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How to Overcome Barriers to Adequate Pain Management in Ukraine

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How to Overcome Barriers to Adequate Pain Management in Ukraine How to Overcome Barriers to Adequate Pain Management in Ukraine by Olena Stetskevych Thesis submitted to The University of Ottawa, Faculty of Graduate and Postdoctoral Studies in partial fulfillment of the requirements for the degree of Master of Laws Faculty of Law, University of Ottawa Ottawa, Ontario, Canada January 2015 © Olena Stetskevych, Ottawa, Canada, 2015 Acknowledgements This interdisciplinary study could not have been accomplished without perfect guidance of my supervisor Professor Amir Attaran. I deeply appreciate his immense investment of time, effort and care to provide advice and comments. I am grateful for his teaching me a lot of things and for his belief in my ability to undertake this research project. I am also appreciative to Professor Attaran for supporting my travels to Ukraine to collect the necessary evidence and to attend scientific conferences on the research issues. I am very thankful to other professors and staff members, particularly to the Faculty of Graduate Studies in Law and the University of Ottawa Ethics Board for their great support with this research project. I am deeply grateful to my family for their continued support in my endeavour to write this paper. Particularly, to my husband Viktor, who put aside his professional interests and continuing education for the period of this study. He created the conditions for which I could accomplish this thesis. I want to say most special words of gratitude to my little son Misha, who has been my inspiration, and who as a baby had to travel with me overseas to collect data for the research. I am also very thankful to the Ukrainian doctors who participated in this study. I particularly appreciate the efforts of Vladimir Romanenko (Ukrainian doctor-neurologist, member of the Ukrainian Chapter of the International Association of the Study of Pain) and Yurii Kuchin (Ukrainian doctor-anaesthesiologist, Head of the Association of the Anaesthesiologists of Ukraine), who helped me collect data by distributing the Questionnaire on Barriers to Pain Control to the health professionals. I want to thank everyone who contributed to this research, who supported me and who wished good things. Thank you! Olena Stetskevych ii | P a g e Abstract There is a large gap between contemporary evidence-based remedies for pain control and what is offered to Ukrainian patients with pain. Having thousands of people needlessly suffer from avoidable pain forces a consideration of 1) what prevents from their access to pain relief, 2) are their human rights being violated and 3) how can the situation be improved. In order to identify the obstacles to adequate pain management in Ukraine I collected evidence using two methods. First, I designed a questionnaire for the Ukrainian doctors, received approval from the University of Ottawa Ethics Board, distributed the questionnaire among potential responders and then organized the obtained results. Second, I did an extensive literature review to provide evidence from the patients. Then I analysed the provisions of Ukrainian domestic and international legislation as well as the available case law to find out if the human rights of Ukrainian patients and doctors are being violated by denial of adequate pain relief. According to my findings, the barriers to pain control in Ukraine are multidimensional and interdependent. They cause violations of human rights, which are not being effectively defended through the courts of Ukraine. These findings call for a more constructive approach to the development of the Ukrainian health law and policy, which I offer in this thesis. iii | P a g e List of Acronyms CAT – Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment ECAT – European Convention on Prevention of Torture and Inhuman or Degrading Treatment or Punishment ECPHRFF - European Convention for the Protection of Human Rights and Fundamental Freedoms GDP – Gross Domestic Product HRW – Human Rights Watch IASP – International Association for the Study of Pain ICCPR – International Covenant on Civil and Political Rights ICESCR – International Covenant on Economic, Social and Cultural Rights INCB – International Narcotics Control Board IRF – International Renaissance Foundation UDHR – Universal Declaration of Human Rights WHO – World Health Organization iv | P a g e A Note on Sources 1. In the present paper many sources in Russian and Ukrainian languages were used, with no official translation available. Where this was the case, the translation into English was provided by the author. The present note is made in order to avoid multiple notes throughout the Thesis, indicating that the quote was translated by the author, as required by the McGill protocol. 