RACHEL MARTIN, HOST:
Pain, like death, is a universal phenomenon. That's the first line of reporter Sarah Varney's two-part series for The Guardian newspaper about the opioid boom in India. And that line says so much, right? Whether you're a factory worker in Ohio with chronic pain, or a cancer patient in Mumbai, the pain can be the same. What is also similar, some of the big pharma names behind the drugs - Johnson & Johnson, Purdue Pharma and other American opioid manufacturers see big money in India, where easing restrictions on controlled substances is making pain meds easier to get.
Sarah Varney with Kaiser Health News joins us now to talk about her reporting. Thanks so much for being with us.
SARAH VARNEY: Thank you, Rachel.
MARTIN: It can be hard to imagine here in the U.S., where pain medicine has just been a routine part of our health system now for so long, but just start off by explaining, what has been different in India? How difficult had it been to get treated for pain there?
VARNEY: So for generations, there were doctors who actually had never even seen a morphine tablet. There's a doctor down in southern India, named Dr. Rajagopal, who's really seen as the father of palliative care in India. And he described how as a young medical student that he would see these patients dying of these incredibly agonizing diseases, have cancer, and so on. And he really committed himself to trying to change the laws in India. So he's the one that told me this, that actually, that there had been generations of doctors who had never really seen a morphine tablet. There had been so much hesitation around addiction that government officials were incredibly reluctant to try and loosen these strict narcotics laws.
MARTIN: So what's it like now? I mean, how big is the market for opioid painkillers?
VARNEY: Well, there's 1.37 billion people in India, and there seems to be something available for all of them. So what I found really fascinating when I was there is that you can really see the stratification in the pain management industry. You can see these very high-end clinics in Delhi, like the Delhi Pain Management Center that I went to. They have five clinics in every sector of Delhi. You know, they're well-run shops. You go in there, there's, you know, white leather seats and excellent service. So this would be sort of for the higher-end clientele.
Then you have these neighborhood clinics that are open late at night on a Friday or Saturday night, when people actually have time to go to the doctor. And then in the slums in Mumbai, for instance, you have these storefront kiosks where you can just step up to the storefront and just buy tramadol off the counter.
MARTIN: So if you can just walk up to a kiosk and get an opioid, how regulated is this market? I mean, are they even doctors who are standing behind those kiosks?
VARNEY: There are not doctors standing behind those kiosks. The Indian government will tell you that they are regulating all of this, that it is difficult to get access to these drugs. But that is just not the case. I was able to step up to another kiosk and buy an actual shot of tramadol from Abbott Laboratories. You can go in and buy patches of buprenorphine or fentanyl that are made by Johnson & Johnson and Mundipharma, which is the international affiliate of Purdue Pharma.
So these drugs are readily available. And certainly, there are good actors who are trying to ensure that they don't have a U.S.-style opioid epidemic. There's a lot of concern about that there. But the reality is, this market is just so vast - you know, you're talking about tens of thousands of doctors spread out over this country - that it's just incredibly difficult to regulate.
MARTIN: It's hard to ignore the fact that those names you just mentioned, Johnson & Johnson and Purdue Pharma, both pharmaceutical companies here in the U.S. that are facing huge lawsuits, have already been fined huge amounts of money for their role in exacerbating the opioid epidemic here in the States. How long have they been involved in the Indian market?
VARNEY: So some of these companies have been there for a long time. Johnson & Johnson has been in India for a hundred years. Mundipharma, which has several iterations of the company in India, has been around for a long time. Abbott Laboratories has been there for quite a while, as well. These are known brands in India. Mundipharma in particular, oftentimes what they'll do in these countries is, they'll go in and form a partnership with a local company, a local Indian company. So there's less a distinction between, you know, sort of the global pharmaceutical company and the local company. It's sometimes difficult to tell the difference.
MARTIN: You write that this shift, this opening and the availability of opioids, it represents a cultural change, too, which I found really interesting. You wrote that before pain management was seen as helpful to people, it was viewed as some kind of privileged indulgence of the West.
VARNEY: Yeah. I found this absolutely fascinating. Dr. Dureja, who runs these pain management clinics in Delhi, mentioned this. And he's really considered one of the fathers of the pain management industry there, a good actor, somebody who's really concerned about making sure that pain medications are done in a proper way. But yeah, he mentioned this, you know, that it used to be that there was a sense of you just have to live with your pain. And now he said, no, no, people are coming to him and saying, I've got neck pain or knee pain. He actually said that a lot of 20-year-olds are coming in with wrist and arm pain from typing so much, and that they even want relief.
MARTIN: But like in the U.S., the introduction of legal opioids has meant an increase in addiction in India. How bad is it there?
VARNEY: Well, it's really difficult to get a sense of how bad it is. But I did go up to Chandigarh, which is north of Delhi by about six hours. It sits in what's called the Golden Triangle. So there's a lot of heroin that passes through that area, and there's been a long problem with heroin addiction in that area. I did go to one of these - they call them de-addiction clinics, and I met with a number of these addicts. And they said, you know, when they can't get their hands on heroin or something else, they'll turn to tramadol. They'll turn to buprenorphine.
They'll turn to any of the other drugs that are available. And they said that they can easily go up to these chemists, these pharmacies there and purchase it.
MARTIN: You also point out in your reporting that some of the opening that has allowed these pain meds to come to market has to do with how the prime minister there, Narendra Modi, has approached health care, overhauling it there to some degree, right?
VARNEY: That's right. So last fall, the Indian government launched what is essentially the world's biggest public health insurance program. Over there, they dub it Modicare, and it guarantees half a billion poor Indians about $7,000 in hospital expenses. Now, this is going to be paid to private insurers. But by 2020, the government is saying it's going to open 150,000 primary care centers. So the government has set aside about $484 million to fund this program. And it's certainly the case that drug companies understand that now there is a payer for their products. Whether you go into the hospital, and now you can have some pain treatment along with whatever kind of procedure you are getting done, there's now somebody who actually can pay for this, as well.
MARTIN: So a burgeoning market, to be sure.
VARNEY: Absolutely.
MARTIN: Sarah Varney with Kaiser Health News. Her two-part series on opioids in India appears in The Guardian newspaper. Sarah, thank you so much.
VARNEY: Thank you, Rachel. Transcript provided by NPR, Copyright NPR.