Opioid Analgesic Drugs: Fill & Download for Free

Indians have a lot to learn from the opioid crisis in the USA.How many times have you seen a Hollywood movie or series, where a character who has just been badly shot, asks the doctor or paramedic treating him, “Please, give me some morphine!” and the doctor obliges and injects him with a dose and following which he feels immediate relief and lays back and relaxes for a minute.Have you ever wondered about this morphine thingy and why you’ve never seen them prescribed for pain in India? Yes, therein lies your answer.Analgesics or painkillers are broadly of two types: Narcotic analgesics and non-Narcotic analgesics.Narcotic analgesics are your opioids and the examples are names you’ve heard often i.e, morphine and codeine (and also heroin, which is illegal). Opioid analgesics relieve pain by acting on the central nervous system (CNS) and binding to the opioid receptors found therein (hence, the name).Non-narcotic analgesics work differently. They never touch the CNS but act directly on the peripheral tissues and inhibit pain by blocking prostaglandin synthesis. A common subtype of this are the NSAIDs (non-steroidal anti-inflammatory drugs) and examples are painkillers like aspirin and ibuprofen, things that are a household name in India.[1]Now, opioids like morphine are much more effective in controlling and curbing pain than your aspirin or ibuprofen, but still, doctors in India never recommend you the former, no matter how much pain you are in.Why is that?Because opioids, though effective, have a much darker side to them.If you remember, I had mentioned heroin as an example of opioids. And what heroin is, is basically morphine multplied three times over. Not a huge difference, but enough to make one legal and the other illegal in the USA.[2]So, much like heroin, other opioids like morphine and codeine also share some of its side effects. Like heroin, a dose of morphine could also give you that feeling of euphoria and “highness”.They are also habit-forming meaning you could get addicted to them. And unlike aspirin, opioids have no ceiling effect which means, more the morphine you take, more is the feeling of analgesia. Easy to get drawn in.So why is it a crisis in the USA?You see, patients suffering from pain is something every doctor has to deal with. And for terminal diseases like cancer, simple NSAID analgesics have no good effects whatsoever. In came the pharmaceutical companies in the late 80s and early 90s with their large-scale opioid manufacturing schemes. They purposefully misled the doctors about the safety and efficacy of opioids in curbing pain and then, the doctors too, seeing that opioids actually controlled pain, began prescribing them in unrestricted amounts, often writing entire bottles of pills for one single patient.[3]The result was that in just two decades, opioids have become the largest killer of human life in the United States. In 2015, more than 52,000 people died in the US of accidental drug overdose, of which two thirds were linked to prescription opioids. By comparison, gun deaths killed only 36,000. The image below illustrates this further.[4]Directly banning the prescription and use of opioids isn’t much of a solution either because for one, people will experience painful withdrawals if they are taken off opioids in one go; and secondly, if you stop access to prescription opioids, people will just opt for illegal and much more dangerous drugs like heroin and opium. And no one wants that.Also, about 100 million adults in the US suffer from chronic pain through many diseases. Simply denying them access to such opioids would be barbaric and sadistic.Which brings us to the “opioid crisis” of India.In 1985, inspired by the United States’ war on drugs, the Rajiv Gandhi government introduced the Narcotic and Psychotropic Substances Act intended at controlling the use and distribution of narcotic substances of which opioids are a part.[5]Like the US war on drugs, the intentions of this Act were good. But unfortunately, like the US war on drugs, this Act too, did more harm than good.It laid down a 10-year minimum prison term for errors in prescribing opioids to patients and introduced complex requisition protocols and licence systems to buy and sell them.[6] The result was that morphine simply vanished from pharmaceutical shops and hospitals and within a couple of years, morphine use in India dropped by 97%.[7]According to a Human Rights Watch report from 2009, only 4% of Indians suffering from unimaginable pain have access to morphine and the remaining just get by on combinations of different NSAIDs which are nowhere near as effective as opioids.