Killing pain

Why Russian doctors are reluctant to prescribe pain relievers. 13 criminal cases

A doctor who professionally works with psychoactive drugs or narcotics immediately gets noticed by Russia's Federal Drug Control Services. Any reckless actions with regard to painkiller use can end up in court. The most famous case of the past few years is the case of Alevtina Khorinyak, a 73-year-old district doctor from Krasnoyarsk with a lot of work experience. In 2009, Khorinyak prescribed Tramadol to a patient who was not officially registered in her district. In 2010, Federal Drug Control Services came to see her, and in 2012, a prosecutor asked for a 15-year prison sentence and a 15,000 ruble ($289) fine for the doctor.

In 2014, under pressure from journalists and medical professionals, the 73-year-old Khorinyak was acquitted. However, other doctors who break the numerous rules Russian has in place for prescribing painkillers are caught and put on trial without much media coverage or protest. Together with a “Working group on painkillers,” the journalist Katerina Gordeeva selected 13 cases out of hundreds and recounted their stories for Meduza.

During December 2014, 11 cancer patients in Moscow alone committed suicide. In March, a cardiologist and professor took his life after failing to get painkillers during his fight with cancer. Ever since the first and most famous “cancer suicide” of rear admiral Vyatcheslav Apanasenko, officials have been refusing to acknowledge the link between these deaths with the lack of available painkillers, or with any problems with Russian healthcare at all.

Additionally, it is now against the law for Russian media to describe how and why someone has committed suicide. The Federal Service of Consumer Rights and Health Protection lobbied for this law, and media outlets which disclose reasons behind a suicide face warnings from government agencies. Evidently, the descriptions of cancer patients who decide to take their own lives tarnish the reputation of healthcare providers in Russia, which is undesirable in a situation when they have received significant government funds to “create a positive image of Russian healthcare.”

It is also clear that there are two sides to “the problem of painkillers”: the doctor side, and the patient side. It often happens that the patient cannot get access to medication which will help ease their suffering because doctors cannot or will not prescribe it.

The problems of patients will be largely solved by upcoming amendments to the federal law on “narcotics and psychoactive drugs.” The amendments were drafted with input from doctors, volunteers, and charity organizations, as well as members of the “Working group on painkillers,” founded by two Russian charities, Podari Zhizn’ (Gift of Life) and Vera (Faith). The law will come into effect on July 1, 2015 and will allow doctors to avoid extra bureaucracy and to write prescriptions for 15 days instead of just 5 days.

Unfortunately, this amendment will not solve the problems doctors in Russia are facing today. Any doctor who deals with narcotics and psychoactive drugs professionally will still be monitored by law enforcement and by the Federal Drug Control Services.

The following are just 13 recent cases, selected out of hundreds that are brought to courts across Russia every year.

Case Number 1

During her shift, one of the nurses at the septic surgery unit of a hospital in Smolensk region (west of Moscow) filled a syringe with Trimeperidine (an equivalent of Prodine) as instructed by the doctor, but without the doctor’s presence, as is required by the rules. Then, the nurse came to the room of the patient who was prescribed with the painkiller shot, but the patient refused to take it.

According to the rules, the nurse should have destroyed the syringe with the Trimeperidine in the presence of the doctor. She did not do this.

Instead, the nurse put the syringe with the Trimeperidine in her purse and carried it out of the hospital. In court, she confessed that she was taking the medicine to her neighbor who suffered from debilitating back pain, and that she had done this on several occasions before. Additionally, she said that sometimes patients at the hospital refuse to take prescribed psychoactive drugs, and that nurses then take these painkillers to other patients who did not receive enough medication to relieve them of their pain.

The nurse from Smolensk region confessed to “preparing illegal distribution of narcotic substances, i.e. the large-scale purposeful creation of conditions for the illegal distribution of narcotic substances, and failure to distribute due to extraneous circumstances.” The nurse was sentenced to a suspended sentence of six years and three months.

Case Number 2

A nurse in the Russian city of Kazan was accused of taking Trimeperidine from a special medical facility without the supervision of a doctor, albeit with his permission. The prosecution demanded that the doctor be charged as well. The doctor was also absent when the patient refused the medicine brought by the nurse, which created conditions for “violating the rules of using narcotic substances,” which brought about their disappearance and the creation of circumstances for their “illegal distribution.”

