Saskia Jünger, health scientist at the University Hospital of Bonn (Germany) and member of the ATOME Project Management Team
On 21 March 2013, spring was supposed to have arrived – but the scenery rather reminded us of a winter’s tale with a view of the frozen Daugava at a chilly –10°C and bright sunshine. The ATOME (Access to Opioid Medication In Europe) national conference in Riga, Latvia, was officially opened by the State Secretary of the Ministry for Health of the Republic of Latvia, Mr R Muciņš, and more than 60 delegates worked together with national and international experts on strategies to improve access to opioid medication.
Great achievements were reported in the provision of, and access to, harm reduction services in Latvia since the 1990s. More physicians can offer substitution therapy while previously only narcologists were entitled to do so. Restrictive access criteria to methadone programmes have been released – the only indication required for access is opioid dependence. Methadone and buprenorphine are available in prisons and in 2012 an education programme for prison healthcare professionals was implemented. Also important is the positive change in attitude towards methadone programmes – at the end of the 1990s these used to be referred to as “death programmes”.
Despite these considerable improvements, several Latvian experts highlighted a number of key shortcomings. One challenge is the low coverage. “In Europe-wide comparison, Latvia ranks lowest for the coverage of long-term pharmacological treatment for opioid dependence in relation to the estimated number of problem opioid users”, said Dr Astrīda Stirna, Head of the Latvian Association of Narcologists. Many patients are on a waiting list, while time can be so decisive to prevent harmful consequences of injecting drug use, such as infection with HIV or Hepatitis C, as Dr Jeļena Sorokina, chief physician at Liepaja Regional Hospital, pointed out. “A dose once a day can help changing the lifestyle of a patient and stabilise his identity.”
The importance of good assessment
Several experts underlined the importance of good assessment to offer adequate pain treatment. “Physicians do not have the time for proper assessment of patients’ pain. In the scheduling of patient contacts you need to consider this and take enough time to interview them adequately – this cannot be done in 10 – 20 minutes,” said Dr Ilga Albina from the Latvian Association of Oncologists. Dr Guntis Iļķēns, anaesthetist and pain therapist at Vidzeme Hospital, argued: “Can you imagine a physician treating diabetes without measuring the blood sugar?” Although knowledge and expertise in pain management have increased among physicians in Latvia during the last years, he observed that there are still severe shortcomings in the area of appropriate assessment. “Why don’t we use pain scales or other tools to measure the pain on a regular basis?”
Peaceful persistence and proactive efficiency
Latvia – a small beautiful country that together with Estonia and Lithuania, secured its restoration of independence after the Soviet era with a peaceful demonstration and a human chain from Tallinn via Riga to Vilnius. The country was severely hit by the financial crisis in 2008 / 2009; a lack of funding therefore was a major issue in the provision of healthcare. However, during the past few years important improvements in the access to opioid medicines in palliative care and harm reduction have been made. A high commitment by the ATOME Latvia country team and governmental key decision-makers contributed to a proactive way of tackling the problems and enabling change. Dr Vilnis Sosārs, Head of the Palliative Care Association of Latvia, and Biruta Kleina, Department Deputy Director at the Latvian Ministry of Health, concluded that some of the recommendations resulting from the ATOME analysis of legal and regulatory barriers had already been implemented, for example the removal of inappropriately strict storage requirements for opioids. Future challenges will be the provision of adequate funding, a better collaboration between professions and sectors, and improvements in the language and terminology around opioid use.
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