Pain Characteristics of Adult Haematological Cancer Patients at an Outpatient Clinic in Nigeria – a Cross-sectional Study

Pain Characteristics of Adult Haematological Cancer Patients at an Outpatient Clinic in Nigeria – a Cross-sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Pain Characteristics of Adult Haematological Cancer Patients at an Outpatient Clinic in Nigeria – a Cross-sectional Study ogochukwu izuegbuna, oyewale saburi, chijioke chijindu adindu, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8441132/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract OBJECTIVE Pain is a very common complaint among haematological cancer patients. There is yet to be a study on the portrayal of pain experiences among haematological cancer patients in Nigeria. This main aim of this study is to do an appraisal of the clinical characteristic of pain issues in Nigerian haematological cancer. METHODS The 36 haematological cancer patients from the University of Ilorin Teaching Hospital were divided into myeloma or non-myeloma groups. Their Socio-demographics and clinical attributes were duly recorded. The painDETECT questionnaire (PDQ), the numeric pain rating scale (NPRS) and pain management index were deployed to evaluate their pain levels. RESULTS Approximately 67% study participants complained of pain at presentation, and 92% reported it as their worst in the past 4 weeks. A mean age of 58 years was reported among the patients. multiple myeloma was significantly associated with age (p = 0.035) performance status (p = 0.044), pain at presentation (p = 0.047), worst pain in 4 weeks (p = 0.013) and neuropathic pain (p < 0.001). In the multivariate analysis, performance status (b = 0.902, p = 0.03) and use of a strong opiate (b = 25.667, p = 0.005), weak opiate (b = 15.833, p = 0.001) and age (b = 1.075, p = 0.029) had significant association with multiple myeloma. The percentage of patients receiving inadequate pain therapy (PMI < 0) was 22.2%. DISCUSSION This research shows the characteristic of pain in haematological cancer patients in Nigeria. The findings highlight the unevenly raised frequency of neuropathic pain in multiple myeloma compared to other haematological cancer. In addition, the inadequacy of pain management was also exposed. Haematological cancer multiple myeloma Cancer pain neuropathic pain pain management index Figures Figure 1 1.0 INTRODUCTION Haematological cancers are not quite common worldwide. They are said to constitute about 6.5% of all cancers worldwide, and about 10% of cancers in Africa 1 , 2 . However, the incidence is increasing at a fast rate in Africa with a recent systematic analysis putting the pooled prevalence of hematological malignancies at 27.30% 3 . With an increased incidence comes increase in morbidity and mortality. One of such morbidities is pain. Pain is common in haematological malignancies, with up to 60% actively receiving antineoplastic treatment known to have pain 4 . This can arise from the use of such drugs like vinca-alkaloids, bortezomib, thalidomide and a host of others or it may be as a result of the malignancy itself. The issues of pain in them is rather rife, and with a lack of complete understanding of the pain experienced because the usual narrative is people with solid tumours experience more pain than people with haematological malignancies. However, a study by Kibret et al in Ethiopia showed that apart from gastrointestinal cancer, patients with haematological malignancies had the highest odds of having cancer pain compared to other cancers 5 . In some reported studies in Italy, the prevalence of pain in multiple myeloma and leukaemia/lymphoma patients were 86% and 83% respectively 6 . These records show that pain is very much present in haematological malignancy patients. What is not really known is the characteristics of the pain among Nigerian haematological malignancy patients, and if there is effective pain management. Haematological malignancy patients can present with pain just like any other cancer patient. These pain can either be nociceptive (inflammatory) or neuropathic. It can be the exacerbation of an old pain with varying intensities. More importantly, cancer pain can have adverse effect on a patient well-being including their functionality, social and emotional engagements, compliance to treatment modalities and more. In addition, the proper management of cancer pain should involve a good assessment of pain features and characteristics as well as the utilization of a pain management index. A 3-step pain ladder guideline which entail the use of analgesics for different grades of pain i.e. for pain considered mild - paracetamol, for pain considered moderate - codeine, and for pain considered severe – morphine, as recommended by the World Health Organization (WHO) 7 . The Pain Management Index (PMI) is a tool developed to evaluate the adequacy of pain treatment 8 . The PMI compares the pain level of a patient with the strength of the analgesic prescribed. The PMI score is thus obtained through the subtraction of the categorized pain level from the categorized analgesic level (score). A negative score show that the treatment of the pain was not adequate. The prevalence of cancer pain is quite high in Nigeria, with some studies reporting over 80%, along with inadequate pain management 9 – 11 . However, these studies (and none yet) did not focus on pain in haematological malignancy patients primarily. This study is the first one in Nigeria to take a peep at the characteristics of pain among haematological malignancy patients. The primary aim for this research was to look into the prevalence and clinical characteristics of pain and other contributing elements in haematological malignancy patients in a cohort attending clinic at a teaching hospital in Nigeria. Our secondary objective was to look at features of neuropathic pain and the pattern of pain management in haematological malignancy patients. 2.0 METHODOLOGY Study design and settings The observational study was done at the University of Ilorin Teaching Hospital. The collection of various data occurred between June 2023 to December, 2023, and it was at the adult outpatient haematology clinic. The study employed a cross-sectional design to capture a snapshot of the pain experience in the haematology clinic population. Adult haematological patients aged 18 years and above with a confirmed diagnosis of a haematological malignancy which included leukaemias, lymphomas, myelomas, and myeloproliferative neoplasms without a concomitant solid tumor, and who attended the outpatient haematology clinic at the University of Ilorin Teaching Hospital during the six-month data collection period were included in this study. A non-probability, consecutive sampling technique was deployed in the enrollment of study participants.The exclusion criteria for the study participants included admitted inpatients, those that are critically ill, patients with a significant cognitive impairment or are diagnosed with a psychiatric condition that would impede their ability to provide accurate pain reports, or declined to provide informed consent. Eligible patients were approached in the clinic, the study was explained in detail in their preferred language. The questionnaire was then administered in a private room to ensure confidentiality and patient comfort. Medical records were reviewed to verify the diagnosis and current medications. To ensure data quality, completed questionnaires were checked for completeness and consistency at the end of each clinic day. An ethical approval was obtained from the Committee on ethics and research of the hospital (UITH/CAT/189/21/1119). Each of the patient in the study gave a written informed consent. A questionnaire with socio-demographic and clinical information was filled by each participant. The socio-demographic data captured included the age, gender, level of education, occupation, and marital status; the clinical data collected included the specific haematological diagnosis, the current treatment regimen (e.g., on chemotherapy, radiotherapy), and a performance status assessment using the karnofsky performance status scale. The karnofsky performance status scale is a validated tool that grades a patient's level of functional impairment, from 100 (fully active) to 0 (dead), providing a crucial context for understanding the impact of pain on daily life. Pain levels were evaluated using the numeric pain rating scale (NPRS) and the painDETECT questionnaire for neuropathic pain. The NPRS is a widely used, reliable, and valid unidimensional measure of pain intensity with a pain on a scale from 0 (no pain) to 10 (worst imaginable pain). Two key metrics were assessed: (i) pain intensity at the time of the clinic visit (current pain), and (ii) the worst pain intensity experienced in the past four weeks. The four-week recall period was chosen to capture a more representative picture of the patients' pain experience beyond the immediate moment, accounting for fluctuating pain levels related to treatment cycles or disease activity. Regarding neuropathic pain, The painDETECT questionnaire which was used, is a wholly patient-completed, screening tool designed to identify the presence of neuropathic pain components. It does not require a clinical examination, thus, making it highly practical for the clinic setting. It consists of seven items that assess the quality and pattern of pain (e.g., burning, tingling, electric shock-like sensations) and one item on pain radiation. Its validity and reliability have been established in various populations, including cancer patients. PMI was also calculated. Patients were asked the current pain level at presentation, and their worst pain over the past four weeks. The type of pain relief medications used by the patient was also recorded - All analgesic medications the patient was currently taking for pain relief including non-opioids (e.g., paracetamol, NSAIDs), weak opioids (e.g., tramadol, codeine), strong opioids (e.g., morphine), and co-analgesics (e.g., gabapentin, pregabalin, amitriptyline) were documented. For the categorization of pain, a pain score of “0” was labeled as no pain, while a score of “1” was for mild pain, “2” was labeled moderate pain, and “3” categorized as severe pain. These categorizations stemmed from the NPRS where “0” indicated as no pain, “1–3” indicated as mild pain, “5–7” indicated as moderate pain, and “8–10” was for severe pain 12 . For the calculation of the PMI, the analgesic score was categorized on the type of analgesia used to treat pain with the subtraction of the categorized pain score. Thus, where no analgesia was used, the pain score was “0”, ” where a non-opioid was used (i.e., NSAID or acetaminophen) the score was “1,” a “weak” opioid (e.g. dihydrocodeine, tramadol) was scored “2,” and a “strong” opioid (e.g., morphine, fentanyl) was scored as “3”. The patient’s pain at presentation and the worst pain experienced in the previous 4 weeks were categorized and used to calculate the PMI separately. This dual approach provides a more nuanced view, potentially revealing instances where a patient's background pain is controlled but breakthrough or incident pain is not. The Neuropathic pain (NP) which was screened for using the painDETECT questionnaire has a maximal score of 38. The scores were also categorized: less than 13 were deemed to be improbable, 13–18 was deemed likely, 19 and above was deemed very probable. This categorization helped to ensure that the likelihood of a neuropathic pain component is captured, guiding further clinical evaluation and management. 