Despite significant changes and removal of obstacles to access to opioid analgesics, palliative care in Kyrgyzstan is still at an improper level. Experts specify a range of issues in this sphere, including low level of knowledge among medical workers and lack of medications within reach.
Palliative care is improvement of life quality of terminal patients and their family members. Its main tasks are to relieve pain and other bothersome symptoms, quality care, as well as social, psychological and spiritual support of a patient and their relatives.
There is no precise number of people in need of palliative care in Kyrgyzstan. According to Nurgul Ibraeva, chief of office for organisation of medical care and medicines policy, there are over 25 thousand people having cancer registered in the republic.
There are no government-run hospices delivering palliative care in the republic, while the number of hospice beds in in-patient hospitals is limited. There are several private hospices, including the first children’s hospice, but it does not seem to be enough. Therefore, patients having the most severe pain syndrome and needing palliative care stay at home, generally.
The only way to relieve the pronounced pain is to take opioid medications. Such medications are classified as a group of controlled pain relievers. To prevent their illegal trafficking, the country has special regulations and acts. Unfortunately, some requirements in those acts have become obstacles to the access to pain relief.
(Un)availability of medications
According to the Compulsory Medical Insurance Fund (FOMS), patients having cancer in terminal stage may buy morphine at a 90 per cent discount. Citizens with other chronic diseases that need painkillers have a right to 50 per cent discount.
“In the second case, patients should be registered with a policlinic. If they are not, the medication will be sold at full price,” said Svetlana Baitikova, press secretary of FOMS.
The average cost of 20 morphine tablets in pharmacies of Kyrgyzstan is nearly 900 som (10.08 dollars). It is much cheaper with a discount. However, a range of public organisations carried out a large-scale research in 2018 and found out that it was not easy to find any morphine in pharmacies.
Candidate of pharmaceutical sciences, Milana Turgunalieva, who took part in the research, said that nearly 300 pharmacies obtained licenses to sell narcotic analgesics in Kyrgyzstan. However, only 39 of them had the medications in stock.
The same situation, according to her, has developed because of fear of law and morphine phobia.
“In other words, doctors do not prescribe morphine or other analgesics because of fear and unwillingness to be held responsible. Respectively, there is no demand in pharmacies. In turn, pharmaceutical companies stopped buying them,” the pharmacist said.
Coordinator of public foundation ‘Ergene’, Tynara Kasymalieva, said that the annual demand of Kyrgyzstan for morphine for patients with cancer, according to calculations, is nearly 16 kilograms.
“Moreover, the quota approved by the International Narcotics Control Board is five kilograms, while the country imports only 1.5 kilograms,” Kasymalieva said. “It is because there is no demand and medical practitioners do not prescribe morphine.”
During the research, the experts carried out an entire patient routing from home to a pharmacy in one of the districts of Naryn region. According to Milana Turgunalieva, the results were deplorable. For example, patients’ relatives have to visit the nearest big town because of the lack of necessary pharmacies and hospitals in district centres, and it takes them two hours only to get there.
“In the family practice centre, they need to have four stamps and two signatures, including of the head of centre, on the prescription. They need to wait in a queue and visit three or four offices, And they will be lucky if the head of the family practice centre or another required specialist is available. Otherwise, they have to wait for a few hours,” Turgunalieva said.
She noted that recently a prescription was valid for five days only, and sometimes patients did not have time to get to a pharmacy and were left with nothing.
In 2021, a task force developed a new draft decree, which meant to amend the procedure of dispensing of morphine and other analgesics. They proposed to prolong the validity of prescriptions up to 14 days, eliminate the need to return empty ampules, to have an official stamp and signature of the head on the prescription. There were also some clauses, which provided for compulsory pain relief of a patient in need of palliative care during the period when the patient is being discharged from the hospital, and being registered, etc.
At the end of October 2023, the decree was finally approved. However, it does not mean that everything will work as it should.
