Tramadol: MedlinePlus Drug Information

pronounced as (tra’ ma dole)

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FDA Drug Safety Communication:

[Posted 4/13/2023]

• As part of its ongoing efforts to address the nation’s opioid crisis, FDA is requiring several updates to the prescribing information of opioid pain medicines. The changes are being made to provide additional guidance for safe use of these drugs while also recognizing the important benefits when used appropriately. The changes apply to both immediate-release (IR) and extended-release/long-acting preparations (ER/LA).
• Updates to the IR opioids state that these drugs should not be used for an extended period unless the pain remains severe enough to require an opioid pain medicine and alternative treatment options are insufficient, and that many acute pain conditions treated in the outpatient setting require no more than a few days of an opioid pain medicine.
• Updates to the ER/LA opioids recommend that these drugs be reserved for severe and persistent pain requiring an extended period of treatment with a daily opioid pain medicine and for which alternative treatment options are inadequate.
• A new warning is being added about opioid-induced hyperalgesia (OIH) for both IR and ER/LA opioid pain medicines. This includes information describing the symptoms that differentiate OIH from opioid tolerance and withdrawal.
• Information in the boxed warning for all IR and ER/LA opioid pain medicines will be updated and reordered to elevate the importance of warnings concerning life-threatening respiratory depression, and risks associated with using opioid pain medicines in conjunction with benzodiazepines or other medicines that depress the central nervous system (CNS).
• Other changes will also be required in various other sections of the prescribing information to educate clinicians, patients, and caregivers about the risks of these drugs.

Tramadol may be habit forming, especially with prolonged use. Take tramadol exactly as directed. Do not take more of it, take it more often, or take it in a different way than directed by your doctor. While taking tramadol, discuss with your health care provider your pain treatment goals, length of treatment, and other ways to manage your pain. Tell your doctor if you or anyone in your family drinks or has ever drunk large amounts of alcohol, uses or has ever used street drugs, or has overused prescription medications, or has had an overdose or if you have or have ever had depression or another mental illness. There is a greater risk that you will overuse tramadol if you have or have ever had any of these conditions. Talk to your health care provider immediately and ask for guidance if you think that you have an opioid addiction or call the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-HELP.

Tramadol may cause serious or life-threatening breathing problems, especially during the first 24 to 72 hours of your treatment and any time your dose is increased. Your doctor will monitor you carefully during your treatment. Tell your doctor if you have or have ever had slowed breathing, asthma, or lung disease such as chronic obstructive pulmonary disease (COPD; a group of diseases that affect the lungs and airways). Your doctor will probably tell you not to take tramadol. Also tell your doctor if you have or have ever had a head injury, brain tumor, or any condition that increases the amount of pressure in your brain. The risk that you will develop breathing problems may be higher if you are an older adult or are weak or malnourished due to disease. If you experience any of the following symptoms, call your doctor immediately or get emergency medical treatment: slowed breathing, long pauses between breaths, or shortness of breath.

When tramadol was used in children, serious and life-threatening breathing problems such as slow or difficulty breathing and deaths were reported. Tramadol should never be used to treat pain in children younger than 12 years of age or to relieve pain after surgery to remove the tonsils and/or adenoids in children younger than 18 years of age. Tramadol should also not be used in used in children 12 to 18 years of age who are obese or who have a neuromuscular disease (disease that affects the nerves that control voluntary muscles), a lung disease, or obstructive sleep apnea (condition in which the airway becomes blocked or narrow and breathing stops for short periods during sleep) as these conditions may increase their risk of breathing problems.

Taking certain other medications during your treatment with tramadol may increase the risk that you will experience breathing problems or other serious, life threatening breathing problems, sedation, or coma. Tell your doctor and pharmacist what other prescription and nonprescription medications, vitamins, and nutritional supplements you are taking or plan to take. Your doctor may need to change the dosages of your medications and will monitor you carefully. If you take tramadol with other medications and you develop any of the following symptoms, call your doctor immediately or seek emergency medical care: unusual dizziness, lightheadedness, extreme sleepiness, slowed or difficult breathing, or unresponsiveness. Be sure that your caregiver or family members know which symptoms may be serious so they can call the doctor or emergency medical care if you are unable to seek treatment on your own.

Drinking alcohol, taking prescription or nonprescription medications that contain alcohol, or using street drugs during your treatment with tramadol increases the risk that you will experience these serious, life-threatening side effects. Do not drink alcohol, take prescription or nonprescription medications that contain alcohol, or use street drugs during your treatment.

Tell your doctor if you are pregnant or plan to become pregnant. If you take tramadol regularly during your pregnancy, your baby may experience life-threatening withdrawal symptoms after birth. Tell your baby’s doctor right away if your baby experiences any of the following symptoms: irritability, hyperactivity, abnormal sleep, high-pitched cry, uncontrollable shaking of a part of the body, vomiting, diarrhea, or failure to gain weight.

