When his brain cancer pain became unbearable, Vlad Zhukovsky pleaded for a stronger dose of painkiller, but the doctors refused, citing Ukrainian health regulations. Unable to withstand the agony, he tried to jump out of a hospital window, but a fellow patient held him back.
"He wanted to fall head down to be killed right away to stop the torture, that's how much his head hurt," his 50-year-old mother Nadezhda said sobbing. "He howled like a wolf."
Hundreds of thousands of Ukrainians who suffer from terminal illnesses are denied proper pain relief, Human Rights Watch said in a report Thursday, urging Ukrainian authorities to adopt international guidelines for pain management.
"These people are crossed out from life even before death," said Viktor Paramonov, head doctor at the Cherkasy Regional Oncology Center in central Ukraine.
Rooted in archaic Soviet-era restrictions and a government campaign to fight illegal drug use, Ukrainian regulations for the use of opioid-based analgesics are among the strictest in the world. Unlike most countries, where patients receive morphine in tablets, the drug is administered in Ukraine only in injectable form and only by a professional nurse. Prescribing morphine requires a team of doctors with hard-to-get licenses.
World Health Organization guidelines dictate that patients must receive as much pain medication as they need. But most Ukrainian doctors cap the daily morphine dose at 50 milligrams _ far less than patients in severe pain need _ based on the instructions of a local pharmaceutical company.
With patients often suicidal from pain, some doctors break the law to alleviate their suffering, risking a prison sentence for illegal possession and distribution of drugs.
A report published last year by the International Narcotics Control Board, a U.N. body that monitors drug issues, said the availability of opioid pain medication in Ukraine was "very inadequate."
Experts say the restrictions have done little to stem the growing use of illicit drugs here and instead have deprived already dying or severely suffering patients of a peaceful, dignified death.
"Medicine is not a hotbed for drugs, but medicine finds itself under greater control than all those drug cartels and that violates a person's right to medical help," said Paramonov.
Yuri Gubsky, a palliative care official with the Health Ministry, agreed that the "problem is colossal," but said the government has already begun reforms to make pain treatment more available.
Vlad's 10-year battle with cancer crushed his dreams of becoming a computer scientist. He died last year at age 27 after being bounced from one hospital to another until he was finally discharged to die at home. He spent three years in excruciating pain, while his mother begged health officials for a higher dose of opiate-based analgesics.
Nadezhda, an administrator at a local fertilizer factory, had to fight off accusations her son was a drug addict and she a drug trafficker, while Vlad's moans resonated across their apartment building.
After pressure from local lawmakers and activists, Vlad was prescribed the maximum 50 milligrams per day of Omnopon, an opioid-based pain killer similar to morphine. But that wasn't enough to relieve his pain. Willem Scholten, an expert in controlled medicines at WHO, said a patient like Vlad may require at least 75 milligrams daily and up to 4,000 milligrams per day in the final three months of life.
In a video shot by Human Rights Watch months before his death, an emaciated, pale-faced Vlad, his hair gone after another round of radiation treatment, described his suffering as a "nagging pain as if somebody is sawing through your back."
"Why do I have to endure pain and torture for years, my entire youth?" he asked in a weak voice from a bed he shared with his mother in their two-bedroom apartment in Cherkasy, 200 kilometers (125 miles) southeast of the capital, Kiev.
Anzhela Marchenko, a researcher at Health to the People, the producer of morphine in Ukraine, said the company would consider manufacturing the drug in tablets. But she defended the daily dosage restriction, saying patients could become addicted to morphine or develop side effects if they used more.
WHO's Scholten said that isn't true.
"These is no maximum dosage," he said, adding that the issue of addiction is irrelevant for the terminally ill. "You always should try to take care of people in pain. It is a moral obligation that is on all of us."
Patients living in remote villages often receive even less pain relief than Vlad did. A nurse usually administers the pain medication only once or twice a day, as opposed to every four hours, as most patients require, because rural clinics are understaffed and underfunded.
Serhiy Psyurnik, who runs a small palliative care group in Cherkasy that supported Vlad, said he recently cared for a cancer-stricken retired police officer who kept a handgun under his pillow so he could kill himself if the nurse did not arrive on time and his pain became too severe.
Gubsky of the Health Ministry agreed that the minimum daily dosage for morphine should be abolished, but said it was up to the manufacturer to do so. The government is also trying to make injectable morphine available for self-administration by patients and supports manufacturing morphine in tablets, he said.
Some doctors break the law and commit "heroic deeds" to relieve their patients' pain, giving them stronger doses of the drugs or sending them home with a supply of analgesics to administer themselves without waiting for a nurse to come, Paramonov said.
One doctor interviewed by The Associated Press said on condition of anonymity that some doctors keep a secret, illegal stash of opioid-based painkillers, obtained from the relatives of already deceased patients to help those who can still benefit from the drugs.
The New York-based rights group called on the Ukrainian government to educate doctors and nurses in pain management as they are often unable to recognize and treat pain.
Albina, 31, an emaciated blonde with suspected tumors in her brain and lungs, said she spent five years in severe pain that her doctors treated only with over-the-counter pain pills because they did not realize the severity of her suffering. She declined to give her surname because she didn't want her condition to be known.
"It was a sharp pain in all your body that started in the bones and ended in the skin _ it was like an exposed nerve," said Albina, a mother of two, whose pain was finally relieved by opioid-based analgesics at Paramonov's hospital.
"When I was alone I was simply howling. It was frightening, I wouldn't wish that for my enemy."