Olga Usenko, MD, MPH, is affiliated with the Eastern and Central Europe Palliative Care Task Force
Every year, approximately 300,000 cancer patients, 65,000 patients with myocardial infarction, and 14,000 with HIV/AIDS die in Russia. About 180,000 traffic accidents occur of which 30,000 are fatal. Annually, ambulances serve approximately 50 million calls. 1
However, according to data from the International Narcotics Control Board, since 1992 Russia has markedly decreased the legal consumption of opioids. The total opioid consumption dropped threefold from 4.76 ME, Mg/person in 1992 to 1.60 ME, Mg/person in 2010. Morphine consumption decreased eightfold from 3.64 ME, Mg/person in 1992 to 0.47 ME, Mg/person in 2010.
Short-acting morphine in tablets and liquid for oral administration are not registered for use in Russia. The availability of MST–continus and fentanyl patches for terminally ill cancer patients was assessed in Russia in 2011. The evaluation was made on the assumption that 80% of cancer deaths require 67.5 mg of morphine a day for 91.5 days. The study showed that 6.1% of dying patients in Russia, 20.3% patients in Moscow, and 40% of patients in Kemerovo received oral and transdermal opioids. In general, physicians prescribe tramadol in tablets and ampoules for pain management for terminally ill cancer patients. For example, in 2011 in the Tomsk Region, 94% of dying cancer patients received tramadol, 1% received morphine in ampoules, and only 0.2% of patients were treated with MST-continus in tablets.
In recent years, one tragic story after another has regularly appeared in the Russian media, when patients were killed out of compassion because their families could not bear to see them suffer in uncontrolled pain: in Saratov, a university professor killed his mother who suffered with advanced liver cancer; in Orekhovo-Zuyevo, a policeman strangled his mother, who had breast cancer. A man from the Kurgan Region killed his sister with advanced cancer. In Rostov, 17-year-old and 14-year-old girls killed a 32-year-old woman at her request, who was suffering from the last effects of a traffic injury.
In our recent blog post with Adri Nieuwhof we wrote that Russians were shocked by the case of Dr Alevtina Khorinyak. Many physicians supported her and reported on professional websites their own appalling situations: ambulance staff who do not have morphine for patients injured on the roads; postoperative patients in surgical units anesthetized only by Ketorol (NSAID); gynaecologists and neonatologists in maternity departments who are not allowed to prescribe opioids and anesthesiologists who complain about the inability to provide adequate pain control, especially at night. General practitioners are afraid to make a small error in their prescriptions of opioids and in the numerous records required by regulations.
To physicians, the regulations governing opioids availability are burdensome, inadequate and lead to conflict with the Federal Service for Drug Control. But according to the Russian Ministry of Health in their report to the International Narcotics Control Board, inadequate pain management of Russian patients results from healthcare professionals’ lack of knowledge of pain treatment.
The situation in Russia concerning the decrease in opioid consumption is very complex with more than one cause. In this post I have drawn attention only to one issue because currently the fight against illegal opioids has acquired a monstrous character. I plan to write more on this subject in a future blog post.
1. Russian Federal Statistics Bureau.
Results from the ESMO-led Global Opioid Policy Initiative (GOPI) project have now been published in Annals of Oncology. They reveal that due to a lack of access to inexpensive and effective essential opioids, more than four billion people (that is, over half the world population) live in countries where regulatory barriers leave cancer patients suffering excruciating pain. Download the results here.