Russia is leaving cancer patients to die in pain


10:01 pm - June 13th 2013

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by Steve Hynd

In Russia cancer patients are left to suffer and ultimately die in pain with inadequate access to basic pain control drugs such as morphine. When one doctor defied the state’s overly restrictive laws, she was arrested. It is time for the healthcare community to speak out.

Dr. Khorinyak allegedly wrote out two prescriptions for the pain relief medication tramadol. The prescriptions were for Victor Sechin, a terminally-ill cancer patient. In the eyes of the Russian state, the medical practitioner of more than 50 years broke the law.

In 2011, it is thought that the Russian Federal Drug Control Service discovered the prescriptions at the local pharmacy, and referred the case to the prosecutor and the court. Dr. Khorinyak was then charged under:

Article 234 of the Criminal Code: Trafficking potent substances in large quantities by prior agreement with the intent to sell, an organized group
Article 327 of the Criminal Code, Forgery of documents in order to facilitate the commission of another crime.

The editor of the international edition of ehospice, Kate Jackson, wrote in her defence, saying:

Dr Khorinyak performed her professional duty and acted with compassion towards a patient in pain. If it is outside of the laws of a country for a doctor to treat a patient to the best of their ability, then there is a need for a serious and urgent re-examination of those laws.

Indeed, Russia’s overly restrictive laws regulating access to morphine have been the focus of on-going criticism for a number of years.

In its 2012 annual report, Human Rights Watch commented on Russia’s health policy saying:

Although over 300,000 Russians die of cancer each year, with many facing severe pain, available palliative care services remained limited. As a result, hundreds of thousands of patients die in avoidable agony each year. In much of the country, the government does not make oral morphine available through the public healthcare system, or adequately train healthcare workers on modern pain treatment methods. Existing drug regulations are excessively restrictive and limit appropriate morphine use for pain relief.

In Russia though, 450,000 people are diagnosed with cancer every year resulting in more than 2.5 million people suffering from the disease. Russia not only has a clear moral obligation to support these patients but also a legal human rights responsibility as well – one that it is currently neglecting.

With the noble exception of ehospice and a handful of other professionals, few have spoken out. The Russian government is standing by while thousands needlessly suffer. When one person does speak out, she is prosecuted as a criminal.

It is time for health care professionals from around the world to stand up for Dr. Khorinyak and speak out, not only against her prosecution but also against Russia’s wider neglect of patients in need of pain relief.

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Reader comments


In the meantime England leaves patients to die of dehydration because no one has the time to give them a drink.

So Russia leaves its patients to die in pain. The NHS, run by a communist, leaves its patients to die in pain too. See the connection? Socialism. What a great success story.

3. So Much For Subtlety

1. Tris

In the meantime England leaves patients to die of dehydration because no one has the time to give them a drink.

Yeah but the NHS is the envy of the world innit?

Two small points:

1. I admire our Human Right industry when they have nothing more to complain about than two patients dying of cancer in Russia.

2. Britain is hardly generous with the morphine either.

Of course the second point is completely irrelevant and even if it wasn’t, it is minor. But it is worth keeping in mind. We would not want anyone coming to the UK and judging us by their standards. It would be too embarrassing. After all, most health systems do not regularly allow patients to die of thirst.

See the connection? Socialism.

Whereas no one has ever been left to die in pain in the United States. I…

Oh

Never mind.

5. So Much For Subtlety

4. BenSix

Whereas no one has ever been left to die in pain in the United States.

That is a dishonest representation of that article. It does not say what you claim it says. If nothing else, it does not even mention people dying in pain. It does not claim anyone is left to die either. It takes the higher risk people without insurance have of dying and makes a case for Obamacare from it. However it does not follow that they are right. What do they say:

Overall, researchers said American adults age 64 and younger who lack health insurance have a 40 percent higher risk of death than those who have coverage.