2.1 Data analysis The SPSS 26.0 statistical software was used for data analysis. The normality of data was verified by the one-sample Kolmogorov - Smirnov test. Quantitative variables were conveyed as mean ± standard deviation for analysis of patient characteristics including pain measurements and as proportions for nominal variables. For the convenience of analysis, PMI was grouped as positive and negative, NP was grouped as with NP (total score ≥ 13) and those without NP (total score ≤ 12) and the prevalence of pain (NPRS > 0). Given the prominent findings related to multiple myeloma, the groups were divided into two, myeloma and non-myeloma group for comparative analysis. Inferential analyses were conducted to explore relationships. The Fischer exact test, and the Chi square test were used to analyze the groups; the Chi-square test was used for categorical variables, and Fisher's exact test was employed where cell counts were less than 5. Values < 0.05 were put as statistically significant. A binary logistic regression analysis was done to find relationship between significant variables (p < 0.05) and multiple myeloma, entering variables with a p-value < 0.05 from the bivariate analyses. 3.0 RESULTS In all, 36 haematological malignancy patients participated in this study. They were made up of 22 (61.1%) males and 14 (38.9%) females with a mean age of 56. 2 ± 14.0 (range: 21-82 yr.). the haematological malignancies included: 4 (11.1%) chronic lymphocytic leukaemia, 4 (11.1%) chronic myeloid leukaemia, 2 (5.6%) essential thrombocythemia, 1 (2.8%) Hodgkin lymphoma, 13 (36.1%) multiple myeloma, 11 (30.6%) non-Hodgkin lymphoma, 1 (2.8%) polycythemia vera. Table 1 shows the relevant characteristic of the patients. At presentation, 12 (33.3%) patients had no pain, 18 (50%) had mild pain, 5 (13.9%) had moderate pain and 1 (2.8%) had severe pain; the worst pain over the past 4 weeks, 3 (8.4%) had no pain, 12 (33.3%) had mild pain, 12 (33.3%) had moderate pain, 9 (25%) had severe pain. Categorically, for neuropathic pain, 26 (72.2%) had a score ≤12, while 10 (27.8%) had a score ≥13; out of the 10 patients with the likelihood of neuropathic pain (≥13), 8 (80%) had multiple myeloma. Table 2. Using the worst pain experienced within the past 4 weeks as criteria, the percentage of patients with a negative PMI (PMI < 0) was 22.2% (supplementary table 1). The median NPRS for pain intensity was 2 for pain at presentation, and 5 for the worst pain over the past 4 weeks. A total of 8 (22.2%) complain of their pain radiating. Figure 1. All the patients except for one (2.8%) were on analgesic with paracetamol (88.9%) and NSAIDs (72.2%) being the most used for pain, followed by weak opiates (38.9%) and strong opiates (22.2%); 8.3% were on co-analgesics (pregabalin and amitriptyline). The analgesic score and other pain parameters are presented in Table 3. Majority of the patients complained of back pain (supplementary table 2) Due to the number of multiple myeloma patients with NP score ≥13 being highest among all the patients, they were divided into myeloma and non-myeloma groups for bivariate analysis. Analysis was also done along the presence of neuropathic pain (score ≥13). Age, and performance status were significantly associated with multiple myeloma; performance status and presence of multiple myeloma was significantly associated with neuropathic pain. On their use of analgesia, NSAIDs, weak opiates, strong opiates and co-analgesics were significantly associated with multiple myeloma as well as the analgesic score, while strong opiates, co-analgesics and analgesic score were significantly associated with neuropathic pain. Using the binary logistic regression analysis, the relationship between age (p=0.029), performance status (p=0.03), neuropathic pain (p<0.001), weak opiate use (p<0.001), strong opiate use (p<0.001) against type of haematological cancer (myeloma vs non-myeloma) was significant. Table 4 4.0 DISCUSSION Pain is known to be quite commonly experienced by patients with different types of malignancies. Moreso, in haematological malignancies especially myeloma where it is known that about two-third present with bone pain 13 . Uncontrolled pain significantly impairs performance status as well as other associated factors of well-being. In this study, the prevalence rate of pain was similar what was reported by Shen et al 14 (66.6% vs 63%), though the latter was in cancer patients generally. This was higher than what was reported by Niscola et al 14,15 , and Kibret et al 5 , but was lower than what was reported for different haematological malignancy patient from the Italian ECAD-O survey 16 – 18 . However, the pain intensity among MM patients in this study was higher than reported in previous studies. Ramsenthaler et al 19 in their meta-analysis reported a pain prevalence of 73%, which was similar to the 71.7% reported by Zheng et al 20 in their study. Our figure (92.3% at presentation) was also higher than those reported by Nwabuko et al 21 (84.6%) and Nnoyelum et al 22 (74%) in Nigeria. Their report was primarily bone pain, as none of them reported neuropathic pain in MM, thus, it makes this research perhaps the first to report the occurrence of neuropathic pain in Nigerian MM patients as well as other haematological malignancies. Neuropathic pain has been observed among cancer patients in Nigeria 11 . Apart from being contributory to the total pain milieu in cancer patients, it is not adequately recognized in Nigeria, as the aforementioned report showed that only 7.9% of cancer patients are on co-analgesics like pregabalin 10 . However, our study also showed that MM had an unusually high prevalence of neuropathic pain (61.5%). This was higher than the 33% reported by Jespersen et al 23 . Interestingly, all the patients that were on co-analgesics were all MM patients, and represent about 8.3% of the total patient in the study signifying a low use of co-analgesics in managing pain in haematological cancer patients. This may mean that the managing physicians do not readily recognize neuropathic pain as an important aspect of pain in order to manage it effectively despite the fact that many of the patients are on anti-neoplastic agents that can cause neuropathic pain e.g. bortezomib and thalidomide. Bortezomib is a proteasome inhibitor used in the management of different haematological malignancies, especially multiple myeloma where it has profoundly impacted the condition. However, it is known to cause peripheral neuropathy as a complication of treatment. This side effect of the drug can happen at any stage of using the drug. However, it is more common during the fifth cycle at an accumulated dosage of 30mg/m2 24 . It does this through its neurotoxic effect on peripheral nerves. The mechanism through which it causes neuropathic pain are somewhat different, including impairment of axonal transport and inflammatory damage to sensory nerves. It also causes release of inflammatory mediators such as interleukin 1. The incidence of bortezomib-induced neuropathic pain from clinical trials is reported to be between 15% and 57.2% 25 , but in retreatment of MM it has been reported to be as high as 75% for grade 1–2 neuropathy, and about 30% for grade 3–4 neuropathy 26 . These values are significantly higher than what was reported for carfilzomib-induced peripheral neuropathy which is 21% in all patient with less than 1% having grade 3 neuropathy according to a meta-analysis 27 . Vizcaíno et al in their research reported a prevalence of about 50% 28 . This was lower than our value in this study which is about 61.5%. in MM patients. However, our patients were also on other medications and not bortezomib alone. A synergistic effect can explain this action. Thalidomide is an immunomodulatory agent used in the management of multiple myeloma. It has different mechanism of action in MM, but its primary action is through its interaction with cereblon, a ligand-dependent substrate receptor of the E3 ubiquitin ligase complex cullin-RING ligase 4. Cereblon is critical towards the anti-myeloma activities of thalidomide and other immunomodulatory agents like lenalidomide and pomalidomide 29 . Thalidomide like other immunomodulatory drug is also implicated in neuropathy in multiple myeloma. Banach et al 30 in their study reported more than 60% of MM patients treated with thalidomide developed a thalidomide-induced neuropathy. Thalidomide-induced neuropathy is reported to be between 25% to 75%, and it is advised that MM patients be screened for neuropathy before the commencement of thalidomide 31 . While some of the patients in this study were also on thalidomide, the neuropathy seen can be as a result of different therapies. Our research also showed the first comparative account of pain killer medicines utilization for haematological cancer patients in Nigeria. This was done through the utilization of the PMI. The PMI is a clinical instrument that is used in the evaluation of the adequacy of pain control, particularly in cancer patients. It does this through comparison of the pain intensity value i.e. mild, moderate or severe colloquially known as the pain score against a categorical value assigned to a prescribed analgesic drug known as the analgesic score. The difference between the categorical pain score and the analgesic score becomes the PMI. The primary function of the PMI is to evaluate whether the level of pain relief provided is appropriate for the reported intensity of pain. Using the PMI, our study show that haematological malignancy patients may also suffer from undertreatment of cancer pain. the percentage of hematological malignancy patients with under treated pain in our study was 22.2% which is higher than what was reported by Sichetti et al 32 , but lower than what was reported by Shen et al 33 . However, our results were closer to what was reported in literatures, between 25% and 62% 34–38 . Such a small difference could be as a result of the lower number of participants in our