Palliative Care Falls Short in Armenia

Doctors in Armenia are calling for radical changes to palliative care practices so as to give patients in chronic pain easier access to prescription opiates.

At present, morphine is only prescribed to cancer patients in liquid form used for injection, in a process tightly controlled by the police. Other painkillers, such as methadone pills, are not available at all.

Hrant Karapetyan, head of the Armenian Pain Control and Palliative Care Association, says that only one or two ampoules of morphine can be dispensed at one time, providing a maximum of eight hours of pain relief a day, and requiring regular return visits to the dispensary.

“Every year, there are 80,000 to 100,000 people in need of palliative care,” he said. “In Armenia, however, there is no programme that would allow us to help 80,000-100,000 patients at the one time.”

Palliative care is designed to improve the quality of life of patients who are terminally ill or suffering as a result of medical treatment, and pain relief is an integral part of it.

Eight months ago, Onik Andreasyan, a 53-year-old from the village of Avshar in the Ararat region, was diagnosed with a brain tumour. The pain became unbearable, and his wife Marine found it impossible to help him.

“My husband suffered terrible pain,” she said. “When his head started hurting, he said he felt so bad it was like someone was scratching out his eyes. The pain was uncontrollable. In the first three months, I gave him various painkillers, but nothing helped.”

Onik reached a stage where he was barely able to walk, and his whole left side was severely impaired.

A few months ago, she heard of a pilot project organised by the Global Fund to Fight AIDS, Tuberculosis and Malaria, together with the Open Society Institute and the Armenian health ministry, under which patients receive free methadone pills.

The medication brought her husband’s pain under control, and significantly improved his quality of life.

“We want him not to feel pain. When he was suffering, it was bad for me as well. We know his condition is untreatable, but at least he shouldn’t have to feel the pain,” Marine said.

Karapetyan said it was not just cancer patients who required treatment to help them with pain.

“These medicines are available only to those suffering from cancer, and that isn’t right,” he said. “Patients have a right to a life without pain. If they are in pain, then they must receive painkillers.”

The pilot project was established two years ago to bring palliative care to three Armenian towns. Two schemes are running in Yerevan, and two more in Ararat and Vanadzor.

A few dozen patients are receiving treatment under the project, but experts say more than 3,000 people need daily treatment, so that Armenia would need 90 schemes of this kind rather than four, as well as new legislation allowing doctors to prescribe a greater range of medication.

“We need standards and a law protecting the rights of patients, as well as of doctors and nurses,” said Anahit Papikyan, coordinator of the public health programme at the Open Society Foundation – Armenia. “There isn’t a single document regulating what dose [of methadone] a doctor can give out.”

Stephen Connor, senior executive of the Worldwide Palliative Care Alliance and an advisor to the Open Society Foundation, has studied the situation in Armenia for three years.

“First, a policy of introducing palliative care to the healthcare sector is needed. Second, there is a lack of the principal medicines, specifically of morphine tablets. Third, specialists need to be trained,” he said.

A bill drafted drawn up jointly by the Open Society Foundation and the health ministry will be presented to the government this month and, if approved, will go before parliament in September.

Suren Krmoyan, a senior official at the health ministry, said part of the plan entailed supplying painkillers at lower prices.

“At the moment, these drugs are mainly injected, but we want to introduce them in tablet form,” he said. “When we bring in this programme – which has already been introduced in many countries in the world – the first thing we must do is train the oncologists. We expect this training to include social and psychological elements, and we’re trialling it in our four pilot projects.”

According to Violeta Zopunyan, a lawyer who is helping draft the legislation, the most intractable difficulty is designing simplified mechanisms for prescribing opiates, with less supervision by the police.

“At the moment, there seems to be a belief that doctors or patients might sell these narcotics on the black market,” she said. “Another major problem is that only oncologists can prescribe these drugs. However, other doctors also need to have these powers, including those working in mobile palliative care groups and family doctors.”

Lilit Arakelyan is a correspondent for www.medialab.am.