If you are taking the tramadol extended-release tablet or capsule, swallow them whole; do not chew, break, divide, crush, or dissolve them. If you swallow broken, chewed, crushed, or dissolved extended-release preparations, you may receive too much tramadol at once instead and this may cause serious problems, including overdose and death.

Do not allow anyone else to take your medication. Tramadol may harm or cause death to other people who take your medication, especially children.

Your doctor or pharmacist will give you the manufacturer’s patient information sheet (Medication Guide) when you begin treatment with tramadol and each time you refill your prescription. Read the information carefully and ask your doctor or pharmacist if you have any questions. You can also visit the Food and Drug Administration (FDA) website (http://www.fda.gov/Drugs/DrugSafety/ucm085729.htm) or the manufacturer’s website to obtain the Medication Guide.

Tramadol is used to relieve moderate to moderately severe pain in adults and children 12 years of age or older. Tramadol extended-release tablets and capsules are only used by people who are expected to need medication to relieve pain around-the-clock. Tramadol is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain.

Tramadol comes as a tablet, a solution (liquid), an extended-release (long-acting) tablet, and an extended-release (long-acting) capsule to take by mouth. The regular tablet and solution are taken usually with or without food every 4 to 6 hours as needed. The extended-release tablet and extended-release capsule should be taken once a day. Take the extended-release tablet and the extended-release capsule at about the same time of day every day. If you are taking the extended-release tablet or extended-release capsule, you should take it consistently, either always with or always without food. Take tramadol exactly as directed. Do not take more medication as a single dose or take more doses per day than prescribed by your doctor. Taking more tramadol than prescribed by your doctor or in a way that is not recommended may cause serious side effects or death.

Your doctor may start you on a low dose of tramadol and gradually increase the amount of medication you take, not more often than every 3 days if you are taking the solution or regular tablets or every 5 days if you are taking the extended-release tablets or extended-release capsules.

If you are taking the solution, use an oral syringe or measuring spoon or cup to measure the correct amount of liquid needed for each dose. Do not use a regular household spoon to measure your dose. Ask your doctor or pharmacist if you need help getting or using a measuring device,

Do not stop taking tramadol without talking to your doctor. Your doctor will probably decrease your dose gradually. If you suddenly stop taking tramadol, you may experience withdrawal symptoms such as nervousness; panic; sweating; difficulty falling asleep or staying asleep; runny nose, sneezing, or cough; pain; hair standing on end; chills; nausea; uncontrollable shaking of a part of your body; diarrhea; or rarely, hallucinations (seeing things or hearing voices that do not exist).

This medication is sometimes prescribed for other uses; ask your doctor or pharmacist for more information.

Before taking tramadol,

• tell your doctor and pharmacist if you are allergic to tramadol, other opiate pain medications, any other medications, or any of the ingredients in tramadol products. Ask your pharmacist for a list of the ingredients.
• tell your doctor or pharmacist if you are taking or receiving the following monoamine oxidase (MAO) inhibitors or if you have stopped taking them within the past 2 weeks: isocarboxazid (Marplan), linezolid (Zyvox), methylene blue, phenelzine (Nardil), selegiline (Eldepryl, Emsam, Zelapar), or tranylcypromine (Parnate). Your doctor will probably tell you not to take tramadol if you are taking one or more of these medications, or have taken them within the past 2 weeks.
• The following nonprescription or herbal products may interact with tramadol: St. John’s wort and tryptophan. Be sure to let your doctor and pharmacist know that you are taking these medications before you start taking tramadol. Do not start these medications while taking tramadol without discussing it with your healthcare provider.
• tell your doctor if you have any of the conditions mentioned in the IMPORTANT WARNING section, a blockage or narrowing of your stomach or intestines, or paralytic ileus (condition in which digested food does not move through the intestines). Your doctor may tell you not to take tramadol if you have any of these conditions.
• tell your doctor if you have or have ever had seizures; an infection in your brain or spine; difficulty urinating; low blood levels of sodium; thoughts about harming or killing yourself or planning or trying to do so; diabetes; pancreas, gall bladder, or thyroid problems; or kidney or liver disease.
• tell your doctor if you are breastfeeding. You should not breastfeed while taking tramadol. Tramadol can cause shallow breathing, difficulty or noisy breathing, confusion, more than usual sleepiness, trouble breastfeeding, or limpness in breastfed infants.
• you should know that this medication may decrease fertility in men and women. Talk to your doctor about the risks of taking tramadol.
• if you are having surgery, including dental surgery, tell the doctor or dentist that you are taking tramadol.
• you should know that this medication may make you drowsy and may affect your coordination. Do not drive a car or operate machinery until you know how this medication affects you.
• you should know that tramadol may cause dizziness, lightheadedness, and fainting when you get up from a lying position. To avoid this, get out of bed slowly, resting your feet on the floor for a few minutes before standing up.
• you should know that tramadol may cause constipation. Talk to your doctor about changing your diet and using other medications to treat or prevent constipation.

