The lure of apain-free life is a revelation in a country where incomes arerising for many city dwellers and 300 million to 400 millionpeople.

This story is the first in a two-part series. Read part twohere: "InIndia's Slums, Painkillers Part Of Daily Routine."

NEW DELHI — Pain, like death, is a universal phenomenon.

The sour grimace on the woman's face, registering her bodilycomplaints to Dr. G.P. Dureja in his East Delhi office, would berecognized anywhere. Slouched shoulders, pinched forehead. She worea willowy black kurta and cast a disapproving glance at the fivepain physicians-in-training huddled behind Dureja, founder of DelhiPain Management Centre and one of India's pioneering painphysicians.

The five trainees, participants in the center's acclaimed painfellowship program, recorded the woman's consultation on theirsmartphones, eager to see India's famous pain doctor do his work.After their fellowships, they will return home, to Chennai,Kashmir, Rajasthan, ready to forge careers in India's explodingpain industry.

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The woman had been under Dureja's care for some time now; hediagnosed her with fibromyalgia, a chronic neurological disorder ofmysterious origin that causes pain throughout the body. But theregimen of Paracetamol and tramadol, an opioid analgesic, was notworking and she was beyond fatigued. She wanted more relief.

Indians once thought of pain relief as an indulgence of theWest, Dureja said after the woman left his office gripping her newprescriptions. The old way of thinking was, "Nobody has time tocomplain about pain in our country. But I'm getting five to sevennew patients per day."

Storefront for-profit pain clinics like Delhi Pain ManagementCentre are opening by the score across Mumbai, Kolkata, Bangaloreand other cities in this teeming nation. After decades of stringentnarcotics laws, borne of debilitating opium epidemics of centuriespast, India is a country ready to salve its pain.

And American pharmaceutical companies — architects of the opioidcrisis in the United States and avid hunters of new markets — standat the ready to feed and fuel that demand.

For Indian cancer patients who once writhed in agony, there arefentanyl patches from a subsidiary of Johnson & Johnson.

For the country's vast army of middle-class office workerswracked with back and neck pain, there is buprenorphine fromMundipharma, a network of companies controlled by the Sacklerfamily, owners of Connecticut-based Purdue Pharma.

And for the hundreds of millions of aging Indians with achingjoints and knees, there are shots of tramadol from AbbottLaboratories.

Palliative care advocates, who recount stories of patientsenduring excruciating cancer pain or dying in agony, have persuadedreluctant government officials to allow high-powered opioidpainkillers into doctors' offices and onto chemists' shelves inthis nation of 1.37 billion people.

But what began as a populist movement to bring inexpensive,Indian-made morphine to the diseased and dying poor has given riseto a pain management industry that promises countless new customersto American pharmaceutical companies facing a government crackdownand mounting lawsuits back home.

The lure of a pain-free life is a revelation in a country whereincomes are rising for many city dwellers and 300 million to 400million people are approaching the middle class. Like other markersof the country's post-colonial sprint into modernity, newly mintedpain doctors promise aspiring Indians that life has more to offerin a body free from pain, and foreign brands are worth the extrarupees.

"Don't listen to your forefathers," Dureja said, a mantra forthe shifting mindset. "They said you should tolerate pain, youshould not complain, you should not take painkillers. Now,everybody wants a better quality of life, and everybody wants toget rid of pain early."

As major pharmaceutical companies look to capitalize on theopportunity, the playbook unfolding in India seems eerily familiar.Earnest advocates share heartbreaking stories of sufferingpatients; physicians and pharmaceutical companies champion painrelief for cancer patients and persuade regulators to grant greateraccess to ever more powerful opioids; well-meaning pain doctorsopen clinics; shady pain clinics follow; and a spigot ofprescription opioids opens — first addressing legitimate medicaluses but soon spilling into the streets and onto the blackmarket.

A looming deluge of addictive painkillers terrifies some Indianmedical professionals, who are keenly aware that despite governmentregulations most drugs are available for petty cash at the chemistshops that occupy nearly every city block and village center.

"Are people going to figure out every trick in the game to make[opioid painkillers] widely available?" asked Dr. Bobby John, aleading Indian public health expert based in New Delhi. "Of courseit will happen."