study, so that a larger number could possibly show more patients with a negative PMI. On the other hand, the analgesic score shows that all MM patient were on analgesia with the majority on strong opioid signifying the relationship between pain and MM. the analgesic score was also significantly associated with neuropathic pain in our study (data not shown), implying that most pain that require the use of strong opioids has some neuropathic components in it. This is largely true as there were significant relationships between the neuropathic pain components and the pain at presentation. The binary logistic regression from our study show that neuropathic pain and the use of opiates (weak and strong) are important factors in haematological cancers especially MM. Opioids are the mainstay of pain management in haematological cancers, and in MM patients they have a significant association with the disease 39 , 40 . In our study, more than half of the MM patients (53.8%) were on a strong opiate, and a higher number (76.9%) were on a weak opiate compared the non-myeloma group with only 4.3% on a strong opiate, and 17.4% on a weak opiate. The use of these drugs is related to the high burden of pain syndromes found in haematological cancers, most especially in MM 41, 42 . This pioneering study provides critical insights into the under-explored realm of pain in Nigerian patients with haematological malignancies. The high point prevalence of pain (66.7%) aligns with global data, firmly dispelling the misconception that blood cancers are less painful than solid tumours. More importantly, the disparity between pain 'at presentation' and 'worst pain in the past 4 weeks' is stark. While only 2.8% had severe pain at the clinic visit, a quarter of the cohort had experienced severe pain recently. This underscores the dynamic and often unpredictable nature of cancer pain, particularly in malignancies like myeloma where incident pain (pain on movement) is common. Relying solely on a single-point assessment can significantly underestimate a patient's true pain burden, leading to complacency in management. Also, the finding that 27.8% of all patients and 61.5% of myeloma patients screened positive for neuropathic pain is one of the most significant contributions of this work. Neuropathic pain is notoriously difficult to manage and responds poorly to opioids alone, often requiring higher doses and resulting in more side effects without adequate relief. The mechanisms, as discussed, are multifactorial, involving both disease processes (e.g., nerve infiltration) and neurotoxic chemotherapies. The high prevalence in our myeloma cohort likely reflects the synergistic effect of myeloma bone disease (causing nociceptive and possibly neuropathic pain via nerve compression) and treatment with bortezomib and thalidomide. The fact that only 8.3% of the total study population was on co-analgesics, despite over a quarter screening positive for neuropathic pain, points to a critical therapeutic gap. This gap stems from several potential factors: a lack of awareness or routine screening for neuropathic pain among clinicians, limited familiarity with co-analgesics, concerns about cost and side effects, and poor availability of these drugs within the hospital pharmacy. On another note, the finding that 22.2% of patients had a negative PMI shows that the inadequacy of cancer pain management may be a symptom of broader systemic barriers, and not only a clinical oversight While our study did not look into the such areas like pain medication adherence, and other barriers to pain management in haematological cancer patients, we perceive that opiophobia could be a possible factor in the standard pain management of these patients. This could be as a result of low knowledge about opioid use for haematological cancer pain or its complications; furthermore, there may be a lack of continuous training for healthcare providers on modern pain management principles, including the distinction between nociceptive and neuropathic pain and the appropriate use of adjuvant medications. It can also be a result of patients and families declining the use of the strong opiates or other medications for personal reasons. Thus, investigation into pain medication adherence and barriers to pain medication use among haematological cancer patients is an area of further research in Nigeria. Also, restrictive government policies surrounding the procurement, storage, and prescription of controlled substances like morphine create significant logistical bottlenecks that limit patient access. Very importantly, the out-of-pocket cost of analgesics, particularly the strong opioids and co-analgesics, can be prohibitive for many patients, leading to non-adherence or the use of less effective, cheaper alternatives. This study has some limitations. First, it is a single center study with a small sample size, thus, the result cannot be generalized. But this being a first study that look into the pain characteristic of haematological cancer patients in Nigeria may be a template for future studies. Thus, future multi-center studies with larger sample sizes are warranted to confirm and extend these results. The pre-morbid condition of the patients, especially the myeloma patients, whether they had a pre-existing pain condition (neuropathic or otherwise) before their diagnosis was not known. The cross-sectional nature of the study limits the extent of our knowledge on the pain as we can only make associations, and not causality inference; however, this study gives us a pivot to move for more prospective studies. Due to the small sample size, the multivariate analysis should be seen as exploratory and not to test a predefined hypothesis – it is hoped a larger will do this. A key strength of this study is its pioneering focus on a neglected patient population in Nigeria, using validated tools to provide a comprehensive picture of the pain experience. The use of the PMI provides an objective measure of treatment adequacy. The findings from this study have immediate and long-term implications. One of which is an urgent need to integrate routine, standardized pain assessment into every haematology clinic visit. This should include not just intensity (NPRS) but also quality, using screening tools like painDETECT to identify neuropathic components. For myeloma patients, this should be considered a standard of care. There should be development of local and national guidelines for the management of haematological malignancies which should include dedicated sections on pain and symptom control, emphasizing the high risk of neuropathic pain and the need for a multimodal approach (combining NSAIDs, opioids, and co-analgesics). Targeted education for haematologists, oncologists, and pharmacists on the principles of cancer pain management, with a focus on neuropathic pain and opioid stewardship, is crucial. On prospective future researches, this study should serve as a catalyst for further investigation. Prospective, longitudinal studies are needed to track the evolution of pain over the disease and treatment trajectory. Qualitative studies exploring the patient experience of pain and the barriers to effective management from the perspectives of patients, caregivers, and clinicians are essential to design targeted interventions. Furthermore, interventional studies testing the effectiveness of a standardized pain assessment and management protocol in this population are the logical next step. It is also recommended that evaluation for neuropathic pain by the use of validated instruments be used before the commencement of proteasome inhibitors (e.g. bortezomib) and immunomodulatory drugs (e.g. thalidomide) in multiple myeloma patients. In conclusion, the results of this study have shown that haematological cancer patients in Nigeria also suffer from significant pain complications most importantly multiple myeloma patients. Our analysis confirms that multiple myeloma represents a distinct subgroup with a disproportionately high pain burden – a particularly heavy burden characterized by a high likelihood of neuropathic pain. The strong independent associations between myeloma and neuropathic pain, weak opioid use, and strong opioid use in the regression model highlight this. Myeloma pain is often a complex mix of somatic pain (from lytic bone lesions), visceral pain, and neuropathic pain (from treatment and possibly nerve involvement). This complexity necessitates a more sophisticated, multimodal approach to analgesia than is often employed. The high utilization of opioids in this group, while appropriate for the intensity of pain, also raises the issue of managing opioid-related side effects like constipation, nausea, and sedation, which themselves can impair quality of life if not proactively managed. The significant rate of undertreatment, as measured by the PMI, calls for a paradigm shift in clinical practice. Moving forward, a concerted effort is required to make routine pain assessment, including neuropathic pain screening, a non-negotiable component of haematological oncology care. Designing a pain management plan for haematological cancer patients that also incorporate neuropathic pain assessment and early onset treatment is important especially in MM patients in order to alleviate their suffering. Declarations Acknowledgements We acknowledge and are appreciative of the roles played by different nurses of the haematology department at the University of Ilorin Teaching Hospital. Ethics declarations This study was performed in line with the principles of the Declaration of Helsinki. the Ethics review Committee of University Ilorin Teaching Hospital granted approval for this research (UITH/CAT/189/21/1119). Consent to participate Informed consent was obtained from all individual participants included in the study. Conflict of interest The authors have no conflicts of interest to declare. Funding None Authors’ contributions Ogochukwu Izuegbuna: Conceptualization, Methodology, Formal analysis, Validation, Resources, Investigation, Writing - Original Draft, Writing - Review & Editing, Project administration. Israel Kolawole: Conceptualization, Methodology, Resources, Supervision, Writing - Review & Editing, Project administration. Saliu Oguntola: Conceptualization, Methodology, Resources, Supervision, Writing - Review & Editing, Project administration. Tiwalade WOODS-ALI: Investigation, Data Curation. Oyewale Saburi: Investigation, Data Curation Chijioke Chijindu Adindu: Investigation, Data Curation References Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024 May-Jun;74(3):229-263. doi: 10.3322/caac.21834. Okello CD, Niyonzima N, Ferraresso M, Kadhumbula S, Ddungu H, Tarlock K, Balagadde-Kambugu J, Omoding A, Ngendahayo L, Karagu A, Mwaiselage J, Harlan JM, Uldrick TS, Turner SD, Orem J. Haematological malignancies in sub-Saharan Africa: east Africa as an example for improving care. Lancet Haematol. 