Adequacy of Pain Control in Patients With Advanced Cancer in Pakistan Muhammad Hassan Majeed, MD 1 , Ramsha Nadeem, MBBS 2 , Muhammad Abbas Khokhar, MBBS, FCPS 2 , and Muhammad Nawaz Qaisar, PhD 3 Abstract Purpose: Pain is highly prevalent in advanced cancer and requires aggressive management. However, pain management in cancer is minimally investigated in Pakistan. This cross-sectional study explores the adequacy of pain management in patients with advanced stage cancer in Pakistan. Method: From January 2017 to May 2017, a cross-sectional study was conducted at Mayo Hospital, Lahore, Pakistan. A total of 218 patients with cancers were interviewed, and 136 patients with pain 5 on a Numerical Rating Scale for pain were included in the study. Demographic of patients and clinical characteristics of tumors were also eval- uated. Results: Only about one-third of the patients with advanced cancer reported adequate pain management. Chi-square test, w 2 (1, n ¼ 136) ¼ 33.038, P < .05, indicated that pain scores were inversely associated with pain control; inadequate pain control was observed in patients with higher pain score and vice versa. Of the 55.88% of patients who were prescribed morphine, only 6 patients were compliant with treatment recommendations. Most patients were prescribed nonopioid medications and tramadol and codeine, which are weak opioid medications. Conclusion: The rate of undertreatment of cancer pain in Pakistan is alarming. Inadequate clinicians’ training, patients’ and caregivers’ beliefs, lack of availability of opioid medications, and socioeconomic factors are some of the barriers to effective pain control. A multidisciplinary team approach is necessary to follow the World Health Organization pain ladder guidelines for the treatment of cancer pain. Keywords cancer pain, palliative care, end-of-life care, opioids, Pakistan, WHO pain ladder, analgesia in cancer, pain control, pain Introduction Pain is a common and ominous symptom of cancer. 1 It is prevalent in 50% to 70% of patients with cancer and in almost 90% of patients with advanced illness. 2,3 Pain is poorly understood because it can have many different causes including inflammatory, ischemic, neuropathic, and direct compression effects of the mass. 4,5 Chronic cancer pain is often comorbid with psychiatric illness, and it nega- tively affects the quality of life of the patient. 3 The global burden of cancer continues to grow, particu- larly with an accelerated incidence rate in low-and middle- income countries (LMIC). 6 Among the many causes of rising cancer rates in these countries are increased long- evity, an exponential growth of population, unhealthy life- styles, socioeconomic factors, and lack of access to health care. Overall, the prevalence of cancer in Asia is high and most patients with cancer present in an advanced stage of the disease that is commonly associated with moderate to severe pain. 7 It is projected that by 2030, there will be 10.7 million people in Asia with cancer and 7.5 million cancer-related deaths. 8 Cancer is already the second leading cause of death in LMIC. 9 The World Health Organization (WHO) analgesic ladder provides a framework for the treatment of cancer pain. 10 For mild pain, it recommends nonsteroidal anti-inflammatory drugs (NSAIDs) or other nonopioid medications; for moderate pain, opioids along with nonopioid medications; and for severe pain, potent opioid medications are recommended. 11 Despite these guidelines, unrelieved pain in cancer is a well-documented phenomenon. 12,13 Pakistan is the sixth most populous country in the world and has a unique set of demographic and socioeconomic factors that can influence the prevalence and treatment of cancer. There is no national cancer registry; consequently, there is extremely limited data available about the prevalence of cancer in Pakistan. 14 The estimated incidence of cancer is *150 000 1 Natchaug Hospital, Mansfield Center, CT, USA 2 Mayo Hospital, Lahore, Pakistan 3 Hamdard University, Islamabad Campus, Islamabad, Pakistan Corresponding Author: Muhammad Hassan Majeed, MD, Natchaug Hospital, Mansfield Center, 11 A Stott Ave, Norwich, CT 06360, USA. Email: hassan.majeed@icloud.com Journal of Palliative Care 2018, Vol. XX(X) 1-6 ª The Author(s) 2018 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0825859718800490 journals.sagepub.com/home/pal