While working at the forefront of the opioid epidemic in the United States, I did not realise that Pakistan had its own opioid problem — the lack of one.
I learned this the hard way; my mother direly needed pain medication to manage her cancer pain but couldn’t find it.
It was hard for me to believe when her oncologist told me that no potent opioid pain relievers were available in Pakistan.
The only readily available options were Tramadol and Codeine, both of which are extremely weak opioids and usually ineffective for the treatment of cancer pain.
Morphine is available, but only at select places in Lahore where she lives, and then only in injectable form.
My family was able to arrange for a few ampoules of morphine for my mother, but finding an intravenous line in her arm was a problem.
Since morphine has a short half-life, it requires multiple doses a day to relieve pain and having to endure needle pricks so frequently made her very uncomfortable.
I was so shocked by this information that I did not believe it. To see if it was really true, I called my friend, an oncologist at a hospital in Lahore, and asked him about the availability of pain medications in Pakistan for cancer patients.
He could only add another weak opioid, pethidine, to the list of medications.
He said, “I see patients suffering from cancer pain in front of me every day, but I cannot do much about it. There are no medications. The ones that are available are not easily accessible. There is a lot of unnecessary misery, suffering and pain. We can treat it effectively only if we can get pain medications.”
“Is there any way we can get any medications for my mother?“ I asked him.
He replied, “Unfortunately, no. And the irony is that I see people using heroin right outside the hospital, an illicit but potent opioid pain killer.”
Next, I reached out to a palliative care and end-of-life care physician working in New York to ask him for advice about my mother’s illness.
He calmly replied, “The most you can do is try to keep her pain under control and keep her comfortable.”
The medications he mentioned were oral opioids for pain relief, all of which were several times more potent than morphine.
They were the medications that are the standard-of-care for cancer pain management in the United States and the rest of the world.
Once again I felt helpless: I knew that not even oral morphine was available in Pakistan, let alone stronger pain medications.
Fortunately, my mother has a cancer whose pain could be controlled by a nerve block injection. She underwent this treatment, called celiac plexus block, which reduced her pain tremendously.
She has received three such treatments, and her pain is mostly under control.
At times, she has breakthrough pain, which my family tries to manage by using different pain medications. When it gets severe and constant, it is the indication for them to take her for the next nerve block procedure.
While my mother is fortunate that the pain from her type of cancer can be effectively treated in this way, this is not true for most types of cancer.
Consequently, thousands of people in Pakistan with other cancers are suffering from pain every day and unable to find any effective treatment medications.
Seeing this situation in my own family led me to reflect on my education and training in Pakistan as a medical student and as an intern.
I had seen several cases of cancer and end-of-life care in the course of my training and work, but at the time I did not think about the treatment of retractable pain, nor did I notice that pain management was missing from a medical student’s curriculum and training.
Pain management should be an essential part of medical education and every young doctor in Pakistan should learn the best practices available to manage their patients’ pain.
It is still baffling to me that potent pain medications are not available in pharmacies in Pakistan. Maybe the government and regulatory agencies are worried about the diversion of these medications for other purposes.
But Pakistan must come up with a plan to regulate and monitor these medications and make them available to those who are suffering from severe cancer pain or are in an end-of-life care situation.
Every person should have the right to live in dignity without tormenting physical and mental pain, especially those with a terminal illness.
Pain may be universal, but suffering does not have to be.
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