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Times of India
01 July 2010
By Roli Srivastava
Hyderabad, India

City Doctors Ignore Pain-free Shot For Terminally Ill
City oncologists are aware of the fears of a cancer patient– loss of hair and appetite, cost of treatment but most prominently the fear of a painful death. However, a 30–minute procedure that destroys the pain–transmitting nerve in a patient nearing death, alleviating the pain for three to six months (usually the time left in a patient’s life at the time of giving the shot) has failed to make it to the oncologists’ prescription. Instead, daily doses of oral morphine, coupled with chemo and radio therapies continue to rule.

Called coeliac plexus block, the procedure involves injecting alcohol or longacting pain killers in a suffering patient’s coeliac plexus (a bunch of nerves located behind the stomach that transmit pain to various abdominal organs). The alcohol destroys the coeliac plexus thus permanently blocking the transmission of pain impulse, a boon for patients suffering from excruciating abdominal pain.

Pain specialists in the city say the shot (two needles are passed into the body from the back and the position of the needle checked under CT) gives 70 to even 100 per cent relief to the patient. It improves the quality of life and most importantly, makes death pain–free, they say. While the procedure is offered at corporate hospitals and even Osmania General Hospital, it has hit a referral roadblock.

“Nearly 75 per cent of the cases are not being offered this procedure,’’ says Dr Muralidhar Joshi, secretary, Indian Society for Study of Pain (AP chapter). Pain specialists (an evolved speciality in anaesthesia), say the shot is particularly helpful to patients of pancreatic cancer or even those suffering from cancers of the kidney, intestine, liver and stomach.

The procedure, incidentally, has been around globally for the last 60 years and in India for at least over two decades. Pain specialists in the city, around eight in number, however get just a handful of cases a month. This despite the fact that almost 90 per cent cancer patients die of pain. “And this procedure offers a painfree end to their lives,’’ says Dr P Vijayanand, director, Axon Pain Management Centre.

Priced at Rs 7,000 to Rs 10,000, it may seem expensive but pain specialists note that while morphine tablets are cheaper, the procedure offers both longer and greater relief from pain. Besides, centres like Axon charge a patient only for consumables (costing around Rs 4,000) and the procedure is offered for free at the Osmania General Hospital.

Among the multiple factors responsible for the procedure to remain sidelined (ranging from ignorance of doctors to patients being reluctant to undergo yet another procedure) is a more disturbing one– that of economics taking precedence over patient care. “The referrals come from general or gastroenterology surgeons (as it is used for pancreatic infections too) but rarely from oncologists,’’ says a senior pain specialist wondering if the reluctance to refer is due to oncologists’ concern over losing patients to other doctors.

Oncologists rubbish this claim saying that morphine drugs and other pain killers work better and maintain that the coelic plexus block does not have the longterm effect claimed by pain specialists.

Nevertheless, medical researches and pain specialists note that the problem with morphine is its accessibility (being a narcotic it’s not available at pharmacies but only with corporate hospitals) and that it offers only 35–40 per cent relief from pain, with side–effects ranging from nausea to complete loss of appetite. “Besides, the patient goes off drugs for five to six months.

Also, the relief with morphine is not as good,’’ says Dr Santosh Darisetty, chief of anaesthesiology, Asian Institute of Gastroenterology. “In contrast, the coeliac plexus block procedure, gives 100 per cent relief to 60–70 per cent patients,’’ says Dr J Madhusudan Reddy, senior consultant in anaesthesia, Apollo Hospitals.

Nevertheless, there is a marginal rise in the number of patients seeking pain relief through the block procedure at Osmania General Hospital (OGH). “We are doing 8 to 10 cases a month. There is better awareness, but the referrals are still not from oncologists,’’ says Dr C G Raghuram, professor of anaesthesia and incharge of pain management at OGH.

Oncologists are still not convinced. Senior oncologists from Apollo Hospitals and MNJ Institute of Oncology this newspaper spoke to maintained that the procedure “had a very transient period of relief ’’ whereas oral morphine and dermal patches were non–invasive and effective.

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