2. The author created footnotes and bibliography with a view to follow the rules of McGill Guide. At the same time, citing particularly foreign sources in Russian and Ukrainian languages, as well as many international sources, did not always fit the McGill protocol. Specifically, the McGill Guide requires the name of the source in the original language. However, using the name in Russian or Ukrainian would disable the English-speaking readers from finding the sources and understanding their origin. This relates particularly to the acts in Ukrainian legislation and juris- prudence, which have characteristics different to North-American legislative acts. Also, foreign and international sources do not always provide pieces of infor- mation, necessary to create references in adherence to the McGill protocol. There- fore, I tried to keep the format of the citations close to the requirement of the McGill Guide, providing the necessary information for readers to access the sources cited. v | P a g e Table of Contents Acknowledgements……………………………………………………………………..ii Abstract………………………………………………………………………………...iii List of Acronyms……………………………………………………………………..….iv A Note on Sources………………………………………………………………………v Table of Contents………………………………………………………………………vi Introduction………………………………………………………………...…………….1 Background…………………………………………………………………………………………1 Problematic and the Initiatives for Solving the Issue…………………………………………2 Achievements in Solving the Problem…………………………………………………………..4 Research Questions and the Purpose of the Research…..……………………………………4 Methodology………………………………………………………………………………………..5 Structure of the Thesis…………………………………………………………………………….6 Chapter 1. Identifying Barriers to Adequate Pain Management in Ukraine……......8 1.1. General Identification of the Issue of Pain Management …………………...…..…...8 1.2. Synopsis of the Content and Hierarchy of the Current Ukrainian Legislation Regulat- ing Circulation of Pain Control Medication………………………………………….…..12 1.3. Evidence on Barriers to Pain Control in Ukraine, Provided by the Doctors …….....13 1.4. Discussion of the Barriers to Pain management, Related to Education………...…..16 1.4.1. Lack of Adequate Training for Healthcare Providers as a Barrier to Adequate Pain Control…………………………………………………………………………….………………..16 1.4.2. “Fear of Addiction” and Other Myths about Opioid Analgesics as a Result of Lack of Education………………………………………………………………………………………..18 1.4.3. Absence of a Standard of Care in the Treatment of Pain ………………………….....21 1.4.4. Absence of a System of Notification of Healthcare Providers about New Medicines……………………………………………………………………………………….….23 1.4.5. “Wrong” Diagnosis or Absence of “Necessary” Diagnosis as a Barrier to Pain Relief………………………………………………………………………………………………...2 4 1.5. Discussion on the Barriers related to Health System Policy……………………......26 1.5.1. News on the Ukrainian Rules of Opioids Use in Healthcare………………..…........27 1.5.2. Unfeasible License Requirements for Healthcare Settings to Use Opioids ……..…28 1.4.2. a) Licensing of healthcare settings………………………………………………...28 1.4.2. b) Special permit for healthcare providers……………………………………..….29 vi | P a g e 1.4.2. c) License Requirements for Premises to Store Controlled Substances………...…30 1.5.3. Ambiguous and Often Unfeasible Requirements for the Use of Opioids and Violation of the Official WHO Recommendations……………………………….……………32 1.5.4. Fear of Criminal Prosecution………………………………………….………………...34 1.5.5. Practical Hardships Faced by the Physicians as a Result of Excessive Restrictions in the Use of Opioid Analgesics……………………………………..…………………………..36 1.6. Discussion of the Barriers related to Drugs Availability…………………………….41 1.6.1. Formulary Deficit of Opioid Analgesics……………………………..…………………41 1.6.2. Prices for Analgesics as a Barrier to Pain Control…………………………………...42 1.5. Concluding Remarks…………………………………………………………...…...45 Chapter 2. Practical Outcome of Strict Prohibitions of Opioids Use in Medical Practice in Ukraine…………………………………………………………...…….......48 2.1. Peculiarities of the Ukrainian Use of Opioids as Opposed to Other Countries…..…48 2.1.1. The Use of Opioids in Ukraine in Comparison with other Countries and Region...48 2.1.2. The Correlation between the Level of Drugs Addiction and the Strictness of the Regulations for Opioids use in Medical Practice…………………………..…………………49 2.1.3. The Use of Opioids for Analgesia as a Financial Matter…………………………….51 2.2. How Ukrainian People Act Under Strict Prohibitions Regarding Opioids……...….52 2.2.1. Breaking the Regulations on Circulation of Narcotics for Medical Purposes……..52 2.2.2. Attempting and Committing Suicides……………………………………..……………..53 2.2.3. Trying to Preserve One’s Human Dignity…………………………………………........55 2.2.4. Changing the Patients’ Roles in the Families and Separating Them from Families…………………………………………………………………………………………….56 2.2.5.
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