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What chance of going gently into that good night?

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Russia has an ageing population, a growing HIV/AIDS epidemic, and an inadequate system of palliative care for terminally ill patients that leaves Russians feeling betrayed. The failure of authorities to tackle the problems makes a bad situation worse, says Olga Usenko.

Olga Usenko
11 October 2013

When 76-year-old Nadezhda Olkhovskaya was diagnosed with liver cancer, doctors told her that she had less than six months to live. Her son, 54-year-old Vladimir, a professor at Moscow Pedagogical University, travelled to Saratov to care for his mother; he carried her to the bathroom, chopped up vegetables for her, took her outside to breathe fresh air, and went at night to the pharmacy to pick up her medication. Painkillers, however, were less and less effective, and his formerly strong mother was gnawing at a pillow so that the neighbours would not hear her screams.

‘Why must I suffer like this? Please do something!’ Her son understood what she was asking, and gently closed his mother’s nose with his fingers, hugging her for the last time; then he called the police. A court in Saratov found Vladimir guilty of murdering his mother, and sent him to prison for nine years.

Larisa Korsakova from Orekhovo-Zuyevo near Moscow was diagnosed with advanced breast cancer and metastases in the spine. She was discharged from the hospital, or rather sent home to die. Her 23-year old son Vladimir, a policeman, was caring for her, but treatment brought little relief, and she asked him to put an end to her suffering. He refused so next she asked a cousin, a close friend, and a physician from the local polyclinic, to no avail.

'I’m in favour of euthanasia: better to die than endure the fascism of medical care in Russia.'

Twice she attempted suicide by taking an overdose of pills and cutting her veins. The exhausted woman weighed little more than 40 kg, but her plans to end her life were unsuccessful, because both times she was rescued. On November 10th 2011, after a long conversation, Vladimir strangled his mother with a sheet. His attorney argued that the young man, ‘killed his mother out of compassion, because her doctors had failed to help her.’

The prominent Moscow newspaper Moskovsky Komsomolets published the story of Karina Tivanova’s father, who was discharged from the city hospital in Reutov in the Moscow region, with a diagnosis of lung cancer and metastases in the liver. On December 28th 2012, just before the 10-day New Year holiday, Karina went to her father’s doctor, and asked for a prescription for opioids for her father who had been taking tramadol in tablet form, though the pills were no longer effective. She feared that his health might deteriorate over the holiday period, but was told that no one would prescribe opioids ahead of the holidays; and recommended ampoules. Karina spent many hours traipsing round surgeries and pharmacies, and managed to scrape together just enough medication to get through the long break.

After New Year’s Eve, her father’s condition did indeed deteriorate. None of the family members could sleep, and tramadol was no longer effective. Karina called out the ambulance several times, but the paramedics said that they would be fired if they used opioids for patients with chronic pain. Early in the morning of January 9th, Karina went to the polyclinic, where she was told that ‘there would be no opioids in the city until after January 25th.’ On January 11th, again after trailing around doctors, she managed to get her hands on some more medication, but her father died on January 12th.

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A combination of bureaucratic red tape and a strict regime of opioid control has left end of life care very difficult for Russian families. Photo: Copywrite RIANovosti/Sergei Venyavsky

35-year-old Lesha Gorev, who was hospitalized at the Kaliningrad hospital for infectious diseases, gave an account of attitudes to people suffering from HIV: ‘The pain was unbearable, and I was ready to hang myself. At first, the doctors only gave me Analgin [metamizole] and Dimedrol [diphenhydramine] then they brought me Almagel [an antacid] with an overdue date. Another patient, a drug addict, shared a tramadol pill with me and I slept a little. It’s sadism! I’m in favour of euthanasia: better to die than endure the fascism of medical care in Russia.’

The UN estimates that Russia is the largest heroin market in Europe, valued at $6 billion. Some 30,000 to 40,000 Russians die every year from drug-related illnesses

Recently, even normally stoic Russians were shocked by the case of Alevtina Khorinyak, a doctor with 50 years of experience. Viktor Sechin, a 57–year-old cancer patient, was receiving some medication in patches and tramadol in tablets for his pain. On April 18th 2009, he took his last tramadol pill, but the local pharmacy, which had been providing the pills free of charge on prescription, had run out of them. They were, however, available elsewhere, at full price. Viktor was crying with pain, but his physician refused to increase the dose of the patches or to write a prescription for more tramadol.

Viktor’s mother could bear his suffering no longer and asked Dr Khorinyak, from another polyclinic, to write her son a prescription for tramadol. Dr Khorinyak had known Viktor Sechin for many years. She had diagnosed his cancer and arranged all the necessary consultants and procedures for him. Tramadol is not considered a narcotic drug in Russia, and Dr Khorinyak wrote two prescriptions for it. Lydia Tabarintseva, a family friend, bought this medicine at full price and brought it to Viktor.

Hundreds of thousands of people become victims of the medical drug crisis, which has been “arranged” by health care officials

A court in Krasnoyarsk found Dr. Alevtina Khorinyak and Ms. Lydia Tabarintseva guilty, and handed down a criminal conviction. ‘The worst thing is that this case is typical. Hundreds of thousands of people become victims of the medical drug crisis, which has been “arranged” by health care officials,’ wrote newspaper Novaya Gazeta on May 24th 2013.