What sort of people do not have insurance in America? Well obviously, poor people. Working class people die earlier than middle class people anyway – with or without insurance, in the UK as well as in the US. Even in Cuba I am willing to bet. So how do we know this isn’t just a measure of class not of medical care?

Study co-author Dr. Steffie Woolhandler said the findings show that without proper care, uninsured people are more likely to die from complications associated with preventable diseases such as diabetes and heart disease.

Diabetes and heart disease – diseases of the working class. Especially the non-White working class. So we do not know this is a reflection on health care at all. It looks like a simple class and racial divide.

Big freakin’ deal.

SMFS

If nothing else, it does not even mention people dying in pain. It does not claim anyone is left to die either.

People who die for lack of healthcare, despite its availability, are being left to die. One can accept that – there are no political systems that will abolish needless deaths – but I’m not sure one can deny it. Inferring that many of them die in pain, meanwhile, seems almost as natural as inferring from birth rates that women are childbearing in pain. The sensation is commonly associated with the event.

Diabetes and heart disease – diseases of the working class. Especially the non-White working class…

True, but it controlled for gender, age, race/ethnicity, income, education, unemployment, smoking status et cetera.

I’m not trying to be the NHS’s white knight, by the way. It has problems that no amount of loving hashtags will obscure. It just seems rather superficial, and a bit smug, to say “people left to die in Russia + people left to die in England = socialism iz evil”.

7. So Much For Subtlety

6. BenSix

People who die for lack of healthcare, despite its availability, are being left to die.

No they are not. And again you are distorting what is happening in America. First, not doing something you are obligated to do is very different from not doing something you are not obligated to do. People are dying in Africa but they are not dying because you and me are not giving 99% of our income to saving them. We have no obligation of any consequence. The NHS does. Second, you are confusing the lack of health insurance with the lack of health care. The two are not the same. Anyone can get free medical care in the US in emergencies. They cannot get free medical insurance.

Inferring that many of them die in pain, meanwhile, seems almost as natural as inferring from birth rates that women are childbearing in pain. The sensation is commonly associated with the event.

Heart attacks and diabetes are associated with very short bursts of pain as you die, but not a great deal of long term day-to-day pain. So it is not reasonable to infer that. What is more you are again confusing a lack of health insurance with a lack of health care. You cannot do that in the US where emergency health care, of the sort you might need if you were dying, is free.

True, but it controlled for gender, age, race/ethnicity, income, education, unemployment, smoking status et cetera.

It certainly tried. However your big headline figure does seem to melt away when they do so. They use the weasel phrase “up to” so I assume they know this. I am dubious about the data. Have a look at Table 1. That shows that most Whites have insurance, a lot of Blacks do not, a hell of a lot of Mexican Americans do not, and a sizeable percentage of “others” do not. But notice Whites and Mexican Americans died at exactly the same rate. The figures are being skewed by the Black community with the “others” being even healthier. Go down to Table 2 and you see the important risk factors are being Black, drinking over six units a day, smoking and being unemployed. As it turns out the less insured Mexican Americans and “others” are even healthier than White Americans.

What this looks like is some other factor they have not been able to factor out – assuming they want to. So let me suggest one: gross dysfunction. Dyspraxia if you like. The inability to be organised or get your life together. Which is more likely to be found among alcoholics, the long term unemployed, smokers and so on. Which means that people do not take their meds among other things. They do not stick to diets. And they do not take care of their hearts. This is entirely convincing as an explanation and it would follow a lack of medical insurance.

It just seems rather superficial, and a bit smug, to say “people left to die in Russia + people left to die in England = socialism iz evil”.

I agree. And yet socialised medicine is a de facto monopoly. As with any monopoly it will be captured by special interest groups, usually the workers as with the NHS. And run for their benefit. With no prevailing counterpower such as an impartial government to mediate disputes between patients and medical providers, the abuses in the system will only grow and grow and so inevitably socialised medicine leads to people left to die. It is inevitable. It is just a matter of how fast the moral consciences of the medical providers erode.