Unless your doctor tells you otherwise, continue your normal diet.

If your doctor has told you to take tramadol regularly, take the missed dose as soon as you remember it. However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not take a double dose to make up for a missed one.

Tramadol may cause side effects. Tell your doctor if any of these symptoms are severe or do not go away:

• sleepiness
• headache
• nervousness
• uncontrollable shaking of a part of the body
• changes in mood
• heartburn or indigestion
• dry mouth

Some side effects can be serious. If you experience any of these symptoms or those mentioned in the IMPORTANT WARNING section, call your doctor immediately or get emergency medical treatment:

• hives
• rash
• blisters
• hoarseness
• difficulty swallowing or breathing
• chest pain
• swelling of the eyes, face, throat, tongue, lips, hands, feet, ankles, or lower legs
• agitation, hallucinations (seeing things or hearing voices that do not exist), fever, sweating, confusion, fast heartbeat, shivering, severe muscle stiffness or twitching, loss of coordination, nausea, vomiting, or diarrhea
• nausea, vomiting, loss of appetite, fatigue, weakness, or dizziness
• changes in heartbeat
• nausea, vomiting, headache, confusion, loss of energy, drowsiness, fatigue, restlessness, irritability, muscle weakness, spasms or cramps
• hunger, headache, sweating, shaking of a part of your body that you cannot control, irritability, or difficulty concentrating
• loss of consciousness
• seizures

If you experience a serious side effect, you or your doctor may send a report to the Food and Drug Administration’s (FDA) MedWatch Adverse Event Reporting program online (http://www. fda.gov/Safety/MedWatch) or by phone (1-800-332-1088).

Tramadol may cause other side effects. Tell your doctor if you have any unusual problems while you are taking this medication.

Keep this medication in the container it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture (not in the bathroom).

It is important to keep all medication out of sight and reach of children as many containers (such as weekly pill minders and those for eye drops, creams, patches, and inhalers) are not child-resistant and young children can open them easily. To protect young children from poisoning, always lock safety caps and immediately place the medication in a safe location – one that is up and away and out of their sight and reach. http://www.upandaway.org

Unneeded medications should be disposed of in special ways to ensure that pets, children, and other people cannot consume them. However, you should not flush this medication down the toilet. Instead, the best way to dispose of your medication is through a medicine take-back program. Talk to your pharmacist or contact your local garbage/recycling department to learn about take-back programs in your community. See the FDA’s Safe Disposal of Medicines website (http://goo.gl/c4Rm4p) for more information if you do not have access to a take-back program.

In case of overdose, call the poison control helpline at 1-800-222-1222. Information is also available online at https://www.poisonhelp.org/help. If the victim has collapsed, had a seizure, has trouble breathing, or can’t be awakened, immediately call emergency services at 911.

While taking tramadol, you should talk to your doctor about having a rescue medication called naloxone readily available (e.g., home, office). Naloxone is used to reverse the life-threatening effects of an overdose. It works by blocking the effects of opiates to relieve dangerous symptoms caused by high levels of opiates in the blood. Your doctor may also prescribe you naloxone if you are living in a household where there are small children or someone who has abused street or prescription drugs. You should make sure that you and your family members, caregivers, or the people who spend time with you know how to recognize an overdose, how to use naloxone, and what to do until emergency medical help arrives. Your doctor or pharmacist will show you and your family members how to use the medication. Ask your pharmacist for the instructions or visit the manufacturer’s website to get the instructions. If symptoms of an overdose occur, a friend or family member should give the first dose of naloxone, call 911 immediately, and stay with you and watch you closely until emergency medical help arrives. Your symptoms may return within a few minutes after you receive naloxone. If your symptoms return, the person should give you another dose of naloxone. Additional doses may be given every 2 to 3 minutes, if symptoms return before medical help arrives.

Symptoms of overdose may include the following:

• decreased size of the pupil (the black circle in the center of the eye)
• difficulty breathing
• slow or shallowing breathing
• extreme drowsiness or sleepiness
• unable to respond or wake up
• slowed heartbeat
• muscle weakness
• cold, clammy skin

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• Ultracet^® (containing Acetaminophen, Tramadol)
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^¶ This branded product is no longer on the market. Generic alternatives may be available.