2021 Oct;8(10):e756-e769. doi: 10.1016/S2352-3026(21)00198-8. Mulatie Z, Berta, DM, Gedefie, A. et al. Prevalence of hematological malignancies in Africa: A systematic review and meta-analysis. Sci Rep 15, 9471 (2025). https://doi.org/10.1038/s41598-025-94428-w. Geyer, H. L., Gazelka, H., & Mesa, R. (2020). How I treat pain in hematologic malignancies safely with opioid therapy. Blood, 135(26), 2354–2364. https://doi.org/10.1182/blood.2019003116. Kibret AA, Wolde HF, Moges AM, Aragie H, Teferi ET, Assefa YA, Melese EB, Melesse M, Worku YB, Belay DG, Molla MD and Adugna DG. Prevalence and associated factors of cancer pain among adult cancer patients evaluated at an oncology unit in the University of Gondar Comprehensive Specialized Hospital, northwest Ethiopia. Front. Pain Res. 2023; 3:1061239.doi: 10.3389/fpain.2022.1061239. Bandieri E, Sichetti D, Luppi M, Di Biagio K, Ripamonti C, Tognoni G, Romero M. Is pain in patients with haematological malignancies under-recognised? The results from Italian ECAD-O survey. Leukemia Research. 2010; 34(12), e334–e335. doi:10.1016/j.leukres.2010.08.013. World Health Organization. Cancer pain relief: with a guide to opioid availability, 2nd ed. World Health Organization, 1996. https://iris.who.int/handle/10665/37896. Thronæs M, Balstad TR, Brunelli C, et al. Pain management index (PMI)-does it reflect cancer patients' wish for focus on pain?. Support Care Cancer. 2020;28(4):1675-1684. doi:10.1007/s00520-019-04981-0. Joseph AO, Salako O, Alabi A, Habeebu M, Balogun O, Ayodele O et al. Cancer pain control in a Nigerian oncology clinic: treating the disease and not the patient. The Pan African medical journal. 2021; 40, 104. https://doi.org/10.11604/ pamj. 2021.40.104. 25225. Izuegbuna O, Kolawole I, Oguntola S, et al. Prevalence and Predictors of Cancer-Related Neuropathic Pain Among Cancer Patients in Nigeria, 29 November 2024, PREPRINT (Version 1) available at Research Square [https://doi.org/10.21203/rs.3.rs-5347791/v1]. Izuegbuna O, Kolawole I, Oguntola S, et al. Prevalence and factors associated with cancer-related neuropathic pain among cancer patients in Nigeria - a single-center cross-sectional study. Pain Manag. 2025;15(5):251-258. doi:10.1080/17581869.2025.2494978. Jones KR, Vojir CP, Hutt E, et al. Determining mild, moderate, and severe pain equivalency across pain-intensity tools in nursing home residents. J Rehabil Res Dev. 2007;44(2):305-14. doi: 10.1682/jrrd.2006.05.0051. Diaz-delCastillo M, Chantry AD, Lawson MA, Heegaard AM. Multiple myeloma-A painful disease of the bone marrow. Semin Cell Dev Biol. 2021 Apr;112:49-58. doi: 10.1016/j.semcdb.2020.10.006. Niscola, P., Cartoni, C., Romani, C. et al. Epidemiology, features and outcome of pain in patients with advanced hematological malignancies followed in a home care program: an Italian survey. Ann Hematol 86, 671–676 (2007). https://doi.org/10.1007/s00277-007-0296-4. Niscola P, Romani C, Cartoni C, Cupelli L, Piccioni D, Dentamaro T, Tendas A, Giovannini M, Scaramucci L, Tolu B, Perrotti AP, de Fabritiis P. Epidemiology of pain in hospital haematological setting: an Italian survey. Leuk Res. 2008 Jan;32(1):197-8. doi: 10.1016/j.leukres.2007.03.024. Bandieri E, Sichetti D, Luppi M, Di Biagio K, Ripamonti C, Tognoni G, Belfiglio M, Romero M. Is pain in patients with haematological malignancies under-recognised? The results from Italian ECAD-O survey. Leuk Res. 2010 Dec;34(12):e334-5. doi: 10.1016/j.leukres.2010.08.013. Costantini M, Ripamonti C, Beccaro M, Montella M, Borgia P, Casella C, Miccinesi G. Prevalence, distress, management, and relief of pain during the last 3 months of cancer patients' life. Results of an Italian mortality follow-back survey. Ann Oncol. 2009 Apr;20(4):729-35. doi: 10.1093/annonc/mdn700. Stalfelt AM, Brodin H, Pettersson S, Eklöf A. The final phase in acute myeloid leukaemia (AML). A study on bleeding, infection and pain. Leuk Res. 2003 Jun;27(6):481-8. doi: 10.1016/s0145-2126(02)00262-x. Ramsenthaler C, Kane P, Gao W, Siegert RJ, Edmonds PM, Schey SA, Higginson IJ. Prevalence of symptoms in patients with multiple myeloma: a systematic review and meta-analysis. Eur J Haematol. 2016 Nov;97(5):416-429. doi: 10.1111/ejh.12790. Zeng L, Huang H, Liu Y, Ruan C, Fan S, Xia Y, Zhou J. The core symptom in multiple myeloma patients undergoing chemotherapy: a network analysis. Support Care Cancer. 2023 Apr 25;31(5):297. doi: 10.1007/s00520-023-07759-7. Nwabuko OC, Igbigbi EE, Chukwuonye II, Nnoli MA. Multiple myeloma in Niger Delta, Nigeria: complications and the outcome of palliative interventions. Cancer Manag Res. 2017;9:189-196. https://doi.org/10.2147/CMAR.S126136. Nnonyelum ON, Anazoeze MJ, Eunice NO, Emmanuel OO, Stella AT, Marcus AI, Taiwo BM, Olufela KO, Chinawaeze AJ, Orkuma JA, Dalhat GG, Otobo UI. Multiple myeloma in Nigeria: a multi-centre epidemiological and biomedical study. Pan Afr Med J. 2015 Nov 24;22:292. doi: 10.11604/pamj.2015.22.292.7774. Jespersen E, Nielsen LK, Larsen RF, Möller S, Jarlbæk L. Everyday living with pain - reported by patients with multiple myeloma. Scand J Pain. 2020 Oct 27;21(1):127-134. doi: 10.1515/sjpain-2020-0087. Bilińska M, Usnarska-Zubkiewicz L, Pokryszko-Dragan A. Bortezomib-induced painful neuropathy in patients with multiple myeloma. Contemp Oncol (Pozn). 2013;17(5):421-6. doi: 10.5114/wo.2013.37214. Yang Y, Zhao B, Lan H, Sun J, Wei G. Bortezomib-induced peripheral neuropathy: Clinical features, molecular basis, and therapeutic approach. Crit Rev Oncol Hematol. 2024 May;197:104353. doi: 10.1016/j.critrevonc.2024.104353. Argyriou AA, Iconomou G, Kalofonos HP. Bortezomib-induced peripheral neuropathy in multiple myeloma: a comprehensive review of the literature. Blood. 2008 Sep 1;112(5):1593-9. doi: 10.1182/blood-2008-04-149385. Strifler S and Knop S. The Role of Carfilzomib in Treatment of Newly Diagnosed Multiple Myeloma. Future Oncology. 2018;14(30), 3123–3134. https://doi.org/10.2217/fon-2018-0040. Expósito Vizcaíno S, Casanova-Mollà J, Escoda L, Galán S, Miró J. Neuropathic pain in cancer patients treated with bortezomib. Neurologia (Engl Ed). 2018 Jan-Feb;33(1):28-34. English, Spanish. doi: 10.1016/j.nrl.2016.05.008. Ito T, Handa H. Molecular mechanisms of thalidomide and its derivatives. Proc Jpn Acad Ser B Phys Biol Sci. 2020;96(6):189-203. doi: 10.2183/pjab.96.016. Banach M, Jurczyszyn A, Skotnicki A. Polekowa neuropatia obwodowa u pacjentów ze szpiczakiem plaZmocytowym leczonych talidomidem [Thalidomide induced peripheral neuropathy in multiple myeloma patients]. Przegl Lek. 2015;72(11):629-35. Morawska M, Grzasko N, Kostyra M, Wojciechowicz J, Hus M. Therapy-related peripheral neuropathy in multiple myeloma patients. Hematol Oncol. 2015 Dec;33(4):113-9. doi: 10.1002/hon.2149. Epub 2014 Nov 14. Erratum in: Hematol Oncol. 2016 Jun;34(2):117. doi: 10.1002/hon.2291. Sichetti D, Bandieri E, Romero M, Di Biagio K, Luppi M, Belfiglio M, Tognoni G, Ripamonti CI; for ECAD Working Group. Impact of setting of care on pain management in patients with cancer: a multicentre cross-sectional study. Ann Oncol. 2010 Oct;21(10):2088-2093. doi: 10.1093/annonc/mdq155. Shen WC, Chen JS, Shao YY, Lee KD, Chiou TJ, Sung YC, Rau KM, Yen CJ, Liao YM, Liu TC, Wu MF, Lee MY, Yu MS, Hwang WL, Lai PY, Chang CS, Chou WC, Hsieh RK. Impact of Undertreatment of Cancer Pain With Analgesic Drugs on Patient Outcomes: A Nationwide Survey of Outpatient Cancer Patient Care in Taiwan. J Pain Symptom Manage. 2017 Jul;54(1):55-65.e1. doi: 10.1016/j.jpainsymman.2017.02.018. Fujii A, Yamada Y, Takayama K, Nakano T, Kishimoto J, Morita T, Nakanishi Y. Longitudinal assessment of pain management with the pain management index in cancer outpatients receiving chemotherapy. Support Care Cancer. 2017 Mar;25(3):925-932. doi: 10.1007/s00520-016-3482-x. Donati CM, Zamagni A, Zamfir AA, Aristei C, Cammelli S, Zamagni C, Paolinelli S, Buwenge M, Rossi R, Maltoni M, Morganti AG, Cilla S. Exploring pain management in breast cancer: key findings from the ARISE study. Front Oncol. 2025 Mar 12;15:1536709. doi: 10.3389/fonc.2025.1536709. Shrestha S, Sapkota S, Teoh SL, Kc B, Paudyal V, Lee SWH, Gan SH. Comprehensive assessment of pain characteristics, quality of life, and pain management in cancer patients: a multi-center cross-sectional study. Qual Life Res. 2024 Oct;33(10):2755-2771. doi: 10.1007/s11136-024-03725-w. Greco MT, Roberto A, Corli O, Deandrea S, Bandieri E, Cavuto S, Apolone G. Quality of cancer pain management: an update of a systematic review of undertreatment of patients with cancer. J Clin Oncol. 2014 Dec 20;32(36):4149-54. doi: 10.1200/JCO.2014.56.0383. Epub 2014 Nov 17. Apolone G, Corli O, Caraceni A, Negri E, Deandrea S, Montanari M, Greco MT; Cancer Pain Outcome Research Study Group (CPOR SG) Investigators. Pattern and quality of care of cancer pain management. Results from the Cancer Pain Outcome Research Study Group. Br J Cancer. 2009 May 19;100(10):1566-74. doi: 10.1038/sj.bjc.6605053. Holly L. Geyer, Halena Gazelka, Ruben Mesa; How I treat pain in hematologic malignancies safely with opioid therapy. Blood 2020; 135 (26): 2354–2364. doi: https://doi.org/10.1182/blood.2019003116. Yu C, Cai T, Zhou T, Zeng N, Liang X, Pan G, Ouyang W, Yuan C. Classification of symptom subtypes in patients with multiple myeloma during treatment: a cross-sectional survey study in China. BMJ Open. 2023 Mar 14;13(3):e066467. doi: 10.1136/bmjopen-2022-066467. Niscola P, Tendas A, Scaramucci L, Giovannini M, De Sanctis V. Pain in blood cancers. Indian J Palliat Care. 2011 Sep;17(3):175-83. doi: 10.4103/0973-1075.92333. Paice JA, Moreira J. Pain Syndromes of Hematologic Malignancies. In: Ullrich, C.K., Roeland, E.J. (eds) Palliative Care in Hematologic Malignancies and Serious Blood Disorders. Springer, Cham. 2023. https://doi.org/10.1007/978-3-031-38058-7_13. Tables TABLE 1: Socio-demographic characteristics of patients Variables Myeloma Non-myeloma P- value Age (years) <58 ≥58 Gender Male Female Education None Primary Secondary Tertiary Performance status 60 70 80 90 100 On therapy (chemotherapy) Yes No NP score (myeloma vs non-myeloma) ≤12 ≥13 NPRS 0 (no pain) 1-3 (mild pain) 4-6 (moderate pain) Worst pain (WP) in 4 weeks 0 (no pain) 1-3 (mild pain) 4-6 (moderate pain) 7-10 (severe pain) Body mass index (BMI) Underweight (Below 18.5) Normal (18.5–24.9) Overweight (25.0–29.9) Obesity (30.0 and above Smoking Never Previous Alcohol Never Previous Occasional 15 08 08 05 02 02 02 07 00 05 06 02 00 13 00 05 08 01 09 03 00 01 10 02 00 09 03 01 13 00 07 04 02 03 10 14 09 02 02 08 11 01 01 09 09 03 20 03 21 02 11 09 03 03 11 07 02 02 16 05 00 21 02 15 05 03 0.035 0.968 0.617 0.044 0.288 0.001 0.047 0.013 0.509 0.402 0.884 NP – neuropathic pain TABLE 2: The characteristics of pain and frequency of analgesia use in the patients Characteristic Frequency Percentage NPRS mean ± SD 1.86 ±1.79 Median 2 0 (no pain) 1-3 (mild pain) 4-6 (moderate pain) 7-10 (severe pain) Worst pain (WP) in 4 weeks 0 (no pain) 1-3 (mild pain) 4-6 (moderate pain) 7-10 (severe pain) NP score ≤12 ≥13 Analgesic score 0 1 2 3 Paracetamol Yes No NSAIDs Yes No Weak Opiate Yes No Strong opiate Yes No 12 18 05 01 03 12 12 09 26 10 01 18 09 08 32 04 26 10 14 22 08 28 33.3 50.0 13.9 02.8 08.4 33.3 33.3 25.0 72.2 27.8 02.8 50.0 25.0 22.2 88.9 11.1 72.2 27.8 38.9 61.1 22.2 77.8 NPRS – numeric pain rating scale; NSAIDs – non-steroidal anti-inflammatory drugs TABLE 3: Association between analgesic use and presence of haematological cancer and pain (chi-square/ Fischer test) Variable MM presence NP presence WP in 4 weeks Paracetamol NSAIDs Weak Opiate Strong Opiate Co-analgesic Analgesic score 0.609 0.043 <0.001 <0.001 0.040 <0.001 0.293 0.223 0.107 0.002 0.017 0.001 0.473 <0.001 0.008 0.058 0.250 0.009 NSAIDs – non-steroidal anti-inflammatory; MM – multiple myeloma; NP – neuropathic pain; WP – worst pain. TABLE 4: Logistic regression showing association between the independent variables and presence of multiple myeloma. Variables p-Value OR 95% CI Age Strong opiate use Weak opiate use PS NP 0.029 0.005 0.001 0.030 0.003 1.075 25.667 15.833 0.902 16.800 1.008 – 1.147 2.621 – 251.303 2.947 – 85.075 0.822 – 0.990 2.693 – 104.822 PS – performance status; NP – neuropathic pain Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable123.