I was under the impression that Russia was a neo-liberal capitalist nation since the 90’s. So why is it socialism’s fault?

SMFS

1. To deny people medical testing and treatment, when it is in fact available, is to leave many of them to die. Your argument, that the NHS is formally obliged to provide it while U.S. health care providers aren’t, holds that these cases are not ethical equals. One can agree with both these points. Leaving people to die can be more or less condemnable.

2. As far as I’m aware, heart disease and diabetes can be painful as well as frightening, tiring, frustrating et cetera. It is true that their lethal manifestations are associated with short bursts of pain, but this rather implies that the emergency health care you speak of will arrive too late for many people. Many people who might have avoided or, at least, been able to prepare for such events had they been able to afford tests, drugs and treatment.

3. An interesting point about the Mexican and “other” participants. One thing I will say, however: the Mexicans and the “others” are far likelier to be first generation migrants and, thus, young. An older dude with health insurance is still liable to be on shakier grounds than younger dudes without it.

4. A very legitimate concern. All that I can say is that this applies to the the armed forces and criminal justice system but most people would agree that both are necessary. With socialised healthcare I suppose it comes down to one’s perception of the consequences of going without it, and of the possibility of holding it to account. I quite agree that its advocates have been too relaxed about the latter requirement.

I’ll leave it there, if you don’t mind. Always stimulating.

10. So Much For Subtlety

9. BenSix

1. To deny people medical testing and treatment, when it is in fact available, is to leave many of them to die.

People in America are not denied free testing and treatment. They are denied free health insurance. Not the same thing.

Your argument, that the NHS is formally obliged to provide it while U.S. health care providers aren’t, holds that these cases are not ethical equals. One can agree with both these points. Leaving people to die can be more or less condemnable.

Actually US health providers are obliged to provide free care. They do not, though, leave people to die of thirst all that often, once they are actually in their care. The NHS has a whole different level of obligation to weak and incapacitated people once they are in a ward and drugged up. They do not routinely deny people treatments in the US.

but this rather implies that the emergency health care you speak of will arrive too late for many people. Many people who might have avoided or, at least, been able to prepare for such events had they been able to afford tests, drugs and treatment.

I don’t think many people are fooled by the symptoms of heart disease. Being fat is a little obvious. And again, if they have symptoms, they get free health care. But it is true that for many people it arrives too late – in the UK as well as the US.

3. An interesting point about the Mexican and “other” participants. One thing I will say, however: the Mexicans and the “others” are far likelier to be first generation migrants and, thus, young. An older dude with health insurance is still liable to be on shakier grounds than younger dudes without it.

That is probably true for Mexicans. But then didn’t they control for age? They still seem to have come out with Mexicans being healthier. But it goes to prove the point that there are a lot of more important things than just insurance.

4. A very legitimate concern. All that I can say is that this applies to the the armed forces and criminal justice system but most people would agree that both are necessary.

As we see with Deepcut it is not a trivial problem. And Russia’s problem is spectacular. However soldiers who depend on each other in battle have an incentive not to behave this way. That does not apply to the health care system.

11. the a&e charge nurse

Lets hope the british medical establishment address some of the rottenness found in our system – not that pro-market elements in the major parties are listening to them.

Ex-labour health ministers heading up a private firm looking to cash in the privatisation by stealth of the NHS – it must bring a lump to Tony’s throat?
http://www.pmlive.com/appointments/healthcare/2013/june/former_uk_health_secretary_joins_bupa_board

12. Churm Rincewind

There’s no doubt that in Russia and Eastern Europe generally the availability of opioids is often restricted, not only by straightforward problems of supply and distribution, but also by inappropriate regulation based on legitimate concerns about potential abuse of this powerful family of drugs. As result, in these parts of the world many cancer patients die in considerable and needless pain.

This is a widely noted problem – see for example, relevant reporting from the International Observatory on End of Life Care, the International Narcotics Control Board, the World Health Organisation, the Council of Europe, the Open Society Institute Palliative Care Iniative, and so on. JGI.