'The market for pain is good'

The headquarters of the Pain Clinic of India operates out of acloset-size office in Chembur, a tree-lined suburb in easternMumbai. The company's presence on the internet is so prominent thatDr. Kailash Kothari, the clinic's founder, has turned down requestsfrom people in South Africa, Australia, Europe and the UnitedStates seeking prescription opioids.

Down an alleyway, the clinic's small white-red-and-blue sign isdifficult to spot. Around the side of a faded-pink building is alarger sign showing a shirtless, muscular white man gripping hisback, another gripping his neck, another clutching his knee; awhite woman with an excruciating headache presses her forehead andanother grabs her shoulder. Back Pain. Neck Pain. Headache. KneePain. Shoulder Pain. Cancer Pain. The sign promises "Towards PainFree Life."

One of the principal architects of pain medicine in India,Kothari runs several clinics in Mumbai, consults at numeroushospitals and flies to his clinic in Goa once a week. He co-foundedthe Indian Academy of Pain, an educational branch of the IndianSociety for the Study of Pain that aims to create standardizedtraining for pain medicine, in part by offering qualifying exams toprospective physicians. "This program is going to change thescenery of what we have in pain management," Kothari said.

Asserting control over who can call themselves a "pain medicinedoctor" in this fledgling industry is an urgent question. Spreadacross the subcontinent are nearly 10 million licensed physiciansand a massive number of untrained medical providers. (In ruralIndia, 70% of health care providers have no formal medicaltraining.)

"General practitioners have started prescribing these drugs,"Dureja said. "And we're not educating the population on when to useand not to use."

At Dureja's clinics, as at most medical offices in India,patients pay cash for services and prescriptions. Delhi PainManagement charges $10 for a consultation; $10 for a Johnson &Johnson fentanyl patch; $10 for a Mundipharma buprenorphine patch.Dureja's office takes a 15% cut of sales.

There are hints of American pharma's fingerprints in a glasscabinet in the waiting room of his East Delhi clinic: awards fromJohnson & Johnson honoring Dureja for symposia on painmanagement; a plaque for "his valuable contribution as a speaker"about tapentadol, an opioid marketed by Johnson & Johnson in2009. The dispensing counter does a brisk business in Ultracet,branded tramadol tablets made by a Johnson & Johnsonsubsidiary.

Dureja's training fellowships, like Kothari's, are broadlyconsidered on the level; but many others are shady, and none areregulated.

Each year, some 20 fellows attend Kothari's three- to six-monthtraining programs, and by his calculation, he has trained 150aspiring pain doctors. "There are more than 50 people who alreadyhave their pain clinics in different parts of India," he said. Ofthose clinics, five or six "are training people, and it's a chainreaction, which is going to benefit pain management as aspecialty."

Kothari remembers when only a few hospitals in Mumbai treatedcancer patients and had access to opioids. "But every year, we areaccessing more of these kinds of drugs," he said. "Many chemists,hospitals and medical shops started acquiring the licenses forkeeping these drugs, and availability is much, much better. Opioidsare available in not just oral, but injectable, patches,syrups."

Most large Indian hospitals have added pain management as aspecialty in recent years. At the insistence of the professionalsocieties that accredit hospitals in India, Kothari said, nursesand doctors now are required to assess pain as a fifth vital sign,along with pulse, temperature, breathing and blood pressure.

The pharmaceutical industry has kept pace. Twenty years ago,only a few pharmaceutical companies marketed pain medicines inIndia, Kothari said. "Today, almost every company is having painmanagement as a separate division. In the last five years alone, Imust have met more than 15 or 20 companies that have startedseparate pain management divisions."

A salesman for Sun Pharma, India's largest drugmaker by sales,echoed the point during an interview in Chandigarh, the capital ofPunjab and Haryana. The market for pain medications "has totallychanged" in the past five years, he said. He shifted nervously andagreed to speak frankly only if his name wasn't published, for fearof losing his job.

"Now everyone has a car, and [they get] back pain, and now theytake medication." Growing obesity rates in India were also fuelingdemand, he said, as patients look for relief from weight-relatedknee and back pain. "So the market for pain is good."

