Morphine available in Estonia but not used by cancer patients

TALLINN – A recent United Nations report showed that cancer patients in Estonia are suffering because they are not consuming morphine and other pain relieving drugs, despite claims by doctors that the opioids are readily available in this Baltic nation.

"We haven't had complaints from hospitals, patients or the drug administration. We believe then that the patients are satisfied," said Sven Kruup, head of the health department at the Ministry of Social Affairs. "We are a little surprised at the international data."

The report, released on Feb. 23 by the UN's drug board, said that in developing countries, many poor people die in pain because of a lack of morphine and other pain-relievers, while Americans and Western Europeans are overmedicated.

"While large quantities of drugs are available on illicit markets, it is unbelievable that in the age of globalization, many people in developing countries have no access to drugs which are essential for the alleviation of pain and suffering," said Loureneo Martins, president of the Vienna-based International Narcotics Control Board in the opening message of the annual report.

The report also pointed out that in Estonia, along with the Czech Republic, Hungary and Uruguay, incidents of cancer are high, but morphine consumption is low.

"The consumption of morphine is relatively low in Estonia, but has increased year by year," said Ly Rootslane, senior pharmaceutical officer at the state Agency of Medicines. "During Soviet times, doctors prescribed morphine for cancer pain only for the terminally ill patients – now the tradition of cancer treatment has changed."

Kruup concedes that many patients may not be using morphine, but it is not because of legal restrictions or small quantities of the opioid as the UN report suggests. He said cancer patients in Estonia complain of the drug's painful injection and are weary of oral administration, a consumption method commonly accepted and widely used in the West.

"One problem is that the patients think it should only be injected," Kruup said. "The patients don't believe in tablets or pills and the injection is uncomfortable. They think opioids in injection form are stronger and more effective too. They don't ask about the oral scheme."

Still, the significance of the UN report holds true: Estonians are not using the drugs. Furthermore, the report says the "possibility of undertreatment of cancer-related pain cannot be excluded" when considering how a nation is responding to people in pain. The report notes that one of the frequently mentioned causes of inadequate opioid availability in countries of low consumption is "cumbersome administrative procedures," a reason Kruup can't dispute.

"The only difference in prescribing morphine is that the doctor must do more paper work," he said.

Doctors are partly to blame for the variance in use, he added.

"In some cases doctors have certain habits and they may believe and be used to other pain killers [that are not as effective as morphine]," Kruup said.

Research shows that 75 to 90 percent of opioid treatment of patients with cancer-related pain can be effective.

Better training of physicians in modern forms of pain-relief should help increase the use of certain pain-killers, including morphine, according to specialists.

"Before 1995 or 1994 it was difficult to get the modern pain-killers. Nowadays this is not a problem. The problem is the way of thinking of most physicians," said Indrek Oro, head physician at the Estonian Cancer Center. "They provide injections of morphine and don't think of different schemes of prescribing drugs."

Estonia has recognized the need to ease the suffering of cancer patients and has held different workshops and seminars for physicians explaining the use of narcotic analgesics to provide better control of cancer pain.

Morphine has been administered in Estonia for the past eight years. More recently, the drug was made available in pill form and sold at pharmacies. Kruup said there are no legal barriers to prescribing the drug and, in fact, morphine is in the group of narcotics whose costs are covered 90 percent by the state's Central Sick Fund. A patient with cancer pays 20 kroons per each prescription of morphine, about the same as one liter of Coca-Cola.

The use of morphine in Estonia has increased more than 3.5 times over the last six years, according to State Agency of Medicines statistics.

The global consumption of morphine has been practically doubling every five years since 1984, the UN report said. However, this trend is mainly attributed to increasing consumption and over medication in richer nations.

"The 10 largest consumer countries accounted for as much as 80 percent of analgesic morphine consumption," the report said. "The average per capita consumption of morphine in 1998 in the 10 countries with the highest morphine consumption levels was 31 grams per 1,000 inhabitants."

Comparatively, in the poorest 120 nations, which doesn't include Estonia, less than one gram of morphine is taken per 1,000 inhabitants.

The number of cancer patients in Estonia increases by roughly 6,000 every year. Nearly 220 women and 320 men in 100,000 suffer from cancer, according to Social Ministry statistics.