[8]This is a human rights situation that is so hidden from the public eye that it is unbelievable. What's even more unbelievable is that there are some Indian states where the poppy, a plant from which opioids are derived, is cultivated legally and then exported, while so many here struggle to access morphine every single day.[9]So are things ever going to change?Yes, soon.In 2014, the UPA government amended the NDPS Act to relax restrictions placed by the Act on Essential Narcotic Drugs (Morphine, Fentanyl, and Methadone), making them more accessible for use in pain relief and palliative care.[10] But as Indian bureaucracy goes, changes will be slow to come.There is also some kind of pussyfooting on the part of the government and other agencies involved here because sure, we want to improve the accessibility of opioids to the needy, but that shouldn’t be done in a way that India ends up being next to the United States in drug overdose deaths each year.The need is to strike some kind of balance, an equilibrium between India’s current situation and that of the USA’s. We need a rational approach to this.Also, a whole generation of medical professionals have graduated from medical schools and have rendered years of service without ever having been trained in proper palliative care or properly administering and prescribing opioids to patients.[11] This needs to change too and on the positive side, the Medical Council of India approved Palliative Medicine as an independent medical subspecialty, which will hopefully take things in a better direction.[12]So, as an Indian, you need to understand that there is an opioid crisis both in the USA and in India. In the USA, from using too much of opioids, and in India, from using too little.Footnotes[1] Differences between Opioid and Non-opioid Analgesics[2] The Difference Between Morphine and Heroin[3] The opioid epidemic, explained[4] How the opioid epidemic became America’s worst drug crisis ever, in 15 maps and charts[5] How do you treat pain when most of the world's population can't get opioids?[6] Narcotic Drugs and Psychotropic Substances Act, 1985 - Wikipedia[7] Connecting People Through News[8] Unbearable Pain[9] India: The principle of balance to make opioids accessible for palliative care[10] Narcotic Drugs and Psychotropic Substances Act, 1985 - Wikipedia[11] India: The principle of balance to make opioids accessible for palliative care[12] Medical Council of India Approves MD Palliative Medicine!

We can formulates petitions, but will it make a difference?Developing a new drug takes a long time, but what we can do today is provide better management. It can be done today.Ensure the diagnosis is correct. Confirm that the pain is not a case of neuropathy that can be treated with other drugs such as TCAs or Lyrica.Doctors should start with the lowest effective doses. When tolerance develops, switch to opioids that act at different opioid receptors.Regularly switch between low dose opioids so that tolerance develops slower. Before trying opioids, attempt non-opioid analgesics, if they fail, switch to opioids.Consider if minor procedures could alleviate the pain and reduce or eliminate the use for opioids.

Author’s Note : As both Bryan Mak and I share a background in the Singapore Armed Forces (albeit having vastly different vocations), you can consider this a “Standalone Expansion Pack” to his answer.In order to answer the question in a more reasonable way, I will have to re-phrase the question.“Are analgesic drugs administered to wounded personnel in the modern day?”Yes, they are.Thanks to Hollywood and video games, there is a misconception that painkillers (primarily Morphine) are liberally used in any and all situations involving wounded military personnel. Worse still, is the misconception that only Morphine is used.As an EMT (Combat) / Combat Medic (Underwater Medicine) of the SAF, perhaps I might be able to shed some light on the issue.Warning : The following contains long, boring details and descriptions of drugs and the procedures involved in administering them. Skip towards the end where I will talk about everyone’s favourite drug - morphine, if you wish. I will also refer to “painkillers” as “analgesics”, because that’s what they’re supposed to be called.First off, in order to understand the use of analgesics, one first has to understand what “pain” is.