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8441132","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":566803891,"identity":"73e76894-fd4f-49e6-8a34-5ee5b255234d","order_by":0,"name":"ogochukwu 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14:29:56","extension":"html","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":153909,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8441132/v1/e03ebc27f238936296e3748b.html"},{"id":99622260,"identity":"7ab1aa5e-a276-4721-a358-4ac8bc6065a9","added_by":"auto","created_at":"2026-01-06 14:29:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":42060,"visible":true,"origin":"","legend":"\u003cp\u003eA pictorial depiction of radiating pain in haematological cancer patients. Only 22.2% complain of radiating pain.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8441132/v1/676284f57e98e6a31c79f8d1.png"},{"id":99804500,"identity":"4aefa5ca-e388-43b9-b436-7531f66f584c","added_by":"auto","created_at":"2026-01-08 14:13:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":665743,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8441132/v1/91ea14bd-8d31-4896-81e2-865a6a6858f7.pdf"},{"id":99793314,"identity":"45920f87-d310-4acf-9c88-22a32ce555ba","added_by":"auto","created_at":"2026-01-08 13:31:24","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":19067,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable123.docx","url":"https://assets-eu.researchsquare.com/files/rs-8441132/v1/7e1584d68eb09e07e82764a6.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePain Characteristics of Adult Haematological Cancer Patients at an Outpatient Clinic in Nigeria – a Cross-sectional Study\u003c/p\u003e","fulltext":[{"header":"1.0 INTRODUCTION","content":"\u003cp\u003eHaematological cancers are not quite common worldwide. They are said to constitute about 6.5% of all cancers worldwide, and about 10% of cancers in Africa\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. However, the incidence is increasing at a fast rate in Africa with a recent systematic analysis putting the pooled prevalence of hematological malignancies at 27.30%\u003csup\u003e3\u003c/sup\u003e. With an increased incidence comes increase in morbidity and mortality. One of such morbidities is pain. Pain is common in haematological malignancies, with up to 60% actively receiving antineoplastic treatment known to have pain\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. This can arise from the use of such drugs like vinca-alkaloids, bortezomib, thalidomide and a host of others or it may be as a result of the malignancy itself. The issues of pain in them is rather rife, and with a lack of complete understanding of the pain experienced because the usual narrative is people with solid tumours experience more pain than people with haematological malignancies. However, a study by Kibret et al in Ethiopia showed that apart from gastrointestinal cancer, patients with haematological malignancies had the highest odds of having cancer pain compared to other cancers\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. In some reported studies in Italy, the prevalence of pain in multiple myeloma and leukaemia/lymphoma patients were 86% and 83% respectively\u003csup\u003e6\u003c/sup\u003e. These records show that pain is very much present in haematological malignancy patients. What is not really known is the characteristics of the pain among Nigerian haematological malignancy patients, and if there is effective pain management.\u003c/p\u003e \u003cp\u003eHaematological malignancy patients can present with pain just like any other cancer patient. These pain can either be nociceptive (inflammatory) or neuropathic. It can be the exacerbation of an old pain with varying intensities. More importantly, cancer pain can have adverse effect on a patient well-being including their functionality, social and emotional engagements, compliance to treatment modalities and more. In addition, the proper management of cancer pain should involve a good assessment of pain features and characteristics as well as the utilization of a pain management index. A 3-step pain ladder guideline which entail the use of analgesics for different grades of pain i.e. for pain considered mild - paracetamol, for pain considered moderate - codeine, and for pain considered severe \u0026ndash; morphine, as recommended by the World Health Organization (WHO)\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe Pain Management Index (PMI) is a tool developed to evaluate the adequacy of pain treatment\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. The PMI compares the pain level of a patient with the strength of the analgesic prescribed. The PMI score is thus obtained through the subtraction of the categorized pain level from the categorized analgesic level (score). A negative score show that the treatment of the pain was not adequate.\u003c/p\u003e \u003cp\u003eThe prevalence of cancer pain is quite high in Nigeria, with some studies reporting over 80%, along with inadequate pain management\u003csup\u003e\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. However, these studies (and none yet) did not focus on pain in haematological malignancy patients primarily. This study is the first one in Nigeria to take a peep at the characteristics of pain among haematological malignancy patients.\u003c/p\u003e \u003cp\u003eThe primary aim for this research was to look into the prevalence and clinical characteristics of pain and other contributing elements in haematological malignancy patients in a cohort attending clinic at a teaching hospital in Nigeria. Our secondary objective was to look at features of neuropathic pain and the pattern of pain management in haematological malignancy patients.\u003c/p\u003e"},{"header":"2.0 METHODOLOGY","content":"\u003cp\u003eStudy design and settings\u003c/p\u003e \u003cp\u003eThe observational study was done at the University of Ilorin Teaching Hospital. The collection of various data occurred between June 2023 to December, 2023, and it was at the adult outpatient haematology clinic. The study employed a cross-sectional design to capture a snapshot of the pain experience in the haematology clinic population. Adult haematological patients aged 18 years and above with a confirmed diagnosis of a haematological malignancy which included leukaemias, lymphomas, myelomas, and myeloproliferative neoplasms without a concomitant solid tumor, and who attended the outpatient haematology clinic at the University of Ilorin Teaching Hospital during the six-month data collection period were included in this study. A non-probability, consecutive sampling technique was deployed in the enrollment of study participants.The exclusion criteria for the study participants included admitted inpatients, those that are critically ill, patients with a significant cognitive impairment or are diagnosed with a psychiatric condition that would impede their ability to provide accurate pain reports, or declined to provide informed consent. Eligible patients were approached in the clinic, the study was explained in detail in their preferred language. The questionnaire was then administered in a private room to ensure confidentiality and patient comfort. Medical records were reviewed to verify the diagnosis and current medications. To ensure data quality, completed questionnaires were checked for completeness and consistency at the end of each clinic day. An ethical approval was obtained from the Committee on ethics and research of the hospital (UITH/CAT/189/21/1119). Each of the patient in the study gave a written informed consent.\u003c/p\u003e \u003cp\u003eA questionnaire with socio-demographic and clinical information was filled by each participant. The socio-demographic data captured included the age, gender, level of education, occupation, and marital status; the clinical data collected included the specific haematological diagnosis, the current treatment regimen (e.g., on chemotherapy, radiotherapy), and a performance status assessment using the karnofsky performance status scale. The karnofsky performance status scale is a validated tool that grades a patient's level of functional impairment, from 100 (fully active) to 0 (dead), providing a crucial context for understanding the impact of pain on daily life. Pain levels were evaluated using the numeric pain rating scale (NPRS) and the painDETECT questionnaire for neuropathic pain. The NPRS is a widely used, reliable, and valid unidimensional measure of pain intensity with a pain on a scale from 0 (no pain) to 10 (worst imaginable pain). Two key metrics were assessed: (i) pain intensity at the time of the clinic visit (current pain), and (ii) the worst pain intensity experienced in the past four weeks. The four-week recall period was chosen to capture a more representative picture of the patients' pain experience beyond the immediate moment, accounting for fluctuating pain levels related to treatment cycles or disease activity. Regarding neuropathic pain, The painDETECT questionnaire which was used, is a wholly patient-completed, screening tool designed to identify the presence of neuropathic pain components. It does not require a clinical examination, thus, making it highly practical for the clinic setting. It consists of seven items that assess the quality and pattern of pain (e.g., burning, tingling, electric shock-like sensations) and one item on pain radiation. Its validity and reliability have been established in various populations, including cancer patients. PMI was also calculated. Patients were asked the current pain level at presentation, and their worst pain over the past four weeks. The type of pain relief medications used by the patient was also recorded - All analgesic medications the patient was currently taking for pain relief including non-opioids (e.g., paracetamol, NSAIDs), weak opioids (e.g., tramadol, codeine), strong opioids (e.g., morphine), and co-analgesics (e.g., gabapentin, pregabalin, amitriptyline) were documented.