Abbott Laboratories and Johnson & Johnson did not respond torequests for comment for this report.

Manmohan Singh, a vice president at Modi-Mundipharma in NewDelhi, said opioid pain medications are an important therapeuticoption, especially for cancer pain. He also said company promotionsstress that physicians should familiarize themselves with productsafety information. "Patients should be made aware of the cleartreatment goals related to pain and function, as well as thepotential opioid side effects and the potential for misuse, abuseand addiction," he said in a written statement.

One false step

The ascendance of pain management in India comes at a fortuitouspolitical moment. Ahead of his reelection earlier this year, PrimeMinister Narendra Modi invested heavily in health care. Last fall,the Indian government launched the world's biggest public healthinsurance program, called Ayushman Bharat. Dubbed "Modicare," itguarantees half a billion poor Indians nearly $7,000 in hospitalexpenses, paid to private insurers, and, by 2020, the government isto open 150,000 primary care centers. The government has set aside$484 million to fund Modi's signature program.

None of this would have been possible without the loosening ofIndia's strict narcotics laws.

The International Narcotics Control Board, established in 1968,and the Narcotic Drugs and Psychotropic Substances Act of 1985codified the bureaucratic thicket for any doctor who wanted toprescribe opioid painkillers. Physicians feared fines, jailsentences and losing their medical license if they skirtedregulations. While the government granted licenses to Indianfarmers to grow poppies, most of the morphine produced from thecrops was exported.

Dr. M.R. Rajagopal was a young medical student inThiruvananthapuram at the time and remembers a neighbor withadvanced cancer. "I [had] seen him screaming his way over weeks todeath," Rajagopal said. "It was horrendous, and there was nothingbeing done about it." He chose to become an anesthesiologistbecause it was the only specialty then focused on pain.

Rajagopal is widely viewed as the father of palliative care inIndia; whispers of a Nobel Prize follow him. For decades, he hasworked assiduously to convince national and state lawmakers thatopioid medicines are not an indulgence but a humane refuge, and itis largely a function of his advocacy that morphine and otherpainkillers can be prescribed in India. "Two generations of doctorshad not seen a tablet of morphine," he said.

The Narcotic Drugs andPsychotropic Substances Act, as amended in 2014, recognizedthat the need for pain relief was "an important obligation of thegovernment." The revised law created a class of medicines calledthe "essentialnarcotic drugs" list, which includes morphine, fentanyl,methadone, oxycodone, codeine and hydrocodone.

Rajagopal's days are filled with the tedious work of building amovement: speaking at colleges and public forums, penningeditorials and medical papers about palliative care and overseeingPallium India, a nonprofit medical center and training institutethat is singularly focused on palliative care.

Pallium's pharmacy is a testament to Rajagopal's persistence.Drugs once banned now fill the shelves: fentanyl injections andpatches, oral morphine and, most recently, methadone, approved forpain relief in 2018.

Rajagopal seems aware that one false step would invite thegovernment to clamp down on the availability of opioids, reversingdecades of his work. He does not advise using oxycodone orhydrocodone, though they are included on the "essential narcoticdrugs" list, and he does not accept funding from pharmaceuticalcompanies, instead putting his hand out to temple trustees and fordonations from families cared for by Pallium's home visitingteams.

But the pharmaceutical industry is a wily adversary. Americanactivists made many of the same arguments decades ago as theysought relief for dying patients. Drugs now commonly prescribed forchronic pain first were approved for use by cancer patients. One ofthe first formulations of fentanyl, for example, was a lollipopbecause chemotherapy left cancer patients too nauseated to eat. InIndia, pain physicians now prescribe fentanyl patches to patientswith chronic muscular pain.

Purdue Pharma's international affiliate, Mundipharma, "is verygood at co-opting regulators," said Keith Humphreys, a professor ofpsychiatry at Stanford University. "As happened in the U.S., theyare easily converted into useful idiots."

Read part two of this two-part series: "InIndia's Slums, Painkillers Part Of Daily Routine."

Kaiser HealthNews (KHN) is a national health policy news service. It is aneditorially independent program of the Henry J. Kaiser Family Foundation whichis not affiliated with Kaiser Permanente.

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