Standard narcotic analgesics in the Russian troops
Introduction
The SVO has raised interest in military medicine in the Russian Federation. And what is the situation with standard narcotic drugs in the military?
What are the trends, problems, prospects?
We will try to answer this question in as much detail as possible.
The article provides a review of standard narcotic analgesics in prehospital care.
The legal component of the issue
Here it is necessary to immediately make a remark that such a concept as "narcotic analgesic" is somewhat conditional. This is a legal and legislative relation of an analgesic to one of the groups of "narcotic drugs, psychotropic substances and their precursors subject to control in the Russian Federation" at the current moment in time.
The same analgesic at different times, according to the legislative base of the Russian Federation "On narcotic drugs and psychotropic substances", could be in different groups. That is, the same drug, having constant properties, according to the state register of drugs, could change the group several times over 10 years and, accordingly, the requirements for circulation and storage.
A drug can change its group within one legislative framework, the Federal legislative framework itself changes periodically, requirements within ministries and departments can change. And in all this diversity of laws, by-laws, orders, there is military and civilian medicine.
The authors deliberately do not provide the legislative framework itself in the article, as it is updated periodically.
Modern history of the issue. Liberal and Conservative approaches
In fact, two approaches can be distinguished to the storage, accounting and use of narcotic drugs in the military: liberal and conservative.
Let's look at them below.
1. Liberal
Issue of standard analgesics to all personnel. After use or misuse - replenishment.
Extended medical indications for use.
Simplified write-off, minimum reports or issuance and write-off by the notorious "direct expense". What this "accounting" system can lead to is well demonstrated in the film based on the stories of M.A. Bulgakov - "Morphine".
For example, in the 2000s in the Russian Federation there was a simplified circulation of such a drug as butorphanol. At one point, this drug was practically freely available in Russia and Ukraine. And during the same period in the Russian Federation, in the military link, they tried to replace promedol with butorphanol. The short but eventful period of butorphanol as a standard analgesic will be described below.
2. Conservative
The absence of standard narcotic analgesics in the individual first aid kits of military personnel. But the presence of these drugs in the kits of orderlies and medical instructors.
In the US Army, similar methods were used during the conflict in Afghanistan and Iraq. Where a medical helicopter would arrive 15 minutes after a soldier was wounded. The analgesic, when administered intramuscularly, according to its pharmacological properties, would only begin to act. In general, the configuration options for the individual first aid kit "IFAK" at that time are a subject for discussion.
In the US Army there is a restriction on the distribution of narcotic drugs in individual first aid kits. Considering the large number of "drug-positive" servicemen in the US, this step is entirely justified.
As is known, the army is an extension of society, and those who join the service, even in the USA, are far from being children of the aristocracy. But the US Army has a system of selection and career growth in the troops for privates and sergeants. And medicine is different in different military departments. This is all without counting the large number of military registration specialties in medicine. For example, the arsenal and algorithm of analgesia in the pre-hospital link of the TCCC (Tactical Combat Casualty Care) for US Ranger units from 2007 will be the envy of some anesthesiology and resuscitation departments in the Russian Federation in 2025.
Everything is relatively clear with the options for turnover and control, but what happened in the Russian Federation in the military sector from the 90s to the present in this area?
Search for the optimal drug for the Russian Armed Forces in the 90s - 2010s
In short, in the RF Armed Forces there was a constant struggle between a number of mutually exclusive demands.
1. Safe and injectable analgesic (as a rule, a narcotic drug is more effective).
2. Cheap drug (the drug is needed in large quantities, and that is why it had to be one). Storage at 110% of the drug and issue as needed. And no medical institution will use the drug after it has been stored somewhere responsibly for a couple of years.
This means that after 3–5 years the entire batch of the drug must be disposed of.
3. Minimum requirements for turnover and storage. Iron doors, alarms, accounting books, studies and permits. It is advisable to do without all this. And, of course, no refrigerators.
4. The main question at that time and at the same time the argument: why is this drug needed in such quantities in the RF Armed Forces if no one will use it?
It is clear that a painkiller can be either a ketorol tablet or such a well-known “cough remedy” as diacetylmorphine.
But the drug must be safe and effective, even in the hands of a soldier.
Promedol in combination with ketamine in subnarcotic doses met this requirement well. And we are omitting the rich experience of using amphetamine and its analogues in the armed forces of the USA, NATO countries and the USSR.