“Pain” is caused by receptors found in the end of Free Nerve Endings[1], that transmit stimuli to the brain, triggering the Somatic Nervous System[2]to withdraw from what causes the “pain”. This is known as a Withdrawal Reflex[3], and thus, “pain” felt by any casualty should not be ignored during treatment.This, affects a person's ability to think or act rationally. Therefore, a casualty in "pain" is an "troublesome" causality.Analgesics[4], are used therefore, to relieve "pain" by affecting the Perihperal Nervous System (PNS) and Central Nervous System (CNS) in a multitude of ways (which I am neither qualified nor interested to talk about - consult a doctor should you become interested).In the SAF Medical Training Institute (SMTI) EMT Course Materials, it is stated, “Medical Personnel in support of military operations render First-Aid, Life-Saving Procedures and also Alleviate Pain of the injured as part of their professional duty.”But how do we treat pain you ask? First, we need to assess the scale of the pain.This allows us to determine if, or what kind of analgesics should or should not be administered. Below, I will briefly go through the common types of analgesics available to a typical SAF Army Battalion (On a Platoon, Company and Battalion level).Side Note : There are many other types of analgesics used by the various branches of the SAF, but it’s such a bewildering array that I honestly can’t remember all of them.Paracetamol[5] :Type : ParacetamolIndication : Mild to Moderate Pain (2–4)Issued to : All platoon and company medics, part of Battalion Casualty Station Field Dispensary (Basically Everyone)Route of Administration : OralAh yes, the famous “panadol”, the only analgesic issued during peacetime to medics. As a GSL[6]drug, paracetamol tends to be criminally underrated due to it’s common availability. When used in combination with Opioid analgesics however, can be effective in treating severe pain. It’s also the “safest” of the analgesics on this list.Diclofenac Sodium[7] :Type : NSAIDIndication : Mild to Moderate Pain (2–4)Issued to : Battalion Casualty Station Field DispensaryRoute of Administration : Oral (Tablet form), Intramuscular or Intravenous Infusion (Ampule Form)WHAT??!! You mean that there’s drugs other than paracetamol for SAF troops? In it’s ampule form, this is administered via rapid intravenous infusion. For when you need mild pain relief with a faster onset than paracetamol.Pethidine HCL[8] :Type : OpioidIndication : Moderate to Severe Pain (6–8)Issued to : Battalion Casualty Station Field DispensaryRoute of Administration : Intramuscular or Intravenous InfusionThe first of the Opioid family, you can pretty much call this “Morphine Junior” - which to be fair, it is. Commonly used during childbirth, has recently fallen out of favour due to it’s addiction rate. For when you need something strong, but haven’t yet justified the use of Morphine.Morphine Sulphate[9]Type : OpioidIndication : Severe Pain and above (8–10)Issued to : All platoon and company medics, part of Battalion Casualty Station Field Dispensary (Basically Everyone)Route of Administration : Intramuscular (Auto-Injector), Intravenous Infusion (Ampule)As a controlled drug[10], Morphine is only issued under the following circumstances:WarOperations Other Than WarHumanitarian Assistance and Disaster ReliefPeace Support OperationsPeacekeeping Operations“Special” casesIn the SAF Medical Training Institute (SMTI) EMT Course Materials, it is stated, “Morphine has been the primary choice of battlefield analgesia due to it’s good safety profile and efficiency in relieving moderate to severe pain at therapeutic doses. In isolated terrain where no medical facilities are available, there may not be a Medical Officer present to administer medical aid. In these circumstances, all SAF Medics and medically-trained SAF personnel are to administer Morphine independently to the injured following SAF protocols and SOPSpeaking of which, “Under Singapore Law, a duly authorised trained SAF personnel is allowed to administer morphine to another SAF member in accordance with regulations."Do note that this only applies while you are IN SINGAPORE. For overseas, there are separate rules.In conclusion, analgesics are like any other drug - there are proper procedures to follow BEFORE, DURING and AFTER administration.Are analgesics drugs administered to wounded personnel in the modern day? - YesAs often as Hollywood and games make it out to be? - NoIs morphine the only “painkiller” used? - NoDo they still administer morphine? - YesIn fact, Morphine was administered as recently as 2012, by the First-Aid Party (FAP) of RSS Endeavour to one ME2 (OR-8) Jason Chee [11], during a horrific incident where he had lost his limbs.So there, I hope this answers any questions you may have.Footnotes[1] Free nerve ending - Wikipedia[2] Somatic nervous system - Wikipedia[3] Withdrawal reflex - Wikipedia[4] Analgesic - Wikipedia[5] Paracetamol - Wikipedia[6] http://www.hsa.gov.sg/content/dam/HSA/HPRG/Useful_Information_for_Applicants/Legislation/MEDICINES%20(GENERAL%20SALE%20LIST)%20ORDER.pdf[7] Diclofenac - Wikipedia[8] Pethidine - Wikipedia[9] Morphine - Wikipedia[10] Misuse of Drugs Act (Singapore) - Wikipedia[11] Jason Chee - Wikipedia