An Indian Perspective on Opioids

To the dismay of many health care professionals, opioid abuse has become an epidemic in the United States, with 4.6% of the total US population estimated to have abused these pain relievers.¹ Given the severity of this health crisis, considerable funds and manpower have been delegated to stop its spread and control the outbreak. However, this raises an important question: is this problem isolated to the United States, or is it prevalent throughout the world?

In order to gain a global perspective of the opioid issue, we traveled to India with 3 other pharmacy students from the University of Findlay in June 2016 to complete an advanced pharmacy practice rotation in various locations throughout the country. While in India, our cohort was able to round with physicians and pharmacists from 3 hospitals, discuss similarities and differences in pharmacy education and health care, gain a better understanding of treating tropical diseases, observe the impact culture and socioeconomics has on treatment, and study the treatment of pain and the use of opioids.

Although opioid misuse is still present, the sheer number of individuals who abuse and are addicted to opioids is significantly lower in India than it is in the United States, and many Indian health care professionals do not view opioid abuse as a major problem. Due to data collection barriers, it is difficult to obtain reliable data on addiction, but opioid abuse rates are estimated at 0.7% of the Indian population.² Instead of opioids, nonsteroidal anti-inflammatory drugs (NSAIDs) are used in India as a first-line therapy to treat any type of pain, except for the most severe. According to students and health care professionals across southern India, these NSAIDs work well for patients experiencing pain, yet it remained uncertain whether this therapy was truly adequate.

Our journey began at the Manipal University College of Pharmacy, where pharmaceutical professors and pharmacy students offered several possible explanations for India’s lower rates of opioid abuse:

• Economics. Opioids cost significantly more than NSAIDs, and because many Indians do not have insurance coverage, the cost can add up extremely quickly and place a burden on patients’ budgets.
• Increased pain tolerance. Injuries and painful situations may occur more frequently in India than in the United States; as a result, Indians develop a higher tolerance to pain and thus have less of a need to manage their pain with opioids.
• Reduced familiarity. Because opioids have not typically been used for the treatment of pain in India, patients and providers may not be fully aware of the medicine class and its effects. Conversely, recommendations from friends and health care professionals contribute to opioids’ being more widely used in the United States.
• Cultural differences in treatment approaches. Unlike patients in the United States, who are more likely to use medication as a first-line treatment, patients in India often approach health issues by making lifestyle modifications or utilizing herbal products before turning to medication.

Following our departure from Manipal University, our cohort traveled to P.N. Panicker Souhruda Ayurveda Medical College in the state of Kerala. Here, students are trained in an Eastern form of alternative medicine known as Ayurveda, which takes a holistic lifestyle approach to maintaining health. For pain management, opium-based treatments are disregarded entirely in favor of herbal treatments and oil massages. Although pain treated at these Ayurvedic hospitals can be acute or chronic, our hosts explained that patients often reported good outcomes in both scenarios.

For the final stage of our trip, we spent 7 days at Bangalore Baptist Hospital in the city of Bengaluru, where our cohort joined students from the Karnataka College of Pharmacy (KCP) in observing case presentations, participating in ward rounds, and visiting rural and urban clinics. Following the presentations, the KCP students reinforced the fact that the cost of opioids often prevent patients from accepting them as treatment. We witnessed the limited use of opioids firsthand during our rounds and clinic visits; for example, a local dentist at the urban clinic prescribed an NSAID for pain following a tooth extraction, rather than an opioid. We also found that many of the clinic patients were underserved members of their communities, and that most of them visited only when presenting with either a serious or chronic condition. Drug-seeking habits, specifically for pain medications, were not observed at the clinics in Bengaluru.

Pain treatment throughout the world is a highly debated and controversial issue in the field of health, especially when dealing with opioids. With the CDC recently releasing their updated guidelines on the prescribing of opioids and announcing their long-term ineffectiveness, the discussion on this topic will not likely come to a close in the near future.³ We hope that the concepts and perspectives we experienced throughout our journey in India can help to inspire new approaches to pain treatment throughout the United States and the rest of the world.

Andrea Seeger completed her BS in biology from the University of Findlay in 2013 and is currently working toward a PharmD and an MBA. She plans to continue her pharmacy career by attaining a residency position in the Ohio area.

Dallas Smith is a current 2017 PharmD candidate at the University of Findlay. After graduating, he hopes to continue his career in health by serving as a volunteer in the Peace Corps.

References

• Matrix Global Advisors, LLC. Health care costs from opioid abuse: a state-by-state analysis. Drugfree.corg website. drugfree.org/wp-content/uploads/2015/04/Matrix_OpioidAbuse_040415.pdf. Published April 2015. Accessed March 24, 2017.
• United Nations Office on Drugs and Crime. National Survey on Extent, Pattern, and Trends of Drug Abuse in India. UNODC website. unodc.org/pdf/india/presentations/india_national_survey_2004.pdf. Published June 25, 2004. Accessed March 23, 2017.
• Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. Morbidity and Mortality Weekly Report. 2016;65(No. RR-1):1—49. doi: http://dx.doi.org/10.15585/mmwr.rr6501e1.