Sunil Sethi: Pain management in the big city

AL FRESCO

"What is the latest form of pain management?" a close friend asked the other day. He was asking the question out of a mixture of sympathy and curiosity. Sentimentality aside, and looking at the situation coldly in the eye, it was a good question.

For the last few months, my mother, detected in the last stages of terminal cancer, had been in and out of hospital. After her second stint there, like many terminally ill patients, she wished to be taken home.

The doctors agreed. Their ominous last words as we left were: "Let nature take its course." And so we got down to the nitty-gritty of "pain management".

And what, after all, is nature's course? It is, we soon discovered, a daily battle between pain and painkillers. For all the advances of modern medicine, the chief opiate of the terminally ill in the early 21st century still remains Mother Morphia.

Morphine, the principal derivative of opium, now comes in a dozen dazzling new formulations. Oncologists and specialists I spoke to in the weeks before my mother died confirmed that the narcotic, given intravenously, remains the most effective and final recourse of relieving pain.

What they mean by keeping the patient "comfortable" in fact means keeping the patient doped, in varying doses of sedatives, many of them morphine-based.

"Take it one day at a time," advised the palliative care specialist from Hyderabad. "The best thing about morphine is that it has few after-effects."

Ever since it was isolated (and named after Morpheus, the Greek god of dreams) by a German pharmacist in 1803 from the seed pods of the opium poppy, morphine can be injected, fed by drip, and, wonder of wonders, in its latest avatar, now comes in patches""as in nicotine patches.

You simply stick them on. Morphine patches are not cheap, nor easily available. Only few chemists stock them, and a prescription dated for the precise day of use is required for what is, after all, a highly addictive narcotic.

But when the patches hit in, depending on their strength, they can provide "comfort" for as long as 72 hours.

Like many people I had a slightly ridiculous, not to say romantic, notion of morphine until I saw my mother gradually pass from daily doses of the opiate into a final comatose state.

It conjured up images of opium dens, Opium Wars, and the Romantic poets. Samuel Taylor Coleridge was an opium addict and so was the French novelist Colette. Starchy ladies in Victorian England used tiny bits in snuff as a sort of pick-me-up.

Indians still use it, lacing paan and tobacco with it. Begum Akhtar, the late ghazal singer, was rumoured to relieve herself with injections of the stuff.

Apart from the enduring use of certain drugs, what also surprised me was the efficiency and organisation of pain management systems in Indian cities.

Provided you can pay, the best private nursing is available, of a quality of care and compassion that foreign friends assured me would be difficult to find in the West.

There are dozens of nursing agencies that will set up a 24-hour shift system within minutes. Friendly chemists will deliver a complicated and ever-changing list of medical supplies at your doorstep as promptly as the neighbourhood grocer.

Ringing for oxygen cylinders becomes an exercise as habitual as calling for cooking gas. Chatting to the oxygen supplier, whose van trundled by every other day, I found that he had a thriving business in supplying to clinics and private homes in various parts of the city.

Talking to the nurses I discovered that they knew our corner of the town intimately for the number of patients they had served over the years.

One simply forgets, or fails to realise, how many ill people there are in any given location. And immediately after my mother's death my family and I were relieved at the calm and brisk efficiency with which the eye-donation people appeared and by the number of charities that contacted us for the efficient and brisk dispersal of the materials of illness.

Vans appeared at the touch of a telephone to carry away the accumulated piles and unfailingly sent letters of gratitude afterwards.

One imagines pain management and its aftermath in a big city as a trial, a difficult, complicated, and heartless exercise. On the contrary, it is one of the effective, organised and reassuringly human systems.