Telling figures

In recent years Russia has been in the grip of a heroin epidemic. In 1990, there were 67,622 drug addicts; by 2013 the number had increased to 8.8 million. Drug addiction among teenagers in the past 10 years has increased 20 times. The UN estimates that Russia is the largest heroin market in Europe, valued at $6 billion. Some 30,000 to 40,000 Russians die every year from drug-related illnesses. The most common method of administering heroin is intravenous, and the relationship between heroin use and HIV/AIDS is well documented.

The HIV/AIDS epidemic in Russia is showing little sign of disappearing. The Federal AIDS Centre official statistics show that HIV-positive numbers dramatically increased from less than 900 in 1994 to over 700,000 in 2012. In 2005, there were nearly 1,000 cases of AIDS, by 2012 that number had risen to over 19,000.

In 2009, only 42,222 cancer and HIV patients (18.7%) had adequate coverage of opioids for their pain; the other 183,134 died in pain.

More pain, fewer official opioids

The pain management situation in the Tomsk region is a microcosm of the situation in the country as a whole. In general, physicians prescribe tramadol in tablets and ampoules for pain management of terminally ill cancer patients, with only small amounts of other opioids available for pain management.

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Every year, approximately 288,000 cancer patients die in Russia. Yet, since 1992, there has been a marked decrease in the legal consumption of opioids. Total opioid consumption dropped by a factor of 3 from 4.76 ME (morphine equivalents) Mg/person in 1992 to 1.60 ME, Mg/person in 2010.

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Research provided by the Global Access to Pain Relief Initiative, Pain & Policy Studies Group, and Human Rights Watch shows that in 2007-09 the average opioid consumption for pain relief in Russia was 260.8 ME/kg. The analysis was made on the assumption that 80% of cancer deaths and 50% of HIV/AIDS deaths require 67.5mg of morphine a day for 91.5 days. As a result, in 2009 only 42,222 cancer and HIV patients (18.7%) had adequate coverage of opioids for their pain. The other 183,134 patients died in pain.

Short-acting morphine in tablet and liquid form is not registered for use in Russia. In 2011, the availability of MST-continus (morphine sulphate) and Duragesic (fentanyl) in patches for terminally ill cancer patients in Russia was assessed using the same methodology. 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.

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 Russian Federal Units by opioid provision in palliative care. (Pink = more than 10% received MST-continus or fentanyl patchs. Grey = less than 9.9% received MST-continus or fentanyl patchs.Green = no MST continus or fentanyl patchs given to patients) 

Only in 11 of Russian federal units (pink) did more than 10% of patients receive MST-continus or fentanyl patches; in 64 federal units (grey) up to 9.9% of patients received this type of treatment; and in 8 federal units (green), terminally-ill cancer patients did not receive any oral or transdermal opioids.

Data analysis from the Moscow endocrine plant that produces narcotic analgesic drugs in Russia shows a disparity between numbers of oral and transdermal opioids required, and those purchased by Russian federal units’ health care authorities. For example, every year, almost 13,000 cancer patients die in St Petersburg, the cradle of the hospice movement in Russia. Comparative analysis shows that in 2012 many fewer transdermal and oral opioids were ordered and purchased by the St Petersburg Health Care Authority than in 2008.

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‘Problem? What problem?’

In every region of Russia, illegal opiates are readily available at relatively low cost. It is estimated that more than 90% of opiates are smuggled to Russia from Afghanistan and other Central Asian States. The trafficking in opiates, especially heroin, is highly profitable and attracts an ever-increasing number of criminals prepared to enter this trade. Organised crime in the post-Soviet era is closely linked with the authorities; this is the problem. In 2012, illegal trafficking of narcotic drugs, psychotropic substances and their precursors was estimated at 87 tonnes. The total legal consumption of opioids was only 554 kg; and a consistent 0.7% of the illegal trade.

On February 4th 2013, officials reported to a meeting at the Russian Ministry of Health that there were no complaints from patients about inadequate pain management; no other problems with pain relief; the Russian controlled drugs list is sufficient; there is no diversion of drugs from the legal to the illegal trade; opioid control is at a high level; palliative care is a well-developed part of oncology.

In 2012, illegal trafficking of narcotic drugs, psychotropic substances and their precursors was estimated at 87 tonnes. The total legal consumption of opioids was only 554 kg

The Ministry of Health of the Russian Federation did, however, report to the International Narcotics Control Board that health care professionals’ lack of knowledge regarding the treatment of pain had been identified as one of the primary impediments to the use of opioid analgesics. Health care professionals are also wary of the consequences of errors in complying with administrative requirements for the use of opioid analgesics. The Ministry has promised that programmes for pre-and post-graduation stages of training will be provided for health care professionals and the legislation will be simplified. 

In memory of his father dying, Dylan Thomas wrote these lines:

Do not go gentle into that good night,

Old age should burn and rave at close of day;

Rage, rage against the dying of the light. 

In the end, all that Russians can hope for is to rage.

 

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