Pakistan's cancer patients are struggling to find morphine

KARACHI: Thousands of cancer patients, including children, and some of who are in the terminal stage of the disease, continue to face miserable and painful deaths in Pakistan as the most effective opioid drugs for pain relief, including morphine and fentanyl, are not being provided to major healthcare facilities in Pakistan, The News has learnt.

Interviews with senior oncologists across the country revealed that even some major tertiary care hospitals that treat cancer patients, including Combined Military Hospitals of Pakistan Army, Shaukat Khanum Memorial Hospital (SKMH) Lahore and Peshawar, Aga Khan University Hospital (AKUH) and Indus Hospital Karachi, are also facing extreme difficulties in acquiring morphine and fentanyl to relieve the pain of under-treatment cancer and other terminally ill patients.

Expressing their helplessness in giving morphine and fentanyl for pain relief, some oncologists (cancer specialists) have started advising family members of the terminally-sick cancer patients to arrange for the medicines on their own, despite knowing that both medicines are not sold in pharmacies and even most influential hospitals are unable to acquire them for their patients.

Confirming the difficulties in acquiring morphine and other opioid painkillers for cancer patients, former Special Assistant to Prime Minister (SAPM) on Health Dr Faisal Sultan said even Shaukat Khanum Memorial Hospital faces difficulties in acquiring morphine and fentanyl as the “approval process is lengthy”.

Referring to a recent meeting with the Federal Ministry of Narcotics Control for the launch of Opioid Substitution Therapy (OST) for Injectable Drug Users in the country, Dr Sultan said the whole topic of pain control (with opioid-based medicines) also came under discussion with the idea of streamlining the process to ease the sufferings of cancers patients and other terminally-ill people.

On the other hand, families of terminally ill patients are moving from pillar to post for opioid-based pain relief medicines as they can’t see and bear the sufferings of their loved ones, who remain in excruciating pain and often ask their relatives to “give them poison” to end their lives to get rid of the pain.

“My elder brother is in the last stage of colorectal cancer and his oncologist at the Combined Military Hospital (CMH), Rawalpindi, has asked us to arrange for fentanyl patches for him from the open market. I sought the patches at all major pharmacies and places in the country but they are not available. He is in such pain that sometimes he asks me to get him some kind of poison to end his suffering,” Samreen, the brother of a cancer patient, told The News.

Relatives of other cancer patients, who are under treatment at major health facilities in the country, especially those having bone cancer, also confirmed that cancer patients, especially children, had to endure extreme pain as morphine injections and tablets as well as fentanyl were not available while substitute medicines had suboptimal pain relief.

Pain management experts at the Aga Khan University Hospital (AKUH) Karachi also confirmed that oral morphine had not been available for cancer patients since March 2021, while injectable morphine was in such a limited quantity that it was only being used in the operation theatres for anaesthesia while hundreds of cancer patients continue to suffer.

"Given the extremely limited quantity of injectable morphine available, its use has to be prioritised in the operating theatres where small doses and single-use of opioid medication can yield benefits for the majority of patients undergoing surgical procedures,” Dr Muhammad Atif Waqar, Section Head of Palliative Medicine, Department of Oncology at AKUH, said.

Unfortunately, because cancer patients require escalating doses of injectable opioids on a long-term basis, there is not enough injectable morphine available and these patients often have to be supplemented with other suboptimal medications to relieve their pain, he said, but added that painkillers other than morphine and fentanyl, especially Tramadol were not much effective for pain management in cancer patients while they also had very severe adverse effects.

Confirming that oral morphine tablets have not been available for cancer patients for a year at the Indus Hospital Karachi, another renowned cancer specialist and oncologist, Dr Shamvil Ashraf, said thousands of cancer patients, who were treated at their homes, needed oral morphine tablets but due to their unavailability, they had to bear an extreme pain and misery on a daily basis.

Licenses, permissions and no-objection certificates (NOCs) are required from provincial and federal authorities to get oral and injectable morphine, he said, adding that it takes six months to a year to get the allocated quota of the medicine, while in this period, hundreds of cancer patients face painful deaths in front of their loved ones.

"The process to get morphine starts only after the hospital that has the licence exhausts all its available medicine. Now there’s no morphine at the hospital, and you have to wait for months before the provincial health and Excise and Taxation departments process your request, which is then sent to the federal narcotics ministry for a NOC,” he added.

Originally published in The News