“Nalbuphine in the military: controlled practice or dangerous addiction

31 January 12:46

Cocaine, heroin, methadone, oxycontin. From ancient times to the present day, people have been looking for ways to change their state of consciousness, and pharmacology only simplifies this process. It all started with medications, but quickly went beyond medical practice and became a source of drug addiction. “Nalbuphine is no exception.

First patented in 1963, it was not very popular for a long time. Its pharmacological characteristics made it unsuitable for use in anesthesiology – after Nalbuphine, other strong opioids, such as fentanyl, work poorly or not at all. But everything changed in 2014, when it was included in the military’s first aid kits. The outbreak of war, a large number of wounded, and problems with supply made Nalbuphine one of the most widely available painkillers in the war zone. Why doctors and pharmacists are categorically against Nalbuphine, and who should be responsible for its distribution, Komersant ukrainskyi found out.

Despite its removal from the first aid kits in 2017, the distribution of Nalbuphine has already been launched. And today is no exception. Anesthesiologist and resuscitator Dmytro Makarov once again drew attention to this . The full-scale invasion of 2022 only worsened the situation: the army was experiencing an acute shortage of medicines, volunteers were buying whatever they could find, and pharmaceutical companies were rejoicing in their profits. During the war, control over drug trafficking was weakened, and Nalbuphine began to be sold over the counter, making it popular not only among the military but also among civilians, Makarov says.

“What did this lead to? In 2023, Nalbuphine became the FIFTH most frequently purchased drug in Ukraine. So people are selling Nalbuphine without a prescription. Just like tramadol used to be. You know where there is a pharmacy in your neighborhood with empty blisters and syringes lying around and “drone watchers” grazing. I’m telling you, it’s nothing new. It’s all been there before. And soon it will get much worse,” says anesthesiologist and resuscitator Dmytro Makarov.

The doctor emphasizes that if the situation is not brought under control now, we will face another surge in drug addiction, this time among those who have returned from the war and are trying to live on.

Indeed, in 2024, pharmacies in Ukraine sold three million packs of the opioid painkiller Nalbuphine, while only six thousand prescriptions were written for it. This was confirmed by Health Minister Viktor Lyashko. He also promised that the Ministry of Health would decide on the process of Nalbuphine circulation in the country by the end of 2024. However, as pharmacists explain, this drug is not currently subject to itemized quantitative accounting. Therefore, no reporting is required for Nalbuphine, and no additional license is required for its sale.

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“Keep in mind that it is there”: an officer on the uncontrolled distribution of Nalbufin

Officer of the Ukrainian Defense Forces Yevhen “Tykhyi” shared his experience of using Nalbufin during the hostilities and expressed his opinion on those responsible for its distribution among the military. According to him, at the beginning of the full-scale invasion, control over medicines left much to be desired. One of the key factors that contributed to this, he says, was the actions (or inaction) of the then Commander of the Medical Forces of the Armed Forces of Ukraine, Tetyana Ostashchenko.

“Many military personnel complained about her [Tetyana Ostashchenko – ed. I believe that she should be held accountable, because providing the necessary medical supplies and proper training of doctors were her direct responsibilities,” says Yevhen “Tykhyi”.

As for Nalbuphine itself, the officer said that his unit was given the drug, although with a warning that its use was undesirable.

“As for Nalbuphine, I had an ampoule once. Specifically, my unit was given it to everyone. We are a professional unit, we did not need to be explained what it was, but we were told that it was advisable not to use this drug. Like, keep in mind that it is there,” Yevhen “Tykhyi”.

Moreover, tactical medicine courses, including TCCC, clearly emphasize that this drug should not be used on the battlefield. This is a drug that can complicate further treatment and surgery, says Officer Tykhyi.

“Doctors will simply not know what to do if a soldier is under its influence,” emphasizes Tykhyi.

Despite this, there have been cases of Nalbuphine use among the military. The officer recalls a story from the ATO when one of the wounded was screaming in pain at first, and after an injection of the drug, he changed his behavior to the point where he started telling jokes, even though his injury was serious.

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“Nalbuphine in the military: isolated cases or systemic use?