Last Revised – 05/15/2023

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Tramadol Definition & Meaning – Merriam-Webster

tram·​a·​dol

ˈtra-mə-ˌdȯl 

: a synthetic opioid analgesic administered orally in the form of its hydrochloride C₁₆H₂₅NO₂·HCl to treat moderate to severe pain

Example Sentences

Recent Examples on the Web

Mexico has long been a mecca for Americans seeking easier and cheaper access to medications that require a prescription in the U. S. — drugs such as Viagra, Xanax and tramadol.

—Connor Sheets, Los Angeles Times, 14 June 2023

Drugs found in his system included methadone, tramadol (a painkiller) and alprazolam.

—Stephanie Sengwe, Peoplemag, 9 June 2023

There are serious side effects that can happen with tramadol, like any other opioid, and even appropriate use of opioids can lead to opioid use disorder.

—Dr. Keith Roach, oregonlive, 6 June 2023

Fentanyl, for example, is grouped with other synthetic opioids like tramadol and nitazenes.

—Deidre McPhillips, CNN, 3 May 2023

Between July 2019 and January of this year, officials seized five shipments containing thousands of zolpidem, tramadol and tapentadol pills, according to the complaint.

—Orlando Mayorquin, USA TODAY, 30 Mar. 2023

More than 50% of the redfish sampled were contaminated with both flecainide, which in humans slows electrical signals in the heart to stabilize heart rhythms, and the habit-forming opioid pain reliever tramadol.

—Bill Kearney, Sun Sentinel, 4 Apr. 2023

The three most common in muscle tissue were opioid pain reliever tramadol, the heart medicine flecainide and haloperidol.

—Bill Kearney, Sun Sentinel, 4 Apr. 2023

Over 50 percent of fish tested had the opioid tramadol and the antiarrhythmic medication flecainide in their systems.

—Matthew Every, Field & Stream, 4 Apr. 2023

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These examples are programmatically compiled from various online sources to illustrate current usage of the word ‘tramadol. ‘ Any opinions expressed in the examples do not represent those of Merriam-Webster or its editors. Send us feedback about these examples.

Word History

First Known Use

1978, in the meaning defined above

Time Traveler

The first known use of tramadol was
in 1978

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Dictionary Entries Near

tramadol

trama

tramadol

trambiyo

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“Tramadol.” Merriam-Webster.com Dictionary, Merriam-Webster, https://www.merriam-webster.com/dictionary/tramadol. Accessed 11 Jul. 2023.

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Medical Definition

tramadol

noun

tram·​a·​dol

ˈtram-ə-ˌdȯl 

: a synthetic opioid analgesic administered orally in the form of its hydrochloride C₁₆H₂₅NO₂·HCl to treat moderate to severe pain

see ultram

Last Updated:
10 Jul 2023
– Updated example sentences

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Merriam-Webster unabridged

Curse of the Painless

• David Cox
• BBC Future

15 June 2017

.

Copyright © iStock

Physical pain is the body’s warning to be careful! However, there are people who have never received such a signal from their body in their entire lives. Can science somehow use their phenomenon to alleviate the suffering of those who suffer from chronic pain?

At the Institute of Human Genetics in Aachen (Germany), Professor Ingo Kurt has an unusual visitor today: 21-year-old Stefan Betz is ready to provide him with samples of his blood for analysis.

Stefan has congenital insensitivity to pain, one of the rarest genetic diseases that affects no more than a few hundred people worldwide.

What does this mean? Stefan can put his hand in boiling water and feel nothing. He can have surgery without anesthesia – he will not feel any discomfort.

In all other respects, his sensory perception is absolutely normal. He sweats when the room is too hot, he shivers in the icy wind.

Is it some kind of blessing to live without pain? But no, for Stefan this is a real curse.

“People think that insensitivity to pain makes you almost a superman,” says Betz. “But for us, for those who live without pain, it’s the other way around. We would really like to know what it means and how it is “to feel pain. Without it, our life is full of difficulties.”

When Stefan was little, his parents initially thought he was a little mentally retarded.

“We couldn’t figure out why he was so clumsy,” recalls Dominic, his father.

Image copyright, iStock

Image caption,

Stefan Betz can stick his hand in boiling water and feel nothing.

Neither parents nor brothers had anything like that. However, shortly after Stefan was 5 years old, he bit off the tip of his tongue, without feeling any pain – that’s when he was diagnosed.

And soon he broke the metatarsal bone of his right leg while jumping down the stairs. And again, I didn’t feel anything.

From an evolutionary point of view, one of the reasons why this disease is so rare is easy to understand: most sufferers simply did not survive to adulthood.

