India grows more legal opium than any other country. Nearly a million licensed farmers, mostly in Madhya Pradesh and Rajasthan, coax the latex out from poppy capsules by scoring them by hand. This then ends up as morphine for pain relief in hospitals worldwide, though rarely in India’s own. Fewer than 3% of Indian cancer patients have access to adequate pain medication, in a country where cancer detection tends to be late, and palliative care is often the only care that can realistically be offered.
Meanwhile, India has three times the global average prevalence of illicit opiate consumption. In Punjab, drug-related offences rates under the Narcotic Drugs and Psychotropic Substances (NDPS) Act are nearly 33 per 100,000 people — the highest of any state. Of the estimated six million Indians with opioid use disorders, more than half are in eight states: Uttar Pradesh, Punjab, Haryana, Delhi, Maharashtra, Rajasthan, Andhra Pradesh, and Gujarat. Mizoram, Nagaland, Manipur, and Arunachal Pradesh have the highest rates as a share of their populations, as they sit on the edges of drug trafficking routes from Myanmar and the Golden Triangle.
The roots of India’s challenge with opioids lie, as with many other public health challenges, in our colonial legacy. The British East India Company made opium collection a deliberate part of its fiscal policy, establishing agencies across Bengal, Benaras, Bihar, and Malwa to manage production and taxation. By 1843, opium had become the second largest source of revenue for the colonial administration after land revenue. It was grown in India and processed in government factories such as those in Neemuch and Ghazipur, both of which are still operational and work under the ministry of finance. In fact, the Ghazipur factory is the oldest and largest legal opium factory in the world. The finished product was shipped to China to balance Britain’s imports of tea and silk and paid for the Empire’s operating costs.
At the same time, domestic consumption in India was restricted because opium was for export and revenue generation, and not for Indian patients. Morphine, even today, is regulated by the excise and revenue departments rather than the ministry of health. When the NDPS Act was passed in 1985, it consolidated those colonial-era restrictions and further tightened them in the name of international drug convention compliance. Medical morphine consumption dropped from 716kg in 1985 to 18kg by 1997. Physicians who kept opiates past a license’s expiry date faced arrest without bail, and prison terms of up to 20 years.
The 2014 amendment to the NDPS Act, which reduced the licensing requirement for morphine from six approvals to one, was a step forward but has failed to change the practice of medicine. Nearly 90% of Indian medical students, in one survey, believed that prescribing morphine for palliative care would cause addiction, a false but deeply embedded assumption. Bureaucratic simplification cannot dissolve a stigma built over decades of medical education, and reinforced by a regulatory culture that has never cleanly separated the dying patient from the street addict.
Into this gap, a for-profit pain industry is expanding rapidly through two channels. The first channel is through chemists and general practitioners. A key drug here is Tramadol — marketed as non-addictive — which has flourished precisely because it fell outside the strict controls on classical opioids. But the drug is widely abused. Regulators tightened controls after widespread misuse in Punjab and evidence that diverted Indian Tramadol had reached Boko Haram networks in West Africa. A paper funded by the German manufacturer Grünenthal and co-authored by specialists who had received fees from Pfizer, Johnson & Johnson, and Mundipharma appeared in the Journal of Pain Research argued that restricting Tramadol would damage pain management across Southeast Asia. As one Delhi-based health expert put it in an interview with The Guardian, the playbook is standard: A sales representative appears at the clinic door with a new drug that is non-addictive, and prescriptions follow.
The second channel is newer: Private, for-profit pain clinics targeting urban, insured patients. Evidence on their behaviour in India is limited, and it would be premature to assume they will replicate the American model wholesale. But, the incentive structure points towards these clinics serving employed, insured, urban patients with chronic conditions, and not toward terminal cancer patients who need morphine and cannot pay for it. Whether these clinics will worsen the abuse problem while bypassing those most in need is an open question, but one that policymakers should be asking now and not after the sector matures and becomes difficult to rein in.
These patterns look strikingly similar to the situation with antibiotics where there is overuse among wealthier urban populations driving resistance, and underuse in poor and rural communities leaving treatable infections unmanaged. Similarly, pain care is not accessible to the poor. A promising model emerged in Kerala which has routed morphine access through a single state drug controller and approved roughly a hundred palliative care centers with clear operating procedures, resulted in improved access without measurable increase in abuse. Dr. M.R. Rajagopal, the architect of Kerala’s palliative care model, has conducted longitudinal work published in the The Lancet documenting zero instances of misuse among more than 1,700 patients managed on outpatient oral morphine. That model, which is community-based and focused on need, should be the template for national policy. Planning for pain cannot be afterthought to an agenda driven by pharmaceutical marketing plans.
The challenge for India is to simultaneously widen the medical pathway for appropriate use, and police the illicit one. Those are not the same problem and do not have the same solution. The British kept them separate, because one channel generated revenue and the other did not. Renaming cities or repainting colonial buildings is the visible face of decolonisation. But, meaningfully rewriting narcotic laws that deny relief to Indians in pain while preventing abuse would be the substantive one.
Ramanan Laxminarayan is president, One Health Trust. The views expressed are personal