In court during a second trial, the defense succeeded in showing that during the “incident” (when the nurse picked up the medicine, and the patient refused to take it), the doctor had gotten an urgent call to see another patient, and he was thus unable to be with the nurse. The doctor was acquitted. Meduza was unable to determine the outcome of the trial for the nurse from open sources, but we can presume that her fate may resemble that of the nurse from Case Number 1.

Case Number 3

A father of two who works as a deputy chief of medicine at a hospital in Toguchinsk in Siberia was accused of violating the rules for storing, accounting for and using narcotic substances. The doctor was so busy that he failed to notify a department of the Federal Drug Control Services in Novosibirsk that the emergency services of the hospital had hired a new assistant. The doctor also failed to file a request with the authorities to find out whether the new employee has any debts, and whether the Federal Drug Control Services deem him fit to work in emergency services and to have access to psychoactive drugs and narcotics.

Meanwhile, between November 2010 and June 2011, the assistant stored, accounted for and used narcotic medications including Trimeperidine, morphine and fentanyl (while the doctor “took no action,” according to the case file). In court, the deputy chief of medicine pled guilty. He was acquitted.

Case Number 4

A friend asked a doctor in the city of Saratov to use his official forms and stamps to prescribe the drug Theophedrin-N to a patient who is not registered in his district. The doctor complied. He recorded false information on his other patients from his district in order to account for the medicine. In court, the doctor confessed, explaining he was driven by a feeling of empathy for the patient. The court sentenced him to 250 hours of community service and banned him for a period of 6 months from practicing any kind of medicine involving prescriptions.

Case Number 5

A court in Khimki, a town just north of Moscow, ruled to fine a nurse for pouring remnants of a psychoactive narcotic drug used on a patient for anesthesia down the drain instead of calling a doctor, recording the event, and destroying the remaining dose, it as is required by the rules. The fine amounted to 15,000 rubles ($289).

Case Number 6

A doctor in one of the hospitals in Vologda region kept an expired vial of Trimeperidine and two expired vials of ketamine in a safe in the doctor’s office. He also took 30 vials of morphine to a special facility for the destruction of the medication during the day in a car with no security, and without the required support staff. Other medications kept in the office safe were not secured according to the rules, which require a panic button and bars on the windows. The court ruled that the doctor was negligent and that he created circumstances under which “the distribution of psychoactive drugs and narcotics” was made possible. Due to the doctor’s “active repentance,” the case was eventually closed.

Case Number 7

A surgeon in Kazan asked a nurse to fill two syringes with Trimeperidine, but left the room before he could make sure the nurse carried out the injections because he was called to help another patient. According to the prosecution, the surgeon violated the rules. The investigation reported that the nurse made only one injection, and the second syringe was found in her bag as she was exiting the hospital. During court hearings, the doctor said he had asked the nurse to wait for him and was very surprised that she carried out the injection without his supervision, and then recorded that she had used both vials. Additionally, the surgeon managed to prove that the patient to whom he was suddenly called in the middle of the injection process indeed required immediate aid. The court fully acquitted the doctor, and what happened to the nurse remains unclear.

Case Number 8

According to the investigation, an emergency care assistant in the town Tchaikovsky in Perm region purposefully violated the rules for storing narcotics and psychoactive drugs, which caused the loss of narcotics. The assistant had picked up a set of medications from storage to take with her on an ambulance call, including one vial of Trimeperidine, one vial of morphine, and one vial of ketamine. She then handed the set over to another assistant, who was not authorized to access narcotic substances and psychoactive drugs. When the ambulance came back from the call, the set of medications was missing one vial with morphine.

On a separate occasion, the same assistant handed a medication set over to an ambulance assistant who was not authorized to access narcotic substances and psychoactive drugs. This set included two vials of relanium and two vials of clonidine. The vial with clonidine disappeared after the call.

The investigation maintains that the assistant purposefully violated regulations for storing and handling medications, which resulted in the disappearance of medications. The assistant pled guilty and was charged with 25,000 rubles ($480) in fines. She has also been banned for a one-year period from holding any positions in healthcare that require handling narcotics and psychoactive drugs.

Case Number 9

An assistant working at a local hospital in Krasnoyarsk region left his assistant’s medical bag without supervision in the hallway of the hospital. The bag contained one vial of Trimeperidine. The bag was stolen and the assistant was accused of “violating rules for storage of narcotic substances,” leading to their disappearance. In court, he pled guilty. The court took into account the financial situation of the assistant, and charged him with 6,000 rubles ($115) in fines with the possibility of paying them in monthly installments of 2,000 rubles ($38).