The difficulty is that much of this regulation is based on a model of criminalisation in order to prevent inappropriate and illegal use, rather than deriving from a public health perspective of condign measures to mitigate and relieve pain in the terminally ill.

There are solutions, but they are incremental, gradualist and wide-ranging. Drug abuse is a major problem worldwide and opioid availability does have to be regulated. It’s all a question of balance, logistics, and degree.

In the meantime, I can’t see how anyone can take issue with the main thrust of this OP.

13. Churm Rincewind

Oh, and just to dispose of a couple of other points:

@ Tris (1): “England leaves patients to die of dehydration because no one has the time to give them a drink” – the latter part of that sentence is untrue.

@ SFMS (3): “Britain is hardly generous with the morphine either” – again, untrue. Rather the reverse, in fact. Indeed, the UK’s regulations and procedures for non-physician opioid prescribing remain contentious among many medical authorities.

14. So Much For Subtlety

12. Churm Rincewind

There’s no doubt that in Russia and Eastern Europe generally the availability of opioids is often restricted, not only by straightforward problems of supply and distribution, but also by inappropriate regulation based on legitimate concerns about potential abuse of this powerful family of drugs.

Given the simple nature of morphine it is rather impressive that the Russians have managed to produce a shortage. Opium grows almost anywhere, morphine is cheap and easy to produce. However I object to the claim that there is a legitimate fear of opiate abuse in hospitals. There isn’t. Apart from drug-seeking behaviour of users and doctors who are prone to use, medicinal use of opiates appears to be a non-problem as far as abuse goes. It would be hard to find a single regular illegal user who started out with a medical use.

In the meantime, I can’t see how anyone can take issue with the main thrust of this OP.

Although it remains an oddity here as it is hard to blame British people for this shortage and so I doubt it appeals to many readers.

Churm Rincewind

@ Tris (1): “England leaves patients to die of dehydration because no one has the time to give them a drink” – the latter part of that sentence is untrue.

Sure. They are incompetent and indifferent, not over worked.

@ SFMS (3): “Britain is hardly generous with the morphine either” – again, untrue. Rather the reverse, in fact. Indeed, the UK’s regulations and procedures for non-physician opioid prescribing remain contentious among many medical authorities

Actually that is true. Palliative care has got much better, but it is a trivial task to find cancer patients for instance who are denied adequate pain relief.

15. Churm Rincewind

@ SFMS (14)

“Given the simple nature of morphine it is rather impressive that the Russians have managed to produce a shortage. Opium grows almost anywhere, morphine is cheap and easy to produce.”

I didn’t say that there was an actual shortage of morphine in Russia. As you rightly point out, this is not the case. I said there were problems with supply and distribution, and for evidence I’m content to rely on the reports I noted.

“However I object to the claim that there is a legitimate fear of opiate abuse in hospitals. There isn’t. Apart from drug-seeking behaviour of users and doctors who are prone to use, medicinal use of opiates appears to be a non-problem as far as abuse goes. It would be hard to find a single regular illegal user who started out with a medical use.”

I completely agree that this fear is misplaced. However, this doesn’t mean to say that such a fear doesn’t exist, or that concerns about the availability of such powerful drugs aren’t perfectly legitimate.

“…it is hard to blame British people for this shortage and so I doubt it appeals to many readers…”

Again I agree. But that doesn’t mean the issue is not worth noting.

“@ Tris (1): “England leaves patients to die of dehydration because no one has the time to give them a drink” – the latter part of that sentence is untrue.

Sure. They are incompetent and indifferent, not over worked.”

Oo-er. Care to cite any evidence for that rather sweeping statement?

16. the a&e charge nurse

[14] ‘They are incompetent and indifferent’ – ahh, the bad apple hypothesis, eh?

Watch and learn
http://www.ted.com/talks/philip_zimbardo_on_the_psychology_of_evil.html


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