A Win for Palliative Care in Ukraine
By Victoria Tymoshevska & Kseniya Shapoval-Deinega
This past May, terminally ill patients and their families in Ukraine received a long awaited piece of good news. After decades of restrictive drug policies severely limiting access to opioids for pain relief, the Cabinet of Ministers finally lifted burdensome prescription procedures. Decree #333 is a lesson in how doctors, patients, families, and advocacy organizations can work together to improve end-of-life care.
The idea of drug control has driven drug policies in Ukraine since Soviet times. Authorities focused on illicit drug use, paying little or no attention to access to opioids like morphine for pain and symptom control. With each new piece of legislation, the doctors and patients faced more and more restrictions and requirements making pain control and management next to impossible in the country.
Doctors were only allowed to prescribe patients 50 milligrams of morphine per day—an arbitrary amount with no basis in medical evidence. In fact, in countries where access to pain relief is a reality, a typical patient with late-stage cancer might get 2,000 mg or more of morphine per day, whatever is needed to manage his or her pain symptoms.
To address these unnecessary restrictions, in mid-2010 the Open Society Foundations launched a joint campaign aimed at reviewing the Ukrainian legislative and regulatory barriers that limit the supply of opioids in health facilities and pharmacies. The review found that in order to prescribe morphine to a terminally ill cancer patient, a physician would need a panel of three additional doctors to confirm this recommendation. Any change in dosage or administration needed to be verified by the same panel.
Burdensome regulations also surrounded the process for destroying empty morphine vials. Once again, a commission of officials including police officers had to verify that every single vial was destroyed.
In effect, these requirements prevented many terminally ill patients from receiving any pain relief. Patients were told that it was too early to start morphine or that by starting morphine they were risking addiction. Doctors resorted to relying on weak analgesics to treat chronic pain. As a result, many terminally ill patients in Ukraine lived with uncontrolled severe pain.
Despite these hurdles, we were determined to find a solution that could bring about change quickly and prevent patients from experiencing inhumane and degrading treatment. It didn’t take long to find progressive and open-minded people in the opposition. The Ministry of Interior and State Service for Drug Control were attentive to our concerns and soon joined a working group to review and develop changes to existing legislation. The working group soon decided that rather than changing old documents it would be more strategic to push for a new policy that would override the old policies and establish new, more progressive norms.
This work was backed up by two reports: a 2010 publication from the International Narcotics Control Board called Availability of Internationally Controlled Drugs: Ensuring Adequate Access for Medical and Scientific Purpose, which highlighted the disproportionately small use of opioids for medical purposes in Ukraine, and the World Health Organization’s Ensuring Balance in National Policies on Controlled Substances, which called upon governments to ensure balance between control and access measures the group started its work. These publications informed the draft legislation, but it still took more than two years of intensive advocacy at different levels to push the Ministries and other state bodies to agree to these fundamental regulation changes.
During this time advocacy efforts continued, including the Human Rights Watch report Uncontrolled Pain, which sparked national and international media. We launched the short film 50 Milligrams Is Not Enough, featuring a 27-year-old cancer patient in terrible pain whose mother went to extremes in order to get pain relief for her bed-ridden son. This work culiminated in the All-Ukrainian League for Palliative Care continualy writing governement officials to change the law.
Finally, on May 13, 2013, the Cabinet of Ministers passed Decree #333, lifting burdensome procedures for prescribing and accessing opioids. Now:
- individual physicians can prescibe opioids to patients without panel review;
- empty vials can be destroyed without commission oversight;
- per the discretion of chief doctors, facilities can stock up to one month’s worth of drugs;
- physicians must ensure that patient receives adequate supply of opioid medications through a prescription that can be filled in local or hospital pharmacies;
- patients and/or family members can pick up their medication directly from healthcare facilities and store at home.
This huge change came on the heels of another recent win where the government signed MOH Order #77, allowing use of oral morphine in Ukraine.
Of course, this new legislation is not perfect, especially for Ukrainians living in rural areas. In a country that is home to almost 2.4 million people there are only four pharmacies certified to carry controlled medications like morphine. Health care providers also need education on how to prescribe morphine and other controlled medications, in addition to education for pharmacists about filling such prescriptions. Finally, there is still much work to be done in order to dispell myths about opioid use among patients and families. But at least for now, the realization of true palliative care has made great strides in Ukraine.
Victoria Tymoshevska is director of the International Renaissance Foundation’s Public Health Program.
Kseniya Shapoval-Deinega is coordinator of the International Palliative Care Initiative.