“We are all afraid of pain, but for the process of growing up, the process of transition from a child to an adult, pain is extremely important – it teaches us how to curb our physical activity so as not to harm our body. It helps us determine the degree of risk,” explains Professor Kurt.

• Write about your pain and it will go away?
• Why is pain so difficult to measure and relieve?
• How does it feel to be struck by lightning?
• Why is pain pleasant?

Lacking a natural bodily warning mechanism about the dangers of a particular action, people with pain insensitivity sometimes behave self-destructively, especially at a young age.

Kurt talks about a boy from Pakistan whom scholars learned about because of the reputation he earned in his area as a fearless performer, walking on hot coals, sticking a knife into his arm, never showing pain.

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Later, in his early 20s, he crashed by jumping off the roof of a house.

“Of the patients I worked with in Britain, a great many men killed themselves before reaching 30. Unconstrained by pain, they committed absurdly dangerous acts,” says Geoff Woods of the Cambridge Medical Institute. research

Woods researches the feeling of pain. “Others have damaged their joints and now can only move in a wheelchair,” he continues. “Thirds committed suicide because they did not see the point in such a life. ”

Betz has been in the hospital so many times that he has already lost count. He had a lot of various injuries, the consequences of some of them are still being felt.

“You have to deceive your body in order not to commit reckless acts, to pretend that you feel pain,” he says. “Which is not at all easy if you don’t know what pain is…”

Image copyright, iStock

Image caption,

A Pakistani boy walked on hot coals without showing pain

However, there is something about Betz’s story that gives hope to the millions of people who are now suffering from a variety of chronic pains scientists say. Perhaps understanding the mechanisms behind Betz’s disease will help them.

The first case of congenital insensitivity to pain was reported in 1932 in New York. For the next 70 years, scientists paid little attention to this strange phenomenon. However, with the advent of the era of the Internet and social networks, it has become easier for people with this disease to find each other.

And scientists gradually began to understand that studying these patients and their disease can help to understand the pain itself – and, perhaps, how to turn it off or at least reduce it for those who suffer terribly from it.

At the same time, we must understand that a large, global business is built on our pain.

The world’s population consumes about 14 billion doses of painkillers per day. It is estimated that one in 10 adults worldwide each year is diagnosed with a disease that is somehow associated with chronic pain. And such a disease lasts an average of seven years.

• Paracetamol and ibuprofen: what comes from what?
• Pain relief for critically ill patients: is the situation changing?
• Our brain and the whole truth about the “mind pill”

The reasons why we feel pain are known to science. It is also known that in some situations our brain is able to turn off this feeling itself – for example, with the help of adrenaline or endorphins, producing them in stressful situations.

The market for painkillers is dominated by opiates – morphine, heroin and tramadol, which work in much the same way as endorphins, including the effect of euphoria, “high”. And the consequences of this domination are tragic. In the USA, for example, every day 91 person dies from an overdose of opiates – and since 2000, more than half a million have died from it.

Alternatives such as aspirin are not effective for severe pain. In addition, their long-term use causes side effects such as serious gastrointestinal disorders.

Although everyone understands that the science of pain relief is in desperate need of some kind of breakthrough, until recently, little has been achieved.

In the early 2000s, a small Canadian biotechnology company, Xenon Pharmaceuticals, became aware of a Newfoundland family with several relatives suffering from congenital pain insensitivity.

“The boys in this family often broke their legs,” says Xenon CEO Simon Pimstone.

The company began searching for similar cases literally all over the planet – in order to eventually decipher the DNA of these people.

And as a result, her researchers managed to find a common mutation for all these people in the SCNP9A gene, which is responsible for the Nav1.7 sodium channel in our body. The mutation blocks this channel, and with it the ability to feel pain.

This was the breakthrough that the pharmaceutical industry was waiting for.

“Drugs that block the Nav1.7 sodium channel could be a new treatment for those who suffer from chronic pain, including low back pain, neuropathy, osteoarthritis, and more,” says Robin Sherrington, senior vice president of the company. xenon.

“And since all other sensory functions are normal in people with congenital pain insensitivity, we expect the side effects [of such drugs] to be minimal.”

Image Credit, iStock

Photo caption,

About 14 billion doses of painkillers are consumed daily around the world

launching an entirely new class of painkillers on the market.

However, the development of sodium channel blockers specifically targeting the peripheral nervous system has proven challenging.

Although researchers remain optimistic, it may take another five years for them to fully understand whether the blocking of the Nav1.7 channel is indeed the key.

Xenon thinks it is. Clinical trials of three products are currently underway here (in partnership with Teva and Genentech).

“Nav1.7 is one of nine sodium channels that are very similar to each other, and that’s the difficulty,” says Sherrington. something that will only work for a specific channel and only for specific tissues. You have to be very careful.”