\u003c/p\u003e \u003cp\u003eFor the categorization of pain, a pain score of \u0026ldquo;0\u0026rdquo; was labeled as no pain, while a score of \u0026ldquo;1\u0026rdquo; was for mild pain, \u0026ldquo;2\u0026rdquo; was labeled moderate pain, and \u0026ldquo;3\u0026rdquo; categorized as severe pain. These categorizations stemmed from the NPRS where \u0026ldquo;0\u0026rdquo; indicated as no pain, \u0026ldquo;1\u0026ndash;3\u0026rdquo; indicated as mild pain, \u0026ldquo;5\u0026ndash;7\u0026rdquo; indicated as moderate pain, and \u0026ldquo;8\u0026ndash;10\u0026rdquo; was for severe pain\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. For the calculation of the PMI, the analgesic score was categorized on the type of analgesia used to treat pain with the subtraction of the categorized pain score. Thus, where no analgesia was used, the pain score was \u0026ldquo;0\u0026rdquo;, \u0026rdquo; where a non-opioid was used (i.e., NSAID or acetaminophen) the score was \u0026ldquo;1,\u0026rdquo; a \u0026ldquo;weak\u0026rdquo; opioid (e.g. dihydrocodeine, tramadol) was scored \u0026ldquo;2,\u0026rdquo; and a \u0026ldquo;strong\u0026rdquo; opioid (e.g., morphine, fentanyl) was scored as \u0026ldquo;3\u0026rdquo;. The patient\u0026rsquo;s pain at presentation and the worst pain experienced in the previous 4 weeks were categorized and used to calculate the PMI separately. This dual approach provides a more nuanced view, potentially revealing instances where a patient's background pain is controlled but breakthrough or incident pain is not. The Neuropathic pain (NP) which was screened for using the painDETECT questionnaire has a maximal score of 38. The scores were also categorized: less than 13 were deemed to be improbable, 13\u0026ndash;18 was deemed likely, 19 and above was deemed very probable. This categorization helped to ensure that the likelihood of a neuropathic pain component is captured, guiding further clinical evaluation and management.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Data analysis\u003c/h2\u003e \u003cp\u003eThe SPSS 26.0 statistical software was used for data analysis. The normality of data was verified by the one-sample Kolmogorov - Smirnov test. Quantitative variables were conveyed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation for analysis of patient characteristics including pain measurements and as proportions for nominal variables. For the convenience of analysis, PMI was grouped as positive and negative, NP was grouped as with NP (total score\u0026thinsp;\u0026ge;\u0026thinsp;13) and those without NP (total score\u0026thinsp;\u0026le;\u0026thinsp;12) and the prevalence of pain (NPRS\u0026thinsp;\u0026gt;\u0026thinsp;0). Given the prominent findings related to multiple myeloma, the groups were divided into two, myeloma and non-myeloma group for comparative analysis. Inferential analyses were conducted to explore relationships. The Fischer exact test, and the Chi square test were used to analyze the groups; the Chi-square test was used for categorical variables, and Fisher's exact test was employed where cell counts were less than 5. Values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were put as statistically significant. A binary logistic regression analysis was done to find relationship between significant variables (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and multiple myeloma, entering variables with a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 from the bivariate analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"3.0 RESULTS","content":"\u003cp\u003eIn all, 36 haematological malignancy patients participated in this study. They were made up of 22 (61.1%) males and 14 (38.9%) females with a mean age of 56. 2 \u0026plusmn; 14.0 (range: 21-82 yr.). the haematological malignancies included: 4 (11.1%) chronic lymphocytic leukaemia, 4 (11.1%) chronic myeloid leukaemia, 2 (5.6%) essential thrombocythemia, 1 (2.8%) Hodgkin lymphoma, 13 (36.1%) multiple myeloma, 11 (30.6%) non-Hodgkin lymphoma, 1 (2.8%) polycythemia vera. Table 1 shows the relevant characteristic of the patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt presentation, 12 (33.3%) patients had no pain, 18 (50%) had mild pain, 5 (13.9%) had moderate pain and 1 (2.8%) had severe pain; the worst pain over the past 4 weeks, 3 (8.4%) had no pain, 12 (33.3%) had mild pain, 12 (33.3%) had moderate pain, 9 (25%) had severe pain. Categorically, for neuropathic pain, 26 (72.2%) had a score \u0026le;12, while 10 (27.8%) had a score \u0026ge;13; out of the 10 patients with the likelihood of neuropathic pain (\u0026ge;13), 8 (80%) had multiple myeloma. Table 2. Using the worst pain experienced within the past 4 weeks as criteria, the percentage of patients with a negative PMI (PMI\u0026thinsp;\u0026lt;\u0026thinsp;0) was 22.2% (supplementary table 1). The median NPRS for pain intensity was 2 for pain at presentation, and 5 for the worst pain over the past 4 weeks. A total of 8 (22.2%) complain of their pain radiating. Figure 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll the patients except for one (2.8%) were on analgesic with paracetamol (88.9%) and NSAIDs (72.2%) being the most used for pain, followed by weak opiates (38.9%) and strong opiates (22.2%); 8.3% were on co-analgesics (pregabalin and amitriptyline). The analgesic score and other pain parameters are presented in Table 3. Majority of the patients complained of back pain (supplementary table 2)\u003c/p\u003e\n\u003cp\u003eDue to the number of multiple myeloma patients with NP score \u0026ge;13 being highest among all the patients, they were divided into myeloma and non-myeloma groups for bivariate analysis. Analysis was also done along the presence of neuropathic pain (score \u0026ge;13). Age, and performance status were significantly associated with multiple myeloma; performance status and presence of multiple myeloma was significantly associated with neuropathic pain. On their use of analgesia, NSAIDs, weak opiates, strong opiates and co-analgesics were significantly associated with multiple myeloma as well as the analgesic score, while strong opiates, co-analgesics and analgesic score were significantly associated with neuropathic pain. Using the binary logistic regression analysis, the relationship between age (p=0.029), performance status (p=0.03), neuropathic pain (p\u0026lt;0.001), weak opiate use (p\u0026lt;0.001), strong opiate use (p\u0026lt;0.001) against type of haematological cancer (myeloma vs non-myeloma) was significant. Table 4\u003c/p\u003e"},{"header":"4.0 DISCUSSION","content":"\u003cp\u003ePain is known to be quite commonly experienced by patients with different types of malignancies. Moreso, in haematological malignancies especially myeloma where it is known that about two-third present with bone pain\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Uncontrolled pain significantly impairs performance status as well as other associated factors of well-being.\u003c/p\u003e \u003cp\u003eIn this study, the prevalence rate of pain was similar what was reported by Shen et al\u003csup\u003e14\u003c/sup\u003e (66.6% vs 63%), though the latter was in cancer patients generally. This was higher than what was reported by Niscola et al\u003csup\u003e14,15\u003c/sup\u003e, and Kibret et al\u003csup\u003e5\u003c/sup\u003e, but was lower than what was reported for different haematological malignancy patient from the Italian ECAD-O survey\u003csup\u003e\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. However, the pain intensity among MM patients in this study was higher than reported in previous studies. Ramsenthaler et al\u003csup\u003e19\u003c/sup\u003e in their meta-analysis reported a pain prevalence of 73%, which was similar to the 71.7% reported by Zheng et al\u003csup\u003e20\u003c/sup\u003e in their study. Our figure (92.3% at presentation) was also higher than those reported by Nwabuko et al\u003csup\u003e21\u003c/sup\u003e (84.6%) and Nnoyelum et al\u003csup\u003e22\u003c/sup\u003e (74%) in Nigeria. Their report was primarily bone pain, as none of them reported neuropathic pain in MM, thus, it makes this research perhaps the first to report the occurrence of neuropathic pain in Nigerian MM patients as well as other haematological malignancies. Neuropathic pain has been observed among cancer patients in Nigeria\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Apart from being contributory to the total pain milieu in cancer patients, it is not adequately recognized in Nigeria, as the aforementioned report showed that only 7.9% of cancer patients are on co-analgesics like pregabalin\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. However, our study also showed that MM had an unusually high prevalence of neuropathic pain (61.5%). This was higher than the 33% reported by Jespersen et al\u003csup\u003e23\u003c/sup\u003e. Interestingly, all the patients that were on co-analgesics were all MM patients, and represent about 8.3% of the total patient in the study signifying a low use of co-analgesics in managing pain in haematological cancer patients. This may mean that the managing physicians do not readily recognize neuropathic pain as an important aspect of pain in order to manage it effectively despite the fact that many of the patients are on anti-neoplastic agents that can cause neuropathic pain e.g. bortezomib and thalidomide. Bortezomib is a proteasome inhibitor used in the management of different haematological malignancies, especially multiple myeloma where it has profoundly impacted the condition. However, it is known to cause peripheral neuropathy as a complication of treatment. This side effect of the drug can happen at any stage of using the drug. However, it is more common during the fifth cycle at an accumulated dosage of 30mg/m2\u003csup\u003e24\u003c/sup\u003e. It does this through its neurotoxic effect on peripheral nerves. The mechanism through which it causes neuropathic pain are somewhat different, including impairment of axonal transport and inflammatory