One of the first and fundamental principles of palliative care stated in all of its many definitions is excellent pain management. We hope that this article will serve as a catalyst to garner the urgently needed support from the government as well as international organizations to the problem of pain management and palliative care in Russia.
According to a quantitative survey conducted in 2005 to estimate global palliative care service provision: there are 33 inpatient palliative care units, 74 inpatient hospices, 17 consultant teams in hospitals, 1 home care team and no day centers in Russia – a country with a population of over 140 million people. The need for funding, opioid unavailability, need for recognition of palliative care as a medical specialty, and for special education of service providers have been revealed as obstacles to the implementation of palliative care in Central East Europe and the Commonwealth of Independent States.
Palliative care and hospice development in Russia have never been a part of an integrated program and have had no clearly defined strategy. This has resulted in vast areas with no coverage of palliative care at all. Also, the authors believe that Russia’s palliative care would benefit from a united coordinating centre that could forge links between research institutions, hospices, health care givers and consumers. This apparent shortfall of the holistic approach to palliative health care management is acutely felt by many.
The availability of effective pain management remains the most frustrating of the barriers to successful palliative care in Russia. A chain of international documents have stated and strongly emphasized the human right to pain management, the role of opioids in health care, and the need for national policies that guarantee adequate pain relief.
The World Health Organization (WHO) essential medicines list, that presents a minimal formulary for a basic health care system, lists the most efficacious, safe and cost-effective medicines for priority conditions, including pain. It cites morphine (immediate release, controlled release, and injectable) as the only strong opioid analgesic recommended for palliative care.
In 2011 the United Nations political declaration on prevention and control of non-communicable diseases called to promote the use of affordable pharmaceuticals for palliative care.
The last few years were marked by a global call for wide access to immediate-release oral morphine as the safe, effective and cheap first-line treatment for severe pain.
In 2011 the UN announced a failure of the war on drugs, and in the same year WHO published its revised guidelines for governments on achieving balance in national policy on controlled substances – with a call for countries to assess their legislation and policy to reveal barriers to adequate pain management and implement change.
Despite the globally acknowledged need for countries to ensure availability of pain management, Russia continues to show low levels of opioid consumption and a high burden of unrelieved pain. There are huge numbers of people today suffering pain from a variety of conditions with only few of them having access to slight quantities of opioids, if at all.
The range of obstacles to adequate pain control includes political barriers, restrictive drug laws, inconsistent training of physicians and nurses, and the absence of governance and coordination. Several issues around availability of controlled medicines and pain management in Russia can be distinguished and the authors suggest the following actions to address the situation:
- The establishment of a single government body responsible for ensuring availability of controlled drugs (such as opioids etc.) for medical use (including pain treatment) with the authority to initiate and coordinate cross-agency collaboration
- A critical examination of overly cumbersome regulations and restrictions for opioid use. Currently only selected specialties can prescribe, and licensing is made unreasonably difficult for pharmacies
- Immediate-release oral morphine should be made available. Russia purchases and manufactures expensive sustained-release opioids, like fentanyl and MST Continus, and currently does not provide the cheaper and universally recommended immediate-release oral morphine
- Training in palliative care and pain management should be provided. Physicians’ attitudes towards opioids are archaic, with fear of respiratory depression and hastening death, as well as fear of addiction. There is also the danger of legal persecution in case of mistakes germane to nosocomial complications or illegal abuses of these drugs. This results often in total avoidance of strong opioids.
Physicians should be educated in the use of opioids. It seems that evidence-based palliative care in Russia has not yet found due recognition, the required governmental support, or benefited from appropriate development. Patient access to appropriate pain control is strongly restricted due to reasons that are not unique and have been described and dealt with in many other countries.
The authors hope that this article will lead to productive collaboration and improved patient care in the interest of human rights and public health.