Published on: October 27, 2021

Sikkim, the least populous state with 658,019 inhabitants (according to 2021 estimated population), has four districts – East, North, South and West Sikkim. The population-based cancer registry of Sikkim (2008) indicates that approx. 2211 people get cancer each year. Reports also indicate that approx. 5000 people are currently living with cancer in Sikkim; of which at least 3000 of them are in need of opioids to manage their severe pain. Access to morphine is however, currently not available in the State. Government of Sikkim has laid highest priority to health and strives to provide quality care at every level; however challenges remain on access to pain relief and palliative care.

The State Tertiary Care Hospital ‘Sir Thutob Namgyal Memorial (STNM)’ based in Gangtok (East Sikkim) is the only hospital that provides basic Palliative Care services including home care services. The State Palliative Care Unit has been established at the STNM Super Speciality Hospital. Other district hospitals are yet to provision complete palliative care services.

In September 2021, Pallium India conducted a virtual sensitization session for different stakeholders from the State to improve opioid availability. Stakeholders included doctors, pharmacists, drug inspectors, senior medical stores personnel among many others from the State. An approx. 20 volunteers from Namchi District (South) have also recently completed Pallium India’s volunteer training program.

Chairman of Pallium India, Dr M.R Rajagopal explained about access to opioids for pain relief and the importance of concurrent education program to train doctors, nurses and other officials & staffs. Ms Tripti Tandon, a lawyer from Supreme Court explained the opioid availability for medical use under the NDPS Amendment of 2014. Ms Smriti Rana talked about the Principle of Balance of opioids on how to prevent the diversion of illicit use and the availability for medical and scientific purposes. The drug controllers and other officials were sensitised on the amendment. Pallium India also offered to support in creating awareness sessions and developing palliative care units in each government hospital.

Arunachal Pradesh:

In 2021, Papumpare district in Arunachal Pradesh recorded the highest cancer incidence among females in India. The state is witnessing increase in life limiting and life threatening diseases. Arunachal Pradesh’s first palliative care unit was established at Tomo Riba Institute of Health and Medical Sciences (TRIHMS), a tertiary cancer centre, in 2018. Government of Arunachal Pradesh accords highest preference to the quality of life of citizens. However, due to resource constraints, access to palliative care in the state is limited to TRIHMS.

Pallium India reached out to the state health secretary, NHM officials, state drug controller and palliative care physicians at TRIHMS to extend their support to improving access to palliative care services in the state. A meeting was arranged between Pallium India and Arunachal stakeholders on 12th October 2021.The meeting was attended by Mr Parthiban, State Health Secretary Arunachal Pradesh, Senior Drug Inspectors, State NCD Nodal Officer, State Palliative Care Consultant and other dignitaries.

Dr M.R Rajagopal, Chairman of Pallium India explained about 2014 NDPS amendment of Narcotic Drugs and Psychotropic Substances on access to Essential Narcotic Drugs. The drug controllers were sensitised on the amendment and agreed to issue Recognised Medical Institution certificate to applicants as per the amendment. Pallium India also discussed about palliative care training of doctors and nurses at the district level. The health secretary advised the state palliative care officer to work with Pallium India to draft a MoU between Pallium India and NHM Arunachal Pradesh to implement palliative care services in the state.

Jammu and Kashmir:

During the last couple of years, Pallium India has taken several steps to improve access to pain relief and palliative care in India. In Jammu and Kashmir, we have been working with the government and private sector to improve access to palliative care. Pallium India has conducted sensitization session in palliative care for doctors and nurses in 2019 at Regional Institute of Health and Family Welfare Dhobiwan, Kashmir. The session was attended by representatives of the Directorate of Health Services and the drug controller. We also facilitated development of a palliative care unit at Sher E Kashmir Institute of Medical Sciences Srinagar.

Latest data suggest that 80 out of every 1 lakh population in Jammu and Kashmir report fresh case of cancer every year. It is very likely that they suffer from serious health related suffering. Pain is the commonest problem associated with many diseases including cancer. Excruciating pain cannot be effectively treated without palliative care including access to essential opioid medicines like morphine.

With support from Dr Yousuf Tak, renowned palliative care physician in the state, Pallium India organized a virtual workshop on access to essential pain medication in Jammu and Kashmir on 11th October 2021. The meeting was attended by State Drug Controller Ms Lotika Khajuria, palliative care doctors and nurses from the state and civil society organization Palcare foundation.

Key discussion points:

  • State Drug Controller (SDC) is well aware of the 2014 NDPS amendment. However, the excise department continues to send letter to the SDC for clearance for stocking essential pain medications
  • Dr Rajagopal clarified that the licensing process through Excise department is no more valid. He added that the State Drug Controller is the singular authority who can issue Recognized Medical Institution (RMI) license to applicants for stocking Essential Narcotic Drugs (6 drugs of which Morphine, methadone and Phentanyl are  available in India)
  • Dr Rajagopal pointed out that in Kerala, RMI licenses are issued to doctors who complete online training in pain management and palliative care. He suggested SDC J and K to discuss the possibility of issuing RMI license for online training with the SDC Kerala. SDC J and K agreed to consider his suggestion.
  • Ms Lotika and Dr Rajagopal clarified that government hospitals are deemed RMI and need not apply for certification with the SDC. Dr Rajagopal added that, though the government hospitals need not apply for the certification, they are bound to keep all the documentation up to date as prescribed by the NDPS 2014 amendment. She agreed to look into adding the ENDs into the state Essential Drug List (EDL). She added that she is part of the committee that decide the state EDL and would take the suggestion ahead with the concerned authority.
  • Though Deemed RMI, Dr Rajagopal encouraged government hospitals to secure an authorisation from the SDC as they may require it to be produced to drug manufacturers or distributers while placing an order for the medicines. The procedure would be same as the application for RMI license based on which the SDC could issue a letter of authorisation to stock and dispense ENDs.
  • Dr Yousuf Tak shared that he is keen to start palliative care at all govt. district hospitals. He pointed out that palliative care is still not accessible in the periphery. He added that the first step to remedy this would be to train health workers at the district hospital level.
  • Ms Lotika Khajuria shared that she will work with the state essential drug list committee and Jammu and Kashmir Medical Supplies Corporation Limited to include ENDs in the state essential drug list.

(Report prepared by Pallium India’s State Facilitation Team.)

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