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Drug Pragmatics – Who decides: the police or the doctor?

In 2014, a trial was completed in Russia against a doctor, Alevtina Khorinyak, who was prosecuted for writing a prescription for painkillers for a terminal patient. Alevtina was facing 8 years for this. After 3 years of litigation, she was acquitted. But the problem with access to opioid analgesics in Russia has not been solved, and doctors are still afraid to prescribe them. The situation is similar in other countries of the EECA region – in Ukraine and Armenia.

Who should decide on the use of analgesics in palliative care, a policeman or a doctor?

Lawyer Mikhail Golichenko and human rights activist Masha Plotko discuss this issue as part of the NarcoPragmatics podcast series produced by the Eurasian Harm Reduction Association and the HIV Legal Network.

 

Human rights and psychoactive substances

Mikhail Golichenko: If we take Germany as a benchmark, where access is good, the next group of countries is Central and South-Eastern Europe (Greece, Hungary, Czech Republic, Slovakia). In these countries, access to opioid analgesics is about 5 times less than in Germany. In countries like Russia, Moldova, Ukraine the average use of opioid analgesics per capita is about 10 times less than in Greece, Slovakia. Narcotics is an area where all power, all authority, in particular related to decision making, how to regulate and control, is given to law enforcement agencies. Since control and punishment are the main tools of the police, the doctor is very often in the situation of a suspect, afraid to prescribe opioid analgesics, afraid to break formal rules and not to become a suspect in a criminal case on drug sales.

Masha Plotko: Many questions arise: who is responsible for respecting the rights of a person suffering from chronic pain, what rights and responsibilities a doctor has, what role the law enforcement system plays in the country, and where is the line between a person’s right not to feel pain and a crime.

 

Access to pain relief

Masha Plotko: Why, despite the fact that all countries must comply with the 1961 Convention on Narcotic Drugs, which does not call for criminalising such behaviour and instead cares about people’s access to narcotic drugs for medical purposes, is there such a difference between countries in access to pain relief?

Mikhail Golichenko: The conventions that regulate drug trafficking issues at the international level really emphasise that states are obliged to control drug trafficking on the one hand, so that drugs do not go to the black market, and on the other hand states are obliged to ensure that people have access to narcotic drugs and psychotropic substances for medical purposes.

Many people live with chronic pain, are in terminal stages of chronic diseases, when they need access to opioid analgesics as part of palliative care. But for the past 60 years, the rhetoric towards drugs has been a rhetoric of serious negativity. Drugs are commonly thought of as evil. The preamble to the 1961 convention begins by saying that the evil of drug addiction must be defeated. And when the language of stigma and condemnation is chosen to address such an important social issue, unfortunately, society resonates with the fact that, as a rule, the instrument of condemnation and punishment is chosen as the tool of work.

Therefore, despite the formally correct accents in the convention, on the one hand – ensuring medical access, on the other – control from going to the black market, the bias was towards control measures.  Gradually, from 1961 to 1988, even in the conventions themselves, one can see how the language related to ensuring access to drugs for medical purposes shifted to language related to the security of the drug control sphere.

Law enforcement agencies have been given carte blanche, unlimited powers against this backdrop. Many people are accustomed to a culture of judgement, especially when there is a stigma associated with judgement, promoted by the state. And the easiest response to this is to punish, to punish, to deter. And the best way to do this is through law enforcement. By 2010, a system has emerged that is good at punishing, punishing, and indiscriminately investigating. And it is completely incapable of compassion, of taking into account all other aspects related to substance use.

 

Stigma – inherent or a choice

Masha Plotko: There is a fundamental, conceptual question: did stigma come about because drug use and drugs themselves became criminalised, or was there stigma before that, and that’s why it was so easy to apply these laws and introduce such strict, rigid responsibility for simple possession or use of substances?

Mikhail Golichenko: There has always been stigma towards people who use psychoactive substances with certain problems (not only drugs, but also alcohol). Stigma accompanies the use of psychoactive substances, but it all depends on what kind of tuning fork society chooses to work with this or that problem.

If we imagine society as a big orchestra, and the laws and actions of the authorities by analogy with a certain tuning fork, then choosing stigma as this tuning fork, the stigma will increase and stop asking the question to what extent the measures related to punishment, condemnation are adequate to the problem that society is trying to solve. To what extent does the severity of punishment lead people to stop using drugs or use drugs less.  How much it affects the spread of drugs in society. People stop asking these questions. And so an important problem is overshadowed by stigma and hatred, which the state and society itself promotes, having an accepted model fixed in the convention: on the one hand accessibility, but on the other hand control. And control together with stigma gives a bias towards control.

On 13 May 2021, the Eurasian Harm Reduction Association and the HIV Legal Network launched the NARCOPRAGMATICS podcast series.  The first episode “Who decides: the police or the doctor?” (click to listen) answers the question of who should decide on the use of painkilling analgesics in palliative care.

New episodes of the podcast are available on Apple Podcasts, Spotify and ListenNotes platforms.

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