Meanwhile, the study of people who are insensitive to pain offers new options for scientists.

It was found that the PRDM12 gene seems to play the role of a master switch, a kind of knife switch: it is able to “turn on” and “turn off” genes related to neurons that regulate pain sensitivity.

“Perhaps in cases where a person suffers from chronic pain, their PRDM12 gene is simply not working as it should or is too overloaded,” says Woods. “If we can fix it, we will return the neurons to normal.”

“More importantly, the PRDM12 gene works only in neurons that regulate pain sensitivity. So a drug, an analgesic, that modulates this gene will have very few side effects, since it will not affect other cells of the body.”

Alas, while there is hope for millions of chronic pain sufferers, for those born with pain insensitivity, the chances that they will ever experience pain and benefit from it are still low.

Image copyright, iStock

Image caption,

Current research will help develop a system for earlier detection of congenital insensitivity to pain

Pimstone specifically notes that many of those who took part in the research are, in fact, for the first time in their lives receiving consultations from medical professionals regarding your illness.

“Their contribution has been enormous. It is only because of their willingness to cooperate that we have come so far in our research, and we are extremely grateful to them,” he says.

In addition, current research will help establish a system for earlier detection of congenital insensitivity to pain. So the families of volunteers who are now helping scientists can benefit from this.

Gene therapy has not yet reached a level where you can count on the restoration of the sodium channel and the return of a sense of pain to those who have never felt pain in their lives.

But Stefan Betz says he lives in hope. “I want to continue working with scientists, I want to help the world learn more about pain. Perhaps the day will come when they will be able to use this knowledge – including in order to help us.”

Read the original of this article in English at BBC Future .

O – Pain relief – Weekend

In February 2014, it becomes known about the death of Rear Admiral of the Navy Vyacheslav Apanasenko, a veteran submariner, former chief of the armaments staff of the Navy, professor and corresponding member of various military academies – and a cancer patient. He committed suicide because the pain was unbearable and pain relief was unavailable. This tragedy draws the attention of society and the media to the situation with the anesthesia of seriously ill patients. Public outcry and the efforts of philanthropists over the next few years lead to a change in the legislation regulating the circulation of painkillers and the adoption of a law on palliative care.

This text is part of Yuri Saprykin’s project “Words of Russia” , in which he talks about significant events and names of the last twenty years and how these phenomena and people have changed us.

context

On February 10, 2014, a rally was held in Donetsk, the participants of which demanded that the regional authorities consider the issue of restoring the Donetsk-Krivoy Rog Republic. The Consumer Rights Protection Society filed a complaint with the Ostankinsky Court of Moscow against four cable television operators who stopped broadcasting the Dozhd TV channel (included in the register of media-foreign agents in August 2021). At the Olympics in Sochi, Viktor Ahn, a South Korean athlete who took Russian citizenship, brought the Russian team bronze in the 1500 m short track. The premiere of the full version of Lars von Trier’s film “Nymphomaniac” took place at the Berlin Film Festival. In the intensive care unit of the First City Hospital of Moscow Rear Admiral of the Navy Vyacheslav Apanasenko died, hospitalized after a suicide attempt

Apanasenko’s death is striking – the 21st century, a decade and a half of oil stability behind us, the most expensive Olympics in history has just opened with cosmic brilliance. And in the midst of all this well-being, a person passes away, suffering from terrible pain and not being able to relieve this pain – neither for free from the state, nor for money, in any way. And not a simple person, but a representative of the military elite itself, with all possible connections, benefits and privileges; even such a person, it turns out, in such a situation has only one real privilege – without breaking the law, to put a bullet in his forehead from a premium pistol. What is it like for others?

The story of a “status” person, being in the news, makes visible the tragedy of a variety of people. Cancer patients, even at the most advanced stages, cannot receive drugs that would ease their pain – or rather, for those who are not in the hospital, obtaining them is a nightmarishly difficult procedure. You need to get an appointment from an oncologist who assesses the degree of pain “by eye”, and even more often – from the words of relatives, and according to this retelling, he needs to determine the category of medicine and dosage. Next, you need to collect half a dozen signatures and seals in different offices, and there is a queue in front of each. Then make it to the pharmacy – and exactly to the one that is attached to your clinic, and God forbid that there is the right remedy. And the prescription is valid for only five days, and in order to get a new one, you need to hand over all the used ampoules and packages to the district police officer – and start going through the same scheme from the first level. For the relatives of the patient, from some point on, the whole life turns into a hellish quest, where the price of each mistake or inconsistency is monstrous. And if a child is ill, who has no one to leave at home with? And if he has just been discharged from the hospital, is it strictly forbidden to give painkillers upon discharge, even for the first days? And what if a pharmacy where you can buy painkillers – specialized, state-owned, with bars and guards – is a hundred kilometers from home? And if the pain covered during the holidays? What if it’s New Year’s Eve?

