Treatment or Torture: Why Ukrainian Doctors are Afraid to Prescribe Opioids
Despite recently relaxed rules on the medical provision of opioid analgesics, tens of thousands of patients in Ukraine are suffering from unbearable pain. Civil society organisations have attributed this to medical professionals' fear and ignorance of opioids, and “narcophobia”.
The issues surrounding opioid provisions in Ukraine were discussed by experts from various civil society organisations and medical institutions who gathered at the event Uncontrolled Pain 2016. What has changed?.
Between 2013 and 2015, the Ukrainian government lifted practically all barriers for medical professionals to prescribe opioid pain killers. For example, prescription commissions have been abolished, and it is no longer required for witnesses to be present during opioid use. Many other bureaucratic procedures which made the prescription process more challenging for patients have been removed from legislation.
Patients can now buy painkillers from licensed pharmacies and administer them on their own.
A breakthrough in the field happened in 2013 when two Ukrainian pharmaceutical companies started producing oral forms of morphine, in addition to the injecting forms which were already present in the Ukrainian market. This development greatly expanded the set of tools available at hand for the doctors to treat both chronic and acute pain.
During 2016, over 90 patients and their relatives, 50 doctors, and 15 local decision-makers in state medical departments were interviewed across Ukraine. The results of this research – presented at the event in Kiev - demonstrated that, despite progress, access to opioid analgesics in Ukraine is insufficient.
According to Ksenia Shapoval, program officer at the International Renaissance Foundation (IRF), a key barrier to access is the scarcity of pharmacies which hold licenses to procure controlled substances. “For instance, in Kirovograd region, there is only one such pharmacy, and people are destined to travel to the neighbouring Poltava region to get pain killers for their relatives who suffer from pain,” Shapoval has said.
Vasyl (City of Chernihiv, Ukraine): “I was diagnosed with throat cancer and I started to get Ketanov for pain relief. Later on, when pain became unbearable, my wife ran to the polyclinic to demand something stronger. The doctor didn’t recommend me tramadol, because he said after it nothing will help, but at the end of the day I got tramadol.
Tramadol does not remove my pain completely. I take two pills before going to sleep, but I can’t really sleep because my pain gets worse at night. During the day I try to endure pain, because my doctor said I should save my pills. Because of pain I almost don’t eat – my body became so dried up. Tramadol is so hard to get – one needs to spend the whole day in the polyclinic waiting in line, gathering signatures. I am scared of injecting morphine: I will bear pain, until I can.”
Another serious obstacle to wider use of morphine in Ukraine is “narcophobia” - among both doctors and patients.
Andrey Rokhanskiy, a doctor and human right defender from Kharkiv, told TalkingDrugs that narcophobia among patients is the superstition that pain is a natural part of a severe illness and needs to be endured.
Svitlana (City of Rivne, Ukraine): “I have breast cancer, and after radiation therapy I started having fever and pain in my shoulder joint. I started taking Nimid (Nimesulide), but soon it stopped helping me, so oral morphine was prescribed. The pain reduces for 4-5 hours, but never goes away completely. The doctor recommends increasing the daily dose to six pills, but I am afraid to get an addiction, even though doctor tells me I will never become addicted from such small doses.”
The majority of patients refuse to take narcotic pain killers, because their doctors dissuade them from doing so. Patients often hear from medical professionals: “you may get better, but these pills will make you an addict”. But according to the World Health Organisation (WHO), opioid pain killers prescribed in accordance with established protocols do not lead to dependency.
Unfortunately, very few Ukrainian doctors have a detailed knowledge of the international standards and medical protocols of administering controlled substances. According to Andrey Rokhanskiy, only between five and 14 per cent of patients interviewed (depending on the region) experienced relatively successful pain relief. He said that if pain relief medications are properly prescribed, according to WHO recommendations, up to 80 per cent of patients - even those with stage 4 cancer - would not suffer from pain.
Fear and ignorance in the prescribing of opioid pain relief medications among doctors is a direct consequence of repressive drug policies which fail to embrace the needs of patients and doctors. Medical professionals in Ukraine have been scared to prescribe morphine, even to patients with severe pain syndrome. Many patients never had the opportunity to receive adequate pain relief at home due to heavy regulation by law-enforcement authorities, including the criminal prosecution of anyone found with leftovers of such medicines.
Abolishing the old Soviet system, which views patients as potential drug addicts, and doctors as potential dealers, is a challenge. As a result, around 500,000 patients, including 17,000 children, are destined to suffer from pain. According to IRF, the total amount of morphine used for pain relief in Ukraine should be around 500kg per year, but it is currently only 85kg.
Elena (City of Zhytomyr, Ukraine): “My father was diagnosed with nasopharynx cancer in 2009. During the last six months, his pain has become worse and has risen to 10 points (0 point – no pain, 10 points – unbearable pain). He is in pain day and night. I was told by the oncology unit of our hospital that my father can get narcotic medicines for 15 days. The oncologist in charge of his case said he can prescribe only 10 ampoules.
He said to me “Your father can die any day and what I am supposed to do with the left ampoules, pharmacy will never take it back.” My father is not dying yet and these are all excuses. I don’t understand how doctors can be so ignorant. The doctor is authorised to prescribe a bigger dose, but he doesn’t want to. So I have to travel to the bigger city every day to get a new set of pain killers.”
Systemic change in access to controlled substances in Ukraine can only be achieved when healthcare workers are properly educated, including with the introduction of a consistent state curriculum, experts have stressed. “We recommend that all students of medical universities should take a basic study course in palliative care and pain management. Those who will be engaged in palliative medicine should take an advanced study course in pain treatment protocols and do clinical practice,” noted Tatyana Cooper, a Human Rights Watch researcher.
Non-government organisations in the country have now created two training centres for educating medical professionals involved in palliative care and pain management. The centres will educate around 800-1,000 doctors and nurses every year. This is an important step, but it is not enough; there are 120,000 medical doctors in the country, including 8,000 family doctors and 7,000 general practitioners, who should be trained to treat chronic pain syndrome according to international protocols.
Naomi Burke-Shyne, senior program officer of the Open Society Foundations’ Public Health Program, has stated that regulatory reforms related to medical use of opioids, and the introduction of oral morphine in medical practice in Ukraine are positive steps. Burke-Shyne also said: “I hope the Ukrainian government, civil society, and medical experts will continue to implement regulatory reforms related to access to controlled medicines, to improve the quality of life of patients in pain and their families”.