A spate of suicides by terminally ill cancer patients in Russia has sparked a change in the law governing access to pain-killers like morphine, but as Fiona Clark reports, the new law is no better than its predecessor.
Apparently I'm breaking the law if I tell you this: This year in Russia there have been more than 40 suicides by cancer patients. The reason I'm not allowed to report this is because it will cause other cancer patients to follow suit - at least that's the government's justification for telling Russia's media to stop reporting on it. It's not the view of Nuta Federmesser, the president of "Vera," a charity that raises money for in-home and hospice care for terminally ill cancer patients.
Federmesser says copy-cat suicides are not a reality in this case. Instead she says, there are some very simple reasons why these people decided to leave this mortal coil. They are often isolated and lonely, or they feel like a burden on their families or friends, but paramount among them is that they are in pain - excruciating pain that they can no longer endure because they cannot get the medications they need to make their final months, weeks or days bearable.
Moscow's deputy mayor for social issues, Leonid Pechatnikov, isn't quite so sympathetic. He is said to have attributed the recent spate of suicides - 11 of which occurred in February to Seasonal Affective Disorder or SAD. "The fact that this eruption of suicides happens at this time, against the background of an early turbulent spring, is not surprising. People don't want to torture themselves or their relatives," he said. "This is their version of euthanasia."
Among those who have killed themselves in the past year are four high profile military officers, one of whom left a note saying he blamed the state's health services while another said he was "tired of living in agony."
Call it what you will, Russia's draconian laws do make cancer patients feel like a burden to their family and friends and leaves them in unnecessary pain. In order to get a script for an opiate-based pain-killer like morphine the Federal Drug Control Service (FSKN) makes terminally ill patients or their supporters, and their doctors, literally jump through a series of needless bureaucratic hoops.
Firstly the patient or their representative has to go to a clinic or hospital and wait in a long queue to see an oncologist who will write a note saying he or she agrees that pain relief is required. That note needs to be signed by the head of the department.
The patient or representative, if he or she has been lucky enough to get to see the doctor that day, will then take that note to their GP who will write a script that they can then take to a specified pharmacy in order to secure a few days' supply of single dose ampules - that is of course if the pharmacy has them in stock. If they don't, well, bad luck, you can't take the script anywhere else and it's only valid for a five days which means if the pharmacy is out of stock or the person is too weak to go out for a few days the script may run out. As the script only allows for a few days' supply, the process has to be repeated over and over again and the medication won't be dispensed unless the old packaging is produced.
Doctors scared to prescribe
For the doctors, the amount of paper work is suffocating but it pales in comparison to the fear they feel with each script they write. In many cases they refuse to prescribe opiates because they are scared of being investigated by the FSKN and charged with drug trafficking, as recently happened to a 73-year-old doctor who prescribed for a patient who wasn't in her direct care. She and the friend who bought the drugs for the patient who was too weak to go to the clinic were charged and sentenced to six years in jail but were later acquitted.
As a result of these combined factors, the doctor in charge of palliative care in Russia, Diana Nevzorova, says that only 40 percent of terminally ill cancer patients in Moscow receive the medications they need and that figure drops to below 10 percent in regional Russia.
According to Human Rights Watch (HRW), which ranks countries in categories ranging from 'good availability' to 'severe shortages,' Russia is in the second lowest group of 'very limited availability' with more than 191,000 people with cancer or HIV not receiving the pain medications they needed in 2011.
As of July 1 the law is to be eased so that only one corroborative signature will be required, the script will be valid for 15 days and there will be no need to return the old packaging. While that's a tiny step in the right direction, its critics say it doesn't go nearly far enough.
Professor Vasily Vlassov, president of the Society of Evidence Based Medicine, says the law is not "direct" which means that each region will have to enact it and that will take time, but his biggest criticism is that it still regards doctors as potential drug traffickers.
"Russia is the country where all citizens are considered criminals," he says. "If they aren't in prison the police and FSB [successor of the KGB] aren't working hard enough." Initially it was the KGB that looked after narcotic control but the FSKN took over that role in the early 2003. Its director is a former KGB general and he's stuck to the KGB's playbook of monitoring and charging doctors and patients alike, he says. In the case of the 73-year-old doctor, Vlassov claims 10 investigators worked for four years to bring the charges against her, and he adds they relentlessly comb hospital, patient and dispensary records looking for discrepancies for future cases.
There is no doubt that misuse of opiate based medication occurs and laws are required to ensure that it's kept to a minimum, but statistics show that globally the vast majority of illicit drug use comes from what's crossed the border from Afghanistan and other heroin-producing countries, not from an illegally used prescription pad.
And the result of this 'sledgehammer to crush a nut' approach is that this new law, as Vlassov says, still contravenes World Health Organization (WHO) guidelines on pain management and goes virtually nowhere in redressing the inhumanity of the old one.
Why aren't these people in hospital, or even better at home, getting the care they need? Because palliative care is in its infancy in Russia and pain management isn't even on the radar of the health authorities.
The focus instead is misdirected toward potential criminal abuse and makes these sick, dying and vulnerable patients collateral damage in Russia's war on drugs.