Pain Management in Palliative care:  Challenges and strategies in Pakistan -Dr. Ismat Jabeen

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Palliative care is a neglected area of healthcare in Pakistan and with only a handful of institutions providing specialized services to those in need. (1) The ratio of palliative care services relative to the population in Pakistan is 1:90 million and as a result of this less than 1% of the population has access to specialty palliative care services. (2, 3) 

Pain is a highly prevalent symptom in palliative care patients and pain relief is vital in improving the quality of life of patients and their families dealing with life threatening illnesses. (4)

Availability of opioid analgesics remain a challenge in Pakistan. It is estimated that only 2% of terminally ill patients have access to opioids for pain management. (5)

According to the data by the Pain and Policy Studies Group, the mean consumption of morphine in 2014 in the Eastern Mediterranean Regional Office (EMRO) was 0.384 mg/capita compared to the global mean of 6.24 mg/capita. In contrast, the mean opioid consumption in Pakistan is only 0.05 mg/capita. (6)

The availability of controlled opioid analgesics is an issue in many parts of the world, including Asian regions. (7-9)

Pakistan faces this challenge with high severity despite having significant disease prevalence warranting prescription of high potency opioids. Morphine, which is essential for pain management in palliative setting, is not widely available in the country due to limited supplies and stringent national regulatory policies.

Strict control measures instituted to prevent the illegal use of the drugs entirely disregard the necessity of analgesia for those suffering from severe pain at the end of life.

Approval of four different ministries & governmental departments is required to procure the limited amounts of available opioids. Opioid can only be dispensed by the prescription of credentialed tertiary care consultants including oncologists, anesthesiologists and pain specialists.

This prevents adequate pain management for palliative patients in community and forces them to seek end of life care in tertiary care hospital, adding unnecessary burden to the healthcare and suffering to patients. (10)

Available Pharmacotherapies for Palliation are limited to Tramadol oral (immediate and delayed release) and injectable, Tapentadol oral (immediate release), Buprenorphine sublingual, Nalbuphine Injectable and Adjuvant analgesics.

Because of the non-availability of Morphine and other strong opioids, the weak opioid tramadol has become the analgesic most frequently used in the region to treat moderate to severe pain.Radiation and interventions like nerve block are available in advanced care institutions to improve painsymptoms.

Policymakers in Pakistan are being sensitized to promote the availability and accessibility of opioids for those who are in need, to provide effective pain relief. Inclusion of pain management in the core curriculum for both undergraduate and postgraduate training and comprehensive guidelines for goal-directed chronic opiate therapy will potentially enhance the outlook for chronic pain management in Pakistan.

Every person should have right to live with dignity without suffering from pain. Pain may be universal but sufferings should not be.



Dr. Ismat Jabeen

Consultant in Palliative Medicine and Family Medicine, The Aga Khan University


Acknowledgment: I would like to express my sincere gratitude to Dr. Atif Waqar and Dr. Nasreen Muhammad Saleem consultant in Palliative Medicine at the Aga Khan University, Karachi for reviewing the final draft.


  1. Khan RI. 2017. Palliative care in Pakistan. Indian J Med Ethics. Jan-Mar; 2(1):37-42
  2. WHO Global Atlas on Palliative Care at the End of Life. 2014. Retrieved from
  3. Lynch T, Connor S, Clark D (2013) Mapping levels of palliative care development: a global update. J Pain Symptom Manage 45: 1094-1106
  4. Sholjakova M, et al. Pain Relief as an Integral Part of the Palliative Care. Open Access Maced J Med Sci. 2018
  5. HRW (2011) Global State of Pain Treatment: Access to Palliative Care as a Human Right. Human Rights Watch.
  6. Osman H et. Al, Atlas of Palliative Care in the Eastern Mediterranean Region (2017) –
  7. Seya MJ, Gelders SF, Achara OU, Milani B, Scholten WK. A first comparison between the consumption of and the need for opioid analgesics at country, regional, and global levels. J Pain Palliat Care Pharmacother. 2011;25(1):6–18
  8. Cleary J, Silbermann M, Scholten W, Radbruch L, Torode J, Cherny NI. Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in the Middle East: a report from the Global Opioid Policy Initiative (GOPI). Ann Oncol. 2013;24(suppl 11): xi51–xi59
  9. Duthey B, Scholten W. Adequacy of opioid analgesic consumption at country, global, and regional levels in 2010, its relationship with development level, and changes compared with 2006. J Pain Symptom Manage. 2014;47(2):283–297
  10. Khan TH. Availability of essential drugs in Pakistan [Editorial]. Anaesth Pain and Intensive Care. 2009; 13(1):1–3.

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