But, as we know, the law never sleeps. And the requirements for control and circulation of narcotic, potent and psychotropic drugs in the Russian Federation have been tightened, including for military medicine.
In the 90s and 2000s, the Russian Armed Forces were on the path of obtaining a standard narcotic analgesic that did not fall into the group of narcotic drugs.
The Russian Armed Forces searched for, but never found, a replacement for Promedol. At first it was Tramadol. Then it was Butorphanol, which successively moved from group B to group A and then to the group of narcotic drugs.
Both the drug distribution options and the drug itself could be different at different times and in different ministries and departments.
In some places, service analgesics were issued to all servicemen during combat missions. In some places, not to everyone, but only to medical workers. In some places, they were not issued to anyone.
They could issue “Promedol”, “Tramadol”, “Butorphanol”, and somewhere narcotic analgesics were kept in warehouses for the entire expiration date.
The initiation by the Prosecutor's Office and the Investigative Committee of the Russian Federation of licensing medical companies and medical stations as medical organizations in a number of areas of daily medical service activities has seriously limited such searches for the optimal drug. In particular, questions have arisen regarding the licensing of military units for the circulation, storage and use of narcotic drugs.
The decision, frankly speaking, is controversial and does not have a serious impact on the quality of medical care or its availability in the troops.
But the law is the law. After several years of courts and proceedings, everyone came to the conclusion that a medical company and a city hospital are not the same thing, and in a conventional motorized rifle regiment, medical activity is not a core activity. Around 2018, the military was left alone.
What is the current situation in the Russian Armed Forces with standard narcotic analgesics at the military level?
Currently, the Russian Armed Forces are receiving and using Nefopam (Akupan) en masse. Nefopam is produced in injection forms: ampoules and syringe tubes. It is slightly inferior in effectiveness to Promedol, but is not a narcotic drug. Of the minuses, Nefopam, like many other drugs, does not tolerate freezing well.
That is, now in the individual first aid kits of Russian military personnel there can be two types of standard analgesics in injectable form: narcotic - promedol, and non-narcotic - nefopam.
In June 2024, a manual for the RF Armed Forces was published: “Temporary Guidelines for the Use of Analgesics” - May 2024 (Fig. 1). The manual was created under the influence of the analgesia algorithm from the modern version of TCCC (Tactical Combat Casualty Care) (Fig. 2).
The TSSS analgesia algorithm was originally created for US Special Operations Forces servicemen. It is somewhat difficult to implement for an ordinary soldier or a medical instructor. The RF Armed Forces analgesia algorithm version can be called abbreviated and revised for a wider range of servicemen.
This guideline has added another narcotic analgesic for pre-hospital use in the RF Armed Forces – buprenorphine.
For quite a long time there has been a discussion about the use of the following drugs in the pre-hospital setting: ketamine, morphine, fentanyl.
These drugs have a number of restrictions for use in individual first aid kits.
Ketamine is not mass-produced in syringe tubes, and was not produced in the required dosage for single use at the pre-hospital stage.
Morphine is effective and safe only in the hands of a specialist, it has a large number of side effects that need to be noticed and prevented in time.
Fentanyl is more suitable for group paramedic placement or for work at the medical company stage. On the plus side, transdermal forms of this drug are produced in the Russian Federation, which can find their niche of application.
Due to the above restrictions, three drugs: ketamine, morphine, fentanyl - are used from the stage of qualified medical care.
One of the modern realities of the Russian Federation is that, as in the United States, there are a number of servicemen with a history of drug addiction in the Russian military. It is important to understand that this does not change anything. This category of patients has always received and continues to receive all types of medical care from the Ministry of Health. At the same time, for objective reasons, no one in the Ministry of Health is changing the requirements for accounting and turnover due to these patients.
Conclusions
A balanced approach to the accounting, competent distribution and expansion of the arsenal of standard analgesics in individual first aid kits, analgesics in group kits of medical orderlies and paramedics and in the entire pre-hospital link is desirable.
The search and research on the selection of new and effective narcotic and non-narcotic analgesics for the pre-hospital link continues. Priority is given to drugs that are already produced and used in the Russian Federation. And in general, for 3 years in this area, there is reason for cautious optimism.
The article is analytical in nature, does not contain propaganda for the use of psychoactive substances, all data was obtained from open sources.
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