Case Number 10

An anesthesiologist from the city of Novosibirsk in Siberia was found guilty of losing three vials of fentanyl. While she was on duty in the anesthesiology and intensive care unit, the anesthesiologist took three fentanyl vials from the medical safe as she was preparing for anesthetizing a patient before a surgery. She put the vials into a nurse’s desk drawer and did not lock the drawer or the office. After this, a series of patient visits was due, and the anesthesiologist rushed from one room to another, bringing vials to surgery rooms and taking them back from the surgery rooms. At 6 AM, as she was wrapping up her shift, the anesthesiologist could not find the three fentanyl vials, and they were left unaccounted for.

The anesthesiologist pled guilty for violating storage regulations of narcotic substances and “actively repented.” The court closed the case.

Case Number 11

In the town of Belev in Russia’s Tula region, the head nurse of a central hospital received nine vials of remaining doses of Trimeperidine, one vial of fentanyl, and two vials of remnants of ketamine from another nurse. According to instructions, she was to destroy the remaining medications and write them off. Instead, she put the nine vials of Trimeperidine remnants in a cardboard box, wrapped the fentanyl and ketamine vials in some paper, and put them in the bottom drawer of a metal filing cabinet in her office. The vials leaked.

The main issue voiced by the investigation is that the nurse’s office “is not equipped with the technical means for securely storing psychoactive drugs, and thus no permission has been given by narcotics control agencies for handling the drugs in this facility.”

It was also revealed that the nurse usually drove the narcotic substances to their utilization facility not in a special vehicle with security staff, but rather in her personal car on her own. The court charged the nurse with 25,000 ($480) rubles in fines.

Case Number 12

A nurse anesthetist from the village of Lazarevskoe took out a packet of narcotic substances and put them on the floor of the medical storage room in a pre-surgery rush. Five Trimeperidine vials and nine fentanyl vials were left on the floor, and the nurse stepped on one of the vials, crushing it with his foot. The court took into account the fact that the nurse is the father to a young child and charged him 35,000 rubles ($672) in fines. He was also banned for a period of three years from taking up work which has to do with handling narcotic and psychoactive substances in federal and municipal facilities.

Case Number 13

An ambulance assistant from Samara picked up a medicine box containing heavy medication: three vials of clonidine, two vials of Diazepam (Valium), two vials of Tramadol, two vials of naloxone, and two vials of ketorolac. The assistant put the box not into the medical case, but rather into his own bag. He put his bag on the dashboard of the ambulance, and it disappeared when the assistant brought a patient in critical condition to the hospital. Thus, the medication was stolen. The court charged the assistant with 10,000 rubles ($192) in fines.

Ekaterina Chistyakova, director of the charity foundation Podari Zhizn’ (Gift of Life) and founder of the “Working group on painkillers.”

— After the wave of suicides shook the public, officials from the Health Ministry have been trying to do everything they can to give cancer patients access to medicine that will ease their pain. Amendments are being made to regulations in order to give doctors the right to prescribe narcotic pain relievers to patients who no longer respond to other painkillers. But doctors are not particularly keen on using their new rights right away. This is not surprising, given the large number of criminal cases which are initiated against doctors who have violated just one rule out of the many rules governing the handling of narcotic drugs.

And it doesn’t matter that the actions of a doctor who make a mistake or violate a rule out of empathy for a patient do not result in the substance making it to drug dealing market. Criminal proceedings in court await any doctor who misstored a narcotic substance, or drove a vial of morphine in his own car, or prescribed medication without full authorization. It doesn’t matter if the case is closed due to “active repentance” or if it ends in a fine, because criminal proceedings and court hearings are very stressful, take up a lot of time, cause fear and humiliation among medical professionals. The resulting fines are not only many times higher than the cost of the missing medicine, but they are also several times higher than the incomes of doctors and nurses. And the fines take a sizeable toll on the budget. Of course, medical professionals do everything they can in order to avoid all of this.

Medical narcotics make up less than 1 percent of the total narcotics in the illicit drug trade. The main cause of addictions today has nothing to do with medical aid. The problem of medical trading of narcotics lies elsewhere – namely, in the unnecessary criminalization of medical professionals’ activities.

It will be difficult to solve this problem. There must be at least some control over narcotics in the medical field, since there are some cases when medical professionals indeed have ties to the illegal narcotics trade. With the help of doctors and lawyers we will try to find a solution. One of the possibilities is to amend the Criminal Code. Another possibility is to find ways to improve law enforcement practices.

Katerina Gordeeva

St. Petersburg