Saskia Jünger, health scientist at the University Hospital of Bonn, Germany, and member of the ATOME Project Management Team and Marjolein Vranken, pharmacist and lawyer at the Utrecht Institute for Pharmaceutical Sciences (the Netherlands) and member of the ATOME team.
The Access to Opioid Medication in Europe (ATOME) project aims at improving national policy and legislation related to opioid availability and accessibility in 12 European countries. It was already the 7th ATOME national conference when we met in Tallinn, Estonia on 19th September 2013, for the ATOME Estonia National Symposium on Access to Opioid Medication. Yet, there were many firsts at this conference: the first time that a talk was provided via video-presentation (thankfully, technology did not abandon us), the first time that experiences with opioid agonist therapy were presented from a patient-perspective, and the very first time that cutting-edge changes in the national controlled substances legislation were announced at an ATOME conference. Excitingly, the Minister had approved these changes just the night before the conference, and on 23rd September all amendments to the Estonian legislation came into force. This is excellent news for access to opioids in Estonia since it will considerably simplify reception, storing, recording, and reporting of the dispensing of opioid medicines. For example, the government had prepared changes to the legislation to ensure that all pharmacies would be able to dispense controlled substances to patients. Before, only a restricted number of pharmacies (in 2012 only 18%) applied for the special permission that is required to be entitled to dispense opioid medicines. As a consequence, it was not clear to patients where they could get their medicines.
When analysing problems in providing adequate pain treatment and methadone maintenance therapy in Estonia, a number of interesting concepts and metaphors came up, reflecting an ingrained scepticism towards opioid medicines. For example, Aljona Kurbatova, Head of Infectious Diseases and Drug Abuse Prevention Department at the National Institute for Health Development, reported about a leading policeman who had argued that “methadone maintenance treatment for people dependent on heroin is as effective as giving an alcoholic free beer and pickles in the morning and hoping he will give up his vice” – a comparison that completely disregards the strong evidence for the effectiveness of long-acting opioid agonists in the treatment of opioid dependence.
Dr Pille Sillaste, Head of Department of Pain and Perioperative Care at the North Estonia Medical Centre, deplored: “the total lack of awareness with respect to palliative care on all levels – among politicians, health care professionals, and the general public.”
She added: “People think that palliative care means holding the hand of the dying person. When trying to convince hospitals to offer palliative care to dying patients, they replied: ’We are an active treatment clinic; palliative care does not fit into our concept.’ ” Dr Sillaste emphasised that if people do not understand what palliative care is, there will be no vision of what we want to achieve and where we want to go in that area.
Dr Eda Lopato, Head of Bureau of Import, Export, Narcotic Drugs and Psychotropic Substances, State Agency of Medicines and Head of the ATOME Estonia country team, presented the strategic action plan for improving access to opioids in Estonia that the country team had developed during a previous ATOME workshop in Bucharest. Dr Lopato frankly admitted: “At this first meeting I was sceptical because the term “barriers” seemed very strange to me.” However, in the course of the workshop they had identified a number of key barriers including complicated storage and handling of opioids by pharmacies.
Two years later, at this conference in Tallinn, a very committed group of stakeholders convened during the working group sessions in the afternoon – with their hearts and their minds open towards self-reflection, problem identification, and critical discussion. “Unfortunately, there are many issues still waiting for a solution – and we must admit that for some of them perhaps there will not be a good solution possible,” said Dr Lopato. However, a lot has already been achieved in terms of access to opioid medication in Estonia. “We are very grateful to Dr Rüütel and Dr Lopato from the Ministry for carrying the changes in the national opioid policies into everyday life – as a doctor it has become so much easier now to help my patients,” said Dr Sillaste. She added: “Estonians are not particularly inclined to praising or saying thanks. However, we have to say thank you so much to the ATOME project that – just as a lighthouse project – has supported the endeavours of the Estonia country team to improve the situation and enhance access to opioid medicines.”
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