Progress and struggle for palliative care in Armenia

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Cancer mortality is rising in Armenia. The country now has the dubious distinction of having the world’s highest cancer mortality rate among males (210 per 100,000). At the same time, morphine consumption has declined and is down 60% since 2006. In 2014, morphine consumption was 0.3333 mg per capita while the global average is 6.24 mg.

The Ministry of Health have not acted on their promises to approve the National Strategy for Palliative Care and the decree changing restrictive rules for prescribing controlled substances.

Promising developments

In spite of this, there have been some promising developments. The key national strategy for palliative care implementation has now been reviewed and accepted without objection by all the key ministries including justice and finance. Once the Ministry of Health has finalised the strategy, further actions can begin to occur including approval for importation of oral morphine.

Though there were no official actions in recent months toward registering oral morphine, there were productive discussions to get the process moving. The next steps will be to include liquid morphine in the national pain protocol and arrange for refresher training for the oncologists and other polyclinic physicians.

Palliative care training clinic

Dr Connor met with faculty at Yerevan State Medical University (YSMU) to discuss development of palliative care training for physicians at the university. The faculty needed approval to open a small unit and palliative care department at YSMU for teaching purposes. Dr Connor wrote to the rector and vice rector urging them to approve a site for palliative care at their Hospital.

By the September visit, Yerevan State Medical University had dedicated a space for palliative care at the University hospital. The space will be enough for eight beds, as well as offices for the palliative care team. The first group of medical residents to be trained would start next semester (February 2017).

Yerevan State University – Psychology Department

The semester course in palliative care for the psychology department at YSMU was launced in September. There were 32 students signed up for the elective course, but over 50 came for the first lectures. Dr Connor gave two lectures to the students, one on psychosocial concerns in palliative care and one on grief, loss, and bereavement. Based on the success of the course, it may be included as a required course for all students in the master’s psychology program.

Children’s Palliative Care (CPC)

A coalition of pediatric groups has been working on the assessment of need for children’s palliative care in the country. Working with Sergey Sargsyan, MD, PhD, Head of the Institute of Child and Adolescent Health, Dr Connor provided the group with technical assistance.

The needs assessment report was finalised and presented at a round table on 6 April in Yerevan. Over 100 stakeholders attended, including a deputy Minister of Health and the Minister for Social Affairs.

Key further steps for children’s palliative care in the country will be to develop plans for providing training for the institutions that currently care for children and to develop faculty with competence to teach on an ongoing basis. Standards for the provision of children’s palliative care in the existing institutions, and establishmentof home-based care will be needed.

Plans are underway to implement a train the trainer programme in Yerevan. Dr Anna Garchakova from Belarus has agreed to come to Armenia as the course leader and several local leaders will assist as faculty. Only about 15 trainees will be carefully selected to attend the course and will need to demonstrate commitment to teaching professionals at their hospitals and facilities. The course will most likely be held for four days early next year.

National Oncology Center (NOC)

There is a 10 bed palliative care inpatient facility at the NOC. Patients can come for day use of inpatient palliative care. Currently the NOC serves mostly a population of non-citizens with support from the Armenian refugee program. Dr Karapetyan, the Centre Director is able to use methadone for inpatients for pain control. 

However, once the patient has been discharged, they cannot receive methadone and would have to go back to tramadol or morphine injections. The methadone controls the pain effectively, particularly for patients with neuropathic pain, however the patients need to be able to continue on methadone as outpatient. Dr Connor wrote a humanitarian request to Global Fund in Vienna to allow that these medicines be available for cancer pain treatment.

Dr Connor said: “While much progress has been made in palliative care development in Armenia there is so much more work to do. Since the release of the Human Rights Watch report: ‘All I can do is cry: Cancer and the struggle for palliative care in Armenia’ little progress has been made and oral morphine is still not available. The government must honour its commitments to including palliative care in the health care system and prioritise care for the sickest patients!”

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