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March 30, 2011 , , , , , , , ,

Dying Patients

Paperwork Means Pain for Dying Patients

Frame from “Morphine” movie

Anna never imagined that she might end up breaking the law when her mother, Nina, was diagnosed with inoperable liver cancer. But when bureaucracy snarled her efforts to get painkillers to relieve her 60-year-old mother’s suffering, she turned to a drug addict as a last resort.

“I hated feeling helpless,” said Anna, who asked that her last name not be used for fear of possible arrest over her visit to the drug addict.

Living in a developing nation can be painful, but dying in one can be worse when doctors are reluctant to prescribe painkillers due to an accompanying mountain of red tape. In the end, people like Anna’s mother are left suffering.

The amount of medication consumed in Russia mirrors that of developing nations. The population consumes half a kilogram of painkillers per million people every year, compared with the 54 to 56 kilograms in developed countries, according to research from the United Nations Economic and Social Council. Russia ranks 103rd worldwide for total medicinal drug consumption.

People with terminal illnesses tend to suffer the most, doctors said. Cancer is detected too late in one-third of all patients, and they receive the same bleak prognosis.

When Nina was diagnosed with cancer in 2003, the doctor prescribed several types of painkillers and sent her to a local clinic where she could get them free, a right afforded by law. But because Nina was not a Muscovite, she could not receive them here. Anna, the manager of a Moscow-based company that produces audio books, took her to their hometown near Tula, 100 kilometers south of the capital.

At the village clinic, the doctor prescribed injections of promedolum, a Soviet-developed derivative of morphine commonly given to mothers during childbirth. By law, doctors must administer the shots themselves, but Anna said this doctor entrusted her with the medication and instructed her to inject it only when the pain was unbearable. He gave her enough promedolum for 10 injections for the week.

That was fine at first, but the pain grew increasingly agonizing as the cancer spread through Nina’s body.

The effects of an injection last only three to four hours, necessitating at least six shots every 24 hours, said Yelizaveta Glinka, who works with the terminally ill as the head of VALE Hospice International in Russia and Ukraine.

Doctors can order as many painkillers as needed, said Maxim Lakomkin, a spokesman for the government agency that oversees medication, the Federal Health and Social Development Inspection Service. The doctor sends information regarding a cancer patient to the regional health department, which then places orders directly with the pharmaceutical company.

But the health departments receive very few orders.

Doctors avoid painkillers because the procedure for dealing with them is complex. For example, if any medication remains in a vial after a doctor administers an injection, he must solder it shut and send it to a laboratory for its contents to be tested, said Nadezhda Osipova, head of the anesthesiology department at the Gertsen Research Oncology Institute. Also, pills must be swallowed in a doctor’s presence, necessitating home visits to bedridden patients.

“They prescribe drugs reluctantly because they do not want the headaches of endless checkups,” Osipova said.

The system, created by federal health authorities in 1997, was designed to prevent the misuse and abuse of painkillers, Lakomkin said.

The rules, however, appear to cover more territory than necessary. While the misuse of injected drugs is a worry, it is unlikely that addicts could extract the drug substance out of the tablets, said Vladimir Bryuzgin, head of the Center of Cancer Pain Control at the Russian Cancer Research Center.

Furthermore, the state’s priorities seem out of order, he said. Patients and their relatives are not allowed to try to buy painkillers beyond what doctors prescribe.

“When relatives want to purchase painkillers themselves, they are told they have no right to do so because, by law, the patient must receive them for free”, Bryuzgin said.

Anna decided to limit the injections to nighttime, when the pain peaked. But as Nina’s condition worsened, the shots no longer took effect. Anna returned to the doctors to get a stronger medication, like morphine, but was told that there was none and that there hadn’t been any for years.

Anna said her mother’s cries in the night were replaced with moans as she writhed in pain. She unsuccessfully tried to boost the potency of the injections with over-the-counter medication. She contacted a friend who worked in the oncology department of a hospital for help. He rejected her request to sell at least one vial of morphine, saying he did not want to end up in jail.

Anna returned home to find her mother’s face gray on that mid-September night. Loathing her own helplessness, she left the house and sought out a childhood friend, Vladimir, a known drug addict. She begged him to give her some heroin, but he said he had no drugs at home because he was trying to kick the habit. She said that after what seemed like hours of tearful pleading, he finally relented.

“I was trembling and praying to God to help me survive this”, Anna said.

She returned home after midnight, a small bag with a tiny knot of yellow heroin in hand. After preparing it to Vladimir’s instructions, she went to her mother to inject it. Nina feebly shook her head in protest, Anna said. Just moments later, she died.

Four years have passed since that night, but little has changed for the almost 400,000 people who die from cancer each year. Almost 70 percent of late-stage patients need painkillers to cope with their pain, said Osipova, of the Gertsen Research Oncology Institute.

“Even though money and a variety of drugs are available, people in the regions are still dying without painkillers”.


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