or dozens of cancer patients at the Aga Khan University Hospital, pain is no longer a manageable part of their illness. It has become a cruel, unrelenting companion. The reason is a shortage of injectable morphine.

The hospital’s pain management experts say a large number of terminally ill patients, including children and the elderly, need injectable morphine to relieve their agony. By mid-August, the stocks had been exhausted.

Now, the hospital can only offer morphine in capsule form, which releases slowly and takes time to work, too slow for those in acute distress. Morphine syrup, too, is not available. Doctors say capsules are no use when a child screams in agony or an elderly patient cannot swallow.

The situation is only slightly better at Shaukat Khanum Memorial Cancer Hospital in Lahore and Indus Hospital in Karachi. These facilities still have injectable and oral morphine, but want year-round, consistent access, not just annual allocations that might run out mid-year. They also stress the critical need for fentanyl, another powerful pain reliever.

Fentanyl, experts say, is 100 times more potent than morphine. It often comes in patch form, vital for patients who cannot swallow or cannot tolerate morphine. In Pakistan, these patches are unavailable. Fentanyl injections are imported but used only for anaesthesia and not stocked in large enough quantities to be available for cancer pain relief.

The Drug Regulatory Authority of Pakistan defends the limited supply, saying the country’s requests to the International Narcotics Control Board are based on hospital applications and past usage. Requests go through provincial governments, which inspect the requesting facilities before forwarding the applications to the Ministry of Narcotics Control for a No Objection Certificate, with DRAP copied in.

In Islamabad, hospitals can apply directly to the DRAP, which then forwards paperwork for NOC after inspection. Stock levels must drop to 50 to 80 per cent before restocking requests are considered. Drug companies must also apply annually for permission to supply controlled drugs. Once stocks are nearly depleted, hospitals must seek a fresh NOC to accept new shipments.

Pakistan gets around 185,000 new cancer cases each year, with more than 118,000 deaths. Hundreds of thousands of patients at any given time require some form of pain medication; a significant number need strong opioids like morphine or fentanyl.

The Anti-Narcotics Force oversees DRAP, adding another layer of decision-making. Hospitals say the trouble stems from a reluctance to initiate the process for fear of entanglement in red tape.

Pakistan gets around 185,000 new cancer cases each year, with more than 118,000 deaths. At any given time, hundreds of thousands of patients require some form of pain medication; a significant number need strong opioids like morphine or fentanyl. Among them is 17-year-old Eman, battling osteosarcoma, a bone cancer that has wasted away her muscles and left her dependent on others. A planned trip to Islamabad last month had to be cancelled because her pain was too severe.

Her family’s pleas for morphine have often gone unanswered. They have occasionally managed to obtain small amounts from hospitals. She describes her pain as unbearable. Her ordeal is made worse by the knowledge that morphine, a drug in use for more than two centuries, is out of reach.

The World Health Organisation lists oral morphine, morphine injections and fentanyl patches among essential medicines for cancer pain relief. It calls for a balance between availability for medical use and prevention of misuse. In Pakistan, however, many hospitals do not apply for quotas. Some public facilities do not apply at all.

In the absence of morphine and fentanyl, patients are given tramadol, codeine or nalbuphine that are easier to obtain but inadequate for severe cancer pain.

Morphine is relatively inexpensive to produce. Its supply could be improved at little cost if there were a change in policy. Fentanyl patches are more expensive but still affordable in the context of cancer care. Doctors say the solution lies in simplifying hospital applications, increasing flexibility for restocking, ensuring pharmaceutical companies can maintain an uninterrupted supply and reducing the layers of approval that currently slow the process.

M Waqar Bhatti is an investigative reporter, currently covering health, science, environment and water issues for The News International.

Sara Iram Gill is a freelance journalist with several years of experience.