“We need to continue to improve our laws and regulations in terms of calculation of demand for analgesics and pharmacy service range,” she said. “Besides, not all medical workers can properly read and understand decrees. Therefore, we need to keep on training them, teach them to prescribe morphine, relieve from pain, and generally to understand what the palliative care is.”
No doctors, no knowledge
According to experts, a low level of knowledge among doctors is one of the biggest problems in palliative care. Tynara Kasymalieva, coordinator of public foundation ‘Ergene’, cited a case that happened in Dzhalal-Abad region, when parents wanted to get their 8-year-child with cancer to a children’s hospice in Bishkek, and a local medical practitioner prescribed morphine to him only for one day.
“To provide the necessary amount of morphine to the child, we had to provide summaries from laws to the administration and medical practitioners on how to write out prescriptions, how many ampules are acceptable, etc.” Kasymalieva said. “It is nonsense that local practitioners were not aware of such moments. It took a whole day to discuss this issue and to resolve it positively, while the child with cancer was left without mother’s care almost from 8 am to 6 pm.”
According to Maral Turdumatova, doctor of the First Children’s Hospice, sometimes medical workers make mistakes in prescriptions.
According to experts, low level of knowledge is accompanied by morphinophobia both in medical workers and in receivers of palliative care. Taking the medications as narcotics can result in the refusal to take them and the need to tolerate extreme pain. Meanwhile, physicians are afraid of prescribing narcotic analgesics because they understand it is a great responsibility and it is fully on them.
Gulmira Abdyrazakova, head of the Association of Patients of Kyrgyzstan and foundation ‘Together against cancer’, said that the society still has an opinion that if a patient takes morphine, he/she or their relatives can become drug addicts.
“They do not understand that this medication does not have a substance that develops addiction or habituation. Morphine only relieves pain. If you relieve pain of the patient, he/she will sleep and eat well. Thus, it improves the quality of their last days,” Abdyrazakova said.
Another systemic problem of the palliative care in Kyrgyzstan is the shortage of staff in this area. Medical universities of the republic do not train physicians and nurses that specialise only in palliative care. The only solution, according to Tynara Kasymalieva, was and is constant training of practicing general practitioners and specialists. However, there is no constant training but single projects funded by donor organisations, she said.
But according to the ministry of health, training of medical workers in palliative care is gradually introduced since 2016. According to Nurgul Ibraeva, chief of office for organisation of medical care and medicines policy, few hours of training in this subject are provided at a postgraduate level by the Institute for Retraining and Advanced Training. There are also courses at an undergraduate level at the Kyrgyz State Medical Academy.
“We started talking about palliative care only in 2015. The need for training of specialists emerged back then,” Ibraeva said.
She also said that in the beginning students were trained to provide care to cancer patients only, and now the program is expanded and new methods of provision of palliative care to all patients in need are introduced.
Resolving the problem
Experts are optimistic about the draft law “On protection of health of citizens of the Kyrgyz Republic” in terms of improvement of palliative care situation. The draft law is pending presidential signing.
According to Gulmira Abdyrazakova, head of the Association of Patients of Kyrgyzstan and foundation ‘Together against cancer’, the law now has a special article ‘Palliative care’, which was not there before. Thus, now palliative patients will mean not only people with cancer but also all other patients in need.
“Generally, we, the patient community and non-governmental organisations, are now regulating the issue of palliative care. The ministry of health does not have a department in charge of this issue. After the adoption of the law, we will demand that the ministry of health appoint persons responsible for morphine, pain relief and the rest,” Abdyrazakova said.
Also, according to her, every hospital is expected to have beds for palliative patients and multi-mobile teams that will visit patients at home, provide consultations, adjust the necessary dose of morphine, and help resolve other ongoing issues.
Moreover, it is planned that adoption of the new law will contribute to centralised procurement of morphine for outpatient relief of pain for the first time in many years. It is expected that access to pain relievers will be improved in every family practice centre, and the medication will be available in good supply in every pharmacy.
Main photo: Olga Kononenko on Unsplash