In February 2015, journalist Katerina Gordeeva cites the following data in Meduza’s “Pain Epidemic” (included in the register of foreign media agents in April 2021). According to WHO recommendations, a patient experiencing unbearable pain should receive the necessary pain relief within two to three hours, regardless of age, diagnosis, place of residence, and other factors. In Russia, it takes up to three days to receive the necessary pain relief, and if a child is sick, up to 12 (!) days. According to the degree of availability of anesthesia, Russia is in 38th place out of 42 countries (data for 2010). The reason is simple: the ultimate goal of this whole medical-bureaucratic procedure is not to help a patient in need of pain relief, but to keep the consumption of potent drugs under the strictest control. The chief administrators here are not doctors, but drug control: for obvious reasons, the pain of others is the last thing they care about.

Descendants will be able to learn how this system worked, for example, from the first scenes of the film “Doctor Lisa”, released in 2020. A little girl with terminal cancer is discharged from the hospital; to get painkillers, you need another day, and the pain is unbearable even now – and the main character (the role of Elizaveta Glinka, the head of a charitable foundation, was played by the head of another similar foundation, Chulpan Khamatova) runs to a doctor she knows to borrow several ampoules of morphine. But for a doctor, this is certain death: if at the end of the day, when the register is filled out, the ampoules are not in place, this is immediately a criminal case. Any violation of the regulations in cases with painkillers threatens the court and prison. So, in 2012, the Krasnoyarsk procurator demanded that the district doctor Alevtina Khorinyak be sentenced to eight years in prison – she prescribed tramadol to a patient who was not assigned to her district. And any other drugs that are under the scrutiny of drug control can provoke persecution. In 2018, a criminal case was opened against Ekaterina Konnova, the mother of a seriously ill child: she tried to sell diazepam microclysters, which did not suit her child, in the parent community. Two years later, the children’s hospice “House with a Lighthouse” was sentenced to a large fine – the employees of the Ministry of Internal Affairs who came with the check found errors in maintaining accounting logs (the sentence would later be canceled). It is difficult to get painkillers, it is scary to prescribe painkillers, it is impossible to live with pain: in the mid-2010s, cancer patients who do not receive painkillers take their own lives one after another, a year after the suicide of Rear Admiral Apanasenko, retired Air Force Lieutenant General Anatoly Kuznetsov will commit suicide , in February 2015 alone, 11 suicides of cancer patients were recorded.

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“At the cost of Vyacheslav Apanasenko’s life, the right to anesthesia, or rather, its absence, became news number one”

Katerina Gordeeva

It must be understood that all this horror is taking place against the backdrop of a changing attitude towards pain and an improving situation with pain relief. In the early 1990s, the first hospices appeared in Russia, and with them a rudimentary understanding that even the terminally ill should spend their last days with dignity and without pain. The concept of “palliative care” for some of the doctors and officials still looked like a Chinese letter, but somewhere it was already becoming everyday practice. The founder of the First Moscow Hospice Vera Millionshchikova and her daughter Nyuta Federmesser, who created the Vera Hospice Fund in 2006, did a lot to explain to society in general and officials in particular: pain and suffering are not normal, in any form and at any stage disease, a person has the right to get rid of pain, and at the end of the path – the right to leave life without suffering and humiliation. Attitudes are changing not only towards the suffering of the terminally ill, but towards pain in general: the generation that had their adenoids removed and their teeth treated without anesthesia in their childhood suddenly discovered that there was neither meaning nor necessity in these (and any other) physical sufferings – you can perfectly do without them. And this change is part of a wider cultural shift that is happening not only in Russia.

It would seem that pain is an absolutely universal thing, a real human value: it is understandable without translation, its reality cannot be doubted. But pain also has its own history, and there were different approaches to this history. Before the use of chloroform in the 1840s, the only painkillers available, even for military surgeons, were alcohol and a piece of wood between the teeth. But the appeared chloroform facilitates not only the suffering of the patient, but also the work of surgeons: it is easier to operate on a “turned off” patient. In non-surgical cases, for doctors of past eras, pain is a normal thing and in some ways even useful: it is a symptom that allows you to find and neutralize a malfunction in the body, and in general, if it hurts, it means that you are still alive. Pain in the Christian worldview is a purifying suffering, for which it will be rewarded in the afterlife. In Soviet ethics, the pain experienced in labor or battle is a sacrifice that must be made for the sake of the happiness of future generations, the ability to endure pain hardens the character, pain is something to be ashamed to complain about, something that must be endured.

