the same situation - people who might get some relief from their symptoms if oral morphine was more easily available.
Linda Pressly's report for Crossing Continents is on BBC Radio 4 on Thursday 6 January at 1100 GMT and Monday 10 January at 2030 GMT. It will be broadcast on the BBC World Service on 20 January. You can also listen on the iPlayer or download the podcast.