damage to sensory nerves. It also causes release of inflammatory mediators such as interleukin 1. The incidence of bortezomib-induced neuropathic pain from clinical trials is reported to be between 15% and 57.2%\u003csup\u003e25\u003c/sup\u003e, but in retreatment of MM it has been reported to be as high as 75% for grade 1\u0026ndash;2 neuropathy, and about 30% for grade 3\u0026ndash;4 neuropathy\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. These values are significantly higher than what was reported for carfilzomib-induced peripheral neuropathy which is 21% in all patient with less than 1% having grade 3 neuropathy according to a meta-analysis\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Vizca\u0026iacute;no et al in their research reported a prevalence of about 50%\u003csup\u003e28\u003c/sup\u003e. This was lower than our value in this study which is about 61.5%. in MM patients. However, our patients were also on other medications and not bortezomib alone. A synergistic effect can explain this action. Thalidomide is an immunomodulatory agent used in the management of multiple myeloma. It has different mechanism of action in MM, but its primary action is through its interaction with cereblon, a ligand-dependent substrate receptor of the E3 ubiquitin ligase complex cullin-RING ligase 4. Cereblon is critical towards the anti-myeloma activities of thalidomide and other immunomodulatory agents like lenalidomide and pomalidomide\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Thalidomide like other immunomodulatory drug is also implicated in neuropathy in multiple myeloma. Banach et al\u003csup\u003e30\u003c/sup\u003e in their study reported more than 60% of MM patients treated with thalidomide developed a thalidomide-induced neuropathy. Thalidomide-induced neuropathy is reported to be between 25% to 75%, and it is advised that MM patients be screened for neuropathy before the commencement of thalidomide\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. While some of the patients in this study were also on thalidomide, the neuropathy seen can be as a result of different therapies.\u003c/p\u003e \u003cp\u003eOur research also showed the first comparative account of pain killer medicines utilization for haematological cancer patients in Nigeria. This was done through the utilization of the PMI. The PMI is a clinical instrument that is used in the evaluation of the adequacy of pain control, particularly in cancer patients. It does this through comparison of the pain intensity value i.e. mild, moderate or severe colloquially known as the pain score against a categorical value assigned to a prescribed analgesic drug known as the analgesic score. The difference between the categorical pain score and the analgesic score becomes the PMI. The primary function of the PMI is to evaluate whether the level of pain relief provided is appropriate for the reported intensity of pain. Using the PMI, our study show that haematological malignancy patients may also suffer from undertreatment of cancer pain. the percentage of hematological malignancy patients with under treated pain in our study was 22.2% which is higher than what was reported by Sichetti et al\u003csup\u003e32\u003c/sup\u003e, but lower than what was reported by Shen et al\u003csup\u003e33\u003c/sup\u003e. However, our results were closer to what was reported in literatures, between 25% and 62%\u003csup\u003e34\u0026ndash;38\u003c/sup\u003e. Such a small difference could be as a result of the lower number of participants in our study, so that a larger number could possibly show more patients with a negative PMI. On the other hand, the analgesic score shows that all MM patient were on analgesia with the majority on strong opioid signifying the relationship between pain and MM. the analgesic score was also significantly associated with neuropathic pain in our study (data not shown), implying that most pain that require the use of strong opioids has some neuropathic components in it. This is largely true as there were significant relationships between the neuropathic pain components and the pain at presentation.\u003c/p\u003e \u003cp\u003eThe binary logistic regression from our study show that neuropathic pain and the use of opiates (weak and strong) are important factors in haematological cancers especially MM. Opioids are the mainstay of pain management in haematological cancers, and in MM patients they have a significant association with the disease\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e. In our study, more than half of the MM patients (53.8%) were on a strong opiate, and a higher number (76.9%) were on a weak opiate compared the non-myeloma group with only 4.3% on a strong opiate, and 17.4% on a weak opiate. The use of these drugs is related to the high burden of pain syndromes found in haematological cancers, most especially in MM\u003csup\u003e41, 42\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis pioneering study provides critical insights into the under-explored realm of pain in Nigerian patients with haematological malignancies. The high point prevalence of pain (66.7%) aligns with global data, firmly dispelling the misconception that blood cancers are less painful than solid tumours. More importantly, the disparity between pain 'at presentation' and 'worst pain in the past 4 weeks' is stark. While only 2.8% had severe pain at the clinic visit, a quarter of the cohort had experienced severe pain recently. This underscores the dynamic and often unpredictable nature of cancer pain, particularly in malignancies like myeloma where incident pain (pain on movement) is common. Relying solely on a single-point assessment can significantly underestimate a patient's true pain burden, leading to complacency in management.\u003c/p\u003e \u003cp\u003eAlso, the finding that 27.8% of all patients and 61.5% of myeloma patients screened positive for neuropathic pain is one of the most significant contributions of this work. Neuropathic pain is notoriously difficult to manage and responds poorly to opioids alone, often requiring higher doses and resulting in more side effects without adequate relief. The mechanisms, as discussed, are multifactorial, involving both disease processes (e.g., nerve infiltration) and neurotoxic chemotherapies. The high prevalence in our myeloma cohort likely reflects the synergistic effect of myeloma bone disease (causing nociceptive and possibly neuropathic pain via nerve compression) and treatment with bortezomib and thalidomide. The fact that only 8.3% of the total study population was on co-analgesics, despite over a quarter screening positive for neuropathic pain, points to a critical therapeutic gap. This gap stems from several potential factors: a lack of awareness or routine screening for neuropathic pain among clinicians, limited familiarity with co-analgesics, concerns about cost and side effects, and poor availability of these drugs within the hospital pharmacy. On another note, the finding that 22.2% of patients had a negative PMI shows that the inadequacy of cancer pain management may be a symptom of broader systemic barriers, and not only a clinical oversight\u003c/p\u003e \u003cp\u003eWhile our study did not look into the such areas like pain medication adherence, and other barriers to pain management in haematological cancer patients, we perceive that opiophobia could be a possible factor in the standard pain management of these patients. This could be as a result of low knowledge about opioid use for haematological cancer pain or its complications; furthermore, there may be a lack of continuous training for healthcare providers on modern pain management principles, including the distinction between nociceptive and neuropathic pain and the appropriate use of adjuvant medications. It can also be a result of patients and families declining the use of the strong opiates or other medications for personal reasons. Thus, investigation into pain medication adherence and barriers to pain medication use among haematological cancer patients is an area of further research in Nigeria. Also, restrictive government policies surrounding the procurement, storage, and prescription of controlled substances like morphine create significant logistical bottlenecks that limit patient access. Very importantly, the out-of-pocket cost of analgesics, particularly the strong opioids and co-analgesics, can be prohibitive for many patients, leading to non-adherence or the use of less effective, cheaper alternatives.\u003c/p\u003e \u003cp\u003eThis study has some limitations. First, it is a single center study with a small sample size, thus, the result cannot be generalized. But this being a first study that look into the pain characteristic of haematological cancer patients in Nigeria may be a template for future studies. Thus, future multi-center studies with larger sample sizes are warranted to confirm and extend these results. The pre-morbid condition of the patients, especially the myeloma patients, whether they had a pre-existing pain condition (neuropathic or otherwise) before their diagnosis was not known. The cross-sectional nature of the study limits the extent of our knowledge on the pain as we can only make associations, and not causality inference; however, this study gives us a pivot to move for more prospective studies. Due to the small sample size, the multivariate analysis should be seen as exploratory and not to test a predefined hypothesis \u0026ndash; it is hoped a larger will do this. A key strength of this study is its pioneering focus on a neglected patient population in Nigeria, using validated tools to provide a comprehensive picture of the pain experience. The use of the PMI provides an objective measure of treatment adequacy.\u003c/p\u003e \u003cp\u003eThe findings from this study have immediate and long-term implications. One of which is an urgent need to integrate routine, standardized pain assessment into every haematology clinic visit. This should include not just intensity (NPRS) but also quality, using screening tools like painDETECT to identify neuropathic components. For myeloma patients, this should be considered a standard of care. There should be development of local and national guidelines for the management of haematological malignancies which should include dedicated sections on pain and symptom control, emphasizing the high risk of neuropathic pain and the need for a multimodal approach (combining NSAIDs, opioids, and co-analgesics). Targeted education for haematologists, oncologists, and pharmacists on the principles of cancer pain management, with a focus on neuropathic pain and opioid stewardship, is crucial.