The new attitudes towards pain that have appeared in the Western world since the 1960s are due both to the fact that life expectancy has increased (due to which more people have time to live to have cancer) and to the fact that medicine is increasingly perceived as “customer-oriented service”, and simply with an improvement in the quality of life – against the background of which physical and mental pain begins to look something unnatural: pain is just pain, it cannot have explanations and justifications. It is also important that by this moment medicine openly says: pain should not be endured, it is harmful. This shift raises many questions: how to measure pain if it is experienced subjectively and cannot be seen through any microscope? Is there a reliable language for describing pain, and how does this language influence prescriptions? Is it possible to relieve pain without eliminating its cause? What is in pain from the body, and what is from consciousness (psyche, nerves)? Mental pain – is it essentially the same as bodily pain, and should it be treated with medication? Are the experiences of pain influenced by cultural patterns that dictate one or another attitude towards it?

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“In Soviet times, no one died at all. All recovered and flew into space. And all these dying people, confirming that a person is not omnipotent and medicine in matters of life and death sometimes cannot compete with God, remained behind the scenes”

Nyuta Federmesser

Attitude towards pain is always a balance between private and social, pain is experienced individually, but getting rid of it becomes almost a political issue; on the issue of pain, the most painful (sorry for the multiple tautology) are both privileges and discrimination: whoever has more rights will get rid of pain more easily, the more disenfranchised you are, the more pain is your own business. Perhaps, in some sense not yet fully understood, this lack of rights and humiliation is one of the causes (or enhancers) of pain. But in these topical discussions, Russia lags behind by several decades: questions about where discomfort ends and pain begins, and whether it is possible to deal with a symptom without trying to find a cause, and where the personal ends and the political begins – all these questions are somewhat losing their acute, when a child in the terminal stage of cancer cannot receive pain medication for 12 days.

The attitude towards pain is always politics, and in this plot the Russian state manifests itself as senselessly bureaucratic, obsessed with control where it is possible to control anything. Why is the drug control in charge of painkillers? The share of medicines in the total drug turnover is negligible, but doctors are always in sight, and starting a criminal case for a lost ampoule is much easier than catching hucksters on the dark web. On one side – accounting and control, compliance with the procedure, countering possible threats, and on the other – ordinary human pain, and in the system of power bureaucracy the first always outweighs. But before you pronounce a prefabricated judgment on this system, it is worth listening to the end of the story – because in this story the state showed itself not only as obsessed with control, but as learning and adapting. Yes, this happened after a series of high-profile suicides, yes, it took a gigantic effort of philanthropists and public figures who joined them, but the laws and regulations regarding pain relief nevertheless began to change.

The new law on narcotic drugs, which came into force in 2015, is a prescription for 15 days instead of 5, and now there is no need to collect signatures throughout the clinic, and you can not return the used packaging. The Palliative Care Act, passed in 2019, is a statutory right to pain relief and care, palliative wards in hospitals, and outreach services at home. Finally, in 2021, the government releases doctors from liability for lost ampoules, which means from the constant threat of new criminal cases. These laws and regulations are not magic spells that will make pain in Russia disappear as a medical fact; and the queues, and the lack of medicines, and the indifference of other doctors from this, too, will not go anywhere. But these are new regulations that significantly reduce the degree of domestic hell for patients and their relatives, and this is a new attitude towards pain, gradually penetrating administrative corridors: pain relief and palliative care are no longer an exotic whim, but something understandable and important, this must be dealt with, this cannot be.

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“Priorities are set in the law. And if earlier the search for illegal drugs was a priority, now it is to ensure timely pain relief for those in need. There is no need to change anything, it’s just that the Federal Drug Control Service at one time assumed too much authority. ”

Nikolai Gerasimenko, First Deputy Chairman of the State Duma Committee on Health Protection

In the history of Russia in the 2010s, there are several notable, defining plots – external expansion, internal political frosts, strengthening of the power bloc, infringement of civil rights. But next to them and sometimes in antiphase to them, things happen that change the entire scale of social values, and changing the attitude towards pain is one of such quiet revolutions. Quiet because a serious illness is always suffering and a tragedy, and for people experiencing it it does not matter at all that the degree of this suffering has sharply decreased compared to the previous five-year period. But it certainly happened, and before our eyes: doctors often ask patients to rate their pain on a scale from 1 to 10, and so, the realization that physical pain is abnormal and intolerable has shifted noticeably on this coordinate axis. People who have shifted this mark – and not in the eyes of “civil society”, but on the scale of the entire state and administrative system – often hear accusations against them of collaborating with the state, almost “laundering” its police-corruption component: if to proceed from the fact that the Russian state lies in evil, such cooperation looks ethically intolerable, but for people who 10 years ago could not get the right ampoule, and now they can, probably, this story looks somehow different.