Dmytro Kuzmenko, a medic and head of the medical supply department of the 66th separate mechanized brigade, in an exclusive commentary for Komersant ukrainskyi shared his experience of using painkillers in the combat zone.

According to him, as of today, he has not observed any cases of Nalbuphine use among military personnel. However, in 2022, isolated cases of its use did occur. It is important to note that these drugs were not officially issued by military structures, but got to the soldiers in various ways – through personal purchases or humanitarian aid.

“In 2022, when there was a period of massive voluntary involvement of citizens in the defense of the country, people provided themselves with everything they needed, including painkillers. Probably, there could have been cases of Nalbuphine use then, but there is no reason to talk about its massive use. No one kept statistics,” notes Dmytro Kuzmenko.

He also emphasizes that the official protocols of the Ministry of Health of Ukraine, even in their latest versions of 2024, do not provide for the use of Nalbufin in the provision of medical care in combat.

“I don’t know of any military units, including ours, that officially receive or use this drug,” adds Dmytro Kuzmenko.

What is the danger of Nalbuphine?

Doctors and pharmacists are unanimous: “Nalbuphine is an opioid analgesic that is addictive and can negatively affect consciousness and adequate pain perception. Its use in combat conditions not only contradicts tactical medicine protocols, but also endangers the lives of soldiers.

Dmytro Kuzmenko, head of the medical supply department of the 66th Separate Mechanized Brigade, notes that is a prescription drug that should be used only as prescribed by a doctor.

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“The responsibility for controlling medicines in military units is shared by commanders and medical personnel, including combat medics, doctors and paramedics. They must ensure that the first-aid kits are fully stocked and that medicines are updated in a timely manner. If unauthorized medicines are found in the kits of military personnel, they should be seized and the situation should be reported to the command,” said Kuzmenko.

Regarding the possible consequences of using Nalbufin without proper control, the doctor emphasized the risks of respiratory center depression, which complicates the evacuation of the wounded. In addition, due to the specifics of the drug’s action on receptors, further use of stronger painkillers may be less effective, which will only increase the suffering of the wounded.

“The official protocols of the Ministry of Health of Ukraine, including the latest version of 2024, do not provide for the use of Nalbuphine in combat conditions. Its absence in the medical supply system of the Armed Forces of Ukraine indicates the inappropriateness of using this drug in the army,” Dmytro Kuzmenko said.

The real situation with the provision of first aid kits for the military

Dmytro Kuzmenko also talks about the real situation with the provision of first aid kits to military personnel and the use of painkillers in the combat zone. According to him, since the second half of 2022, the provision of individual first aid kits to the personnel has become one hundred percent.

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“The Armed Forces of Ukraine fully provide the military with first aid kits, and I still do not understand why some volunteers continue to raise funds for their purchase,” Kuzmenko said.

He emphasized that a standard individual first aid kit does not contain any medicines except for Pilpak, a painkiller that includes paracetamol and ibuprofen, as well as an antibiotic to prevent infections. In combat conditions, the use of stronger analgesics such as opioids is not allowed under either Ukrainian or international protocols.

“In the red zone, directly on the battlefield, there is no administration of medicines, as there is usually no medical staff there. At best, there may be a rifleman or a combat medic, who in 99% of cases has no medical education and is not authorized to administer medicines,” explained Dmytro Kuzmenko.

However, he admitted that isolated cases of using stronger painkillers have happened and will happen, because war has its own specifics.

“This war is different from previous conflicts, even from NATO’s experience, and blindly following their protocols is not always correct,” Kuzmenko summarized.

So, despite the fact that official medical protocols do not provide for the use of Nalbuphine at the front, cases of distribution of this opioid analgesic remain. The war creates special conditions in which the need for painkillers increases and control over their circulation is weakened.

Systemic solutions are needed: clear mechanisms for controlling the medical supply of the military, responsibility for illegal trafficking of Nalbuphine, and the creation of quality rehabilitation programs for veterans. Only a comprehensive approach will minimize risks and prevent the repetition of past mistakes.

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Anastasiia Fedor
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