Opioids and Sickle Cell Pain: When They Are Habit-Forming and When They Are Not

In India, opioids are scheduled drugs. Prescribing requires a competent doctor, meaning a pain specialist, anaesthesiologist or neurologist, not a general physician, general surgeon or ENT. For morphine and fentanyl specifically, the hospital needs a government licence to hold a set quantity, uses a special designated government form that gets stamped, and patients are required to bring back a consumption chart that is submitted to the drug controller. Tramadol, tapentadol and buprenorphine do not need that special licensing, but they still require a valid, stamped prescription from a competent doctor.

That gap exists, and it falls to drug inspectors to enforce, not to prescribing doctors. In practice it means a large number of chronic pain patients arrive in this clinic having self-medicated with over-the-counter combination painkillers for five, ten, even twenty years. This practice calls it analgesic abuse: a difficult situation created by the fact that these medicines are freely available without a prescription.

The first problem is diagnosis. Ninety per cent of doctors who are not trained for this kind of spinal pain cannot diagnose facetogenic pain. This practice groups facetogenic and discogenic pain together as axial pain, and gabapentinoids have no role in treating it, yet eight in ten axial pain patients are put on these drugs anyway, with zero results. Getting it right needs a specific history, a specific examination, and then a diagnostic block to confirm the pain is actually coming from the facet before moving to facet joint radiofrequency ablation.

A crisis needs aggressive fluid management and correction of the patient's pH and blood gases. These patients do not respond to diclofenac or similar painkillers; they need intravenous opioids, usually through patient-controlled analgesia while admitted. Once the patient stabilises and comes out of crisis, treatment switches to patches or oral medication.

No. A purely diagnostic facet joint injection should not include steroid at all. If a facet block is being used as treatment rather than as a step toward radiofrequency ablation, relief is typically short, six to eight weeks, sometimes up to twelve, so some clinicians add triamcinolone, four to eight milligrams per level, with ropivacaine or bupivacaine. That is not standard of care here, because the pain returns. The approach in this practice is a steroid-free block first, then radiofrequency ablation, with four milligrams of triamcinolone added at every treated level after the ablation.

Not in Dr. Jain's clinical experience. He states opioids used for chronic musculoskeletal pain are habit-forming, but the same drugs used for cancer pain or sickle cell pain, managed on the same principles as cancer pain, are not.

Visceral tissue, involved in sickle cell and cancer pain, carries opioid receptors that peripheral musculoskeletal tissue does not. Visceral pain is also carried by the sympathetic nervous system and needs a neuropathic agent combined with an opioid, rather than conventional painkillers alone.

With aggressive fluid management, correction of blood pH and gases, and intravenous opioids, usually via patient-controlled analgesia while admitted, switching to patches or oral medication once the crisis resolves.

Opioids are scheduled drugs prescribable only by a pain specialist, anaesthesiologist or neurologist. Morphine and fentanyl require a government licence, a stamped designated form, and a submitted patient consumption chart. Tramadol, tapentadol and buprenorphine need only a valid stamped prescription.