\u003c/p\u003e \u003cp\u003eOn prospective future researches, this study should serve as a catalyst for further investigation. Prospective, longitudinal studies are needed to track the evolution of pain over the disease and treatment trajectory. Qualitative studies exploring the patient experience of pain and the barriers to effective management from the perspectives of patients, caregivers, and clinicians are essential to design targeted interventions. Furthermore, interventional studies testing the effectiveness of a standardized pain assessment and management protocol in this population are the logical next step. It is also recommended that evaluation for neuropathic pain by the use of validated instruments be used before the commencement of proteasome inhibitors (e.g. bortezomib) and immunomodulatory drugs (e.g. thalidomide) in multiple myeloma patients.\u003c/p\u003e \u003cp\u003eIn conclusion, the results of this study have shown that haematological cancer patients in Nigeria also suffer from significant pain complications most importantly multiple myeloma patients. Our analysis confirms that multiple myeloma represents a distinct subgroup with a disproportionately high pain burden \u0026ndash; a particularly heavy burden characterized by a high likelihood of neuropathic pain. The strong independent associations between myeloma and neuropathic pain, weak opioid use, and strong opioid use in the regression model highlight this. Myeloma pain is often a complex mix of somatic pain (from lytic bone lesions), visceral pain, and neuropathic pain (from treatment and possibly nerve involvement). This complexity necessitates a more sophisticated, multimodal approach to analgesia than is often employed. The high utilization of opioids in this group, while appropriate for the intensity of pain, also raises the issue of managing opioid-related side effects like constipation, nausea, and sedation, which themselves can impair quality of life if not proactively managed. The significant rate of undertreatment, as measured by the PMI, calls for a paradigm shift in clinical practice. Moving forward, a concerted effort is required to make routine pain assessment, including neuropathic pain screening, a non-negotiable component of haematological oncology care. Designing a pain management plan for haematological cancer patients that also incorporate neuropathic pain assessment and early onset treatment is important especially in MM patients in order to alleviate their suffering.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge and are appreciative of the roles played by different nurses of the haematology department at the University of Ilorin Teaching Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. the Ethics review Committee of University Ilorin Teaching Hospital granted approval for this research (UITH/CAT/189/21/1119).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOgochukwu Izuegbuna: Conceptualization, Methodology, Formal analysis, Validation, Resources, Investigation, Writing - Original Draft, Writing - Review \u0026amp; Editing, Project administration.\u003c/p\u003e\n\u003cp\u003eIsrael Kolawole: Conceptualization, Methodology, Resources, Supervision, Writing - Review \u0026amp; Editing, Project administration.\u003c/p\u003e\n\u003cp\u003eSaliu Oguntola: Conceptualization, Methodology, Resources, Supervision, Writing - Review \u0026amp; Editing, Project administration.\u003c/p\u003e\n\u003cp\u003eTiwalade WOODS-ALI: Investigation, Data Curation.\u003c/p\u003e\n\u003cp\u003eOyewale Saburi: Investigation, Data Curation\u003c/p\u003e\n\u003cp\u003eChijioke Chijindu Adindu: Investigation, Data Curation\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024 May-Jun;74(3):229-263. doi: 10.3322/caac.21834. \u003c/li\u003e\n\u003cli\u003eOkello CD, Niyonzima N, Ferraresso M, Kadhumbula S, Ddungu H, Tarlock K, Balagadde-Kambugu J, Omoding A, Ngendahayo L, Karagu A, Mwaiselage J, Harlan JM, Uldrick TS, Turner SD, Orem J. Haematological malignancies in sub-Saharan Africa: east Africa as an example for improving care. Lancet Haematol. 2021 Oct;8(10):e756-e769. doi: 10.1016/S2352-3026(21)00198-8.\u003c/li\u003e\n\u003cli\u003eMulatie Z, Berta, DM, Gedefie, A. et al. Prevalence of hematological malignancies in Africa: A systematic review and meta-analysis. Sci Rep 15, 9471 (2025). https://doi.org/10.1038/s41598-025-94428-w.\u003c/li\u003e\n\u003cli\u003eGeyer, H. L., Gazelka, H., \u0026amp; Mesa, R. (2020). How I treat pain in hematologic malignancies safely with opioid therapy. Blood, 135(26), 2354\u0026ndash;2364. https://doi.org/10.1182/blood.2019003116.\u003c/li\u003e\n\u003cli\u003eKibret AA, Wolde HF, Moges AM, Aragie H, Teferi ET, Assefa YA, Melese EB, Melesse M, Worku YB, Belay DG, Molla MD and Adugna DG. Prevalence and associated factors of cancer pain among adult cancer patients evaluated at an oncology unit in the University of Gondar Comprehensive Specialized Hospital, northwest Ethiopia. Front. Pain Res. 2023; 3:1061239.doi: 10.3389/fpain.2022.1061239. \u003c/li\u003e\n\u003cli\u003eBandieri E, Sichetti D, Luppi M, Di Biagio K, Ripamonti C, Tognoni G, Romero M. Is pain in patients with haematological malignancies under-recognised? The results from Italian ECAD-O survey. Leukemia Research. 2010; 34(12), e334\u0026ndash;e335. doi:10.1016/j.leukres.2010.08.013.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Cancer pain relief: with a guide to opioid availability, 2nd ed. World Health Organization, 1996. https://iris.who.int/handle/10665/37896.\u003c/li\u003e\n\u003cli\u003eThron\u0026aelig;s M, Balstad TR, Brunelli C, et al. Pain management index (PMI)-does it reflect cancer patients\u0026apos; wish for focus on pain?. Support Care Cancer. 2020;28(4):1675-1684. doi:10.1007/s00520-019-04981-0.\u003c/li\u003e\n\u003cli\u003eJoseph AO, Salako O, Alabi A, Habeebu M, Balogun O, Ayodele O et al. Cancer pain control in a Nigerian oncology clinic: treating the disease and not the patient. The Pan African medical journal. 2021; 40, 104. https://doi.org/10.11604/ pamj. 2021.40.104. 25225.\u003c/li\u003e\n\u003cli\u003eIzuegbuna O, Kolawole I, Oguntola S, et al. Prevalence and Predictors of Cancer-Related Neuropathic Pain Among Cancer Patients in Nigeria, 29 November 2024, PREPRINT (Version 1) available at Research Square [https://doi.org/10.21203/rs.3.rs-5347791/v1].\u003c/li\u003e\n\u003cli\u003eIzuegbuna O, Kolawole I, Oguntola S, et al. Prevalence and factors associated with cancer-related neuropathic pain among cancer patients in Nigeria - a single-center cross-sectional study. Pain Manag. 2025;15(5):251-258. doi:10.1080/17581869.2025.2494978.\u003c/li\u003e\n\u003cli\u003eJones KR, Vojir CP, Hutt E, et al. Determining mild, moderate, and severe pain equivalency across pain-intensity tools in nursing home residents. J Rehabil Res Dev. 2007;44(2):305-14. doi: 10.1682/jrrd.2006.05.0051.\u003c/li\u003e\n\u003cli\u003eDiaz-delCastillo M, Chantry AD, Lawson MA, Heegaard AM. Multiple myeloma-A painful disease of the bone marrow. Semin Cell Dev Biol. 2021 Apr;112:49-58. doi: 10.1016/j.semcdb.2020.10.006.\u003c/li\u003e\n\u003cli\u003eNiscola, P., Cartoni, C., Romani, C. et al. Epidemiology, features and outcome of pain in patients with advanced hematological malignancies followed in a home care program: an Italian survey. Ann Hematol 86, 671\u0026ndash;676 (2007). https://doi.org/10.1007/s00277-007-0296-4.\u003c/li\u003e\n\u003cli\u003eNiscola P, Romani C, Cartoni C, Cupelli L, Piccioni D, Dentamaro T, Tendas A, Giovannini M, Scaramucci L, Tolu B, Perrotti AP, de Fabritiis P. Epidemiology of pain in hospital haematological setting: an Italian survey. Leuk Res. 2008 Jan;32(1):197-8. doi: 10.1016/j.leukres.2007.03.024. \u003c/li\u003e\n\u003cli\u003eBandieri E, Sichetti D, Luppi M, Di Biagio K, Ripamonti C, Tognoni G, Belfiglio M, Romero M. Is pain in patients with haematological malignancies under-recognised? The results from Italian ECAD-O survey. Leuk Res. 2010 Dec;34(12):e334-5. doi: 10.1016/j.leukres.2010.08.013. \u003c/li\u003e\n\u003cli\u003eCostantini M, Ripamonti C, Beccaro M, Montella M, Borgia P, Casella C, Miccinesi G. Prevalence, distress, management, and relief of pain during the last 3 months of cancer patients\u0026apos; life. Results of an Italian mortality follow-back survey. Ann Oncol. 2009 Apr;20(4):729-35. doi: 10.1093/annonc/mdn700. \u003c/li\u003e\n\u003cli\u003eStalfelt AM, Brodin H, Pettersson S, Ekl\u0026ouml;f A. The final phase in acute myeloid leukaemia (AML). A study on bleeding, infection and pain. Leuk Res. 2003 Jun;27(6):481-8. doi: 10.1016/s0145-2126(02)00262-x. \u003c/li\u003e\n\u003cli\u003eRamsenthaler C, Kane P, Gao W, Siegert RJ, Edmonds PM, Schey SA, Higginson IJ. Prevalence of symptoms in patients with multiple myeloma: a systematic review and meta-analysis. Eur J Haematol. 2016 Nov;97(5):416-429. doi: 10.1111/ejh.12790.\u003c/li\u003e\n\u003cli\u003eZeng L, Huang H, Liu Y, Ruan C, Fan S, Xia Y, Zhou J. The core symptom in multiple myeloma patients undergoing chemotherapy: a network analysis. Support Care Cancer. 2023 Apr 25;31(5):297. doi: 10.1007/s00520-023-07759-7. \u003c/li\u003e\n\u003cli\u003eNwabuko OC, Igbigbi EE, Chukwuonye II, Nnoli MA. Multiple myeloma in Niger Delta, Nigeria: complications and the outcome of palliative interventions. Cancer Manag Res. 2017;9:189-196. https://doi.org/10.2147/CMAR.S126136.\u003c/li\u003e\n\u003cli\u003eNnonyelum ON, Anazoeze MJ, Eunice NO, Emmanuel OO, Stella AT, Marcus AI, Taiwo BM, Olufela KO, Chinawaeze AJ, Orkuma JA, Dalhat GG, Otobo UI. Multiple myeloma in Nigeria: a multi-centre epidemiological and biomedical study. Pan Afr Med J. 2015 Nov 24;22:292. doi: 10.11604/pamj.2015.22.292.7774.\u003c/li\u003e\n\u003cli\u003eJespersen E, Nielsen LK, Larsen RF, M\u0026ouml;ller S, Jarlb\u0026aelig;k L. Everyday living with pain - reported by patients with multiple myeloma. Scand J Pain. 2020 Oct 27;21(1):127-134. doi: 10.1515/sjpain-2020-0087. \u003c/li\u003e\n\u003cli\u003eBilińska M, Usnarska-Zubkiewicz L, Pokryszko-Dragan A. Bortezomib-induced painful neuropathy in patients with multiple myeloma. Contemp Oncol (Pozn). 2013;17(5):421-6. doi: 10.5114/wo.2013.37214. \u003c/li\u003e\n\u003cli\u003eYang Y, Zhao B, Lan H, Sun J, Wei G. Bortezomib-induced peripheral neuropathy: Clinical features, molecular basis, and therapeutic approach. Crit Rev Oncol Hematol. 2024 May;197:104353. doi: 10.1016/j.critrevonc.2024.104353. \u003c/li\u003e\n\u003cli\u003eArgyriou AA, Iconomou G, Kalofonos HP. Bortezomib-induced peripheral neuropathy in multiple myeloma: a comprehensive review of the literature. Blood. 2008 Sep 1;112(5):1593-9. doi: 10.1182/blood-2008-04-149385. \u003c/li\u003e\n\u003cli\u003eStrifler S and Knop S. The Role of Carfilzomib in Treatment of Newly Diagnosed Multiple Myeloma. Future Oncology. 2018;14(30), 3123\u0026ndash;3134. https://doi.org/10.2217/fon-2018-0040.\u003c/li\u003e\n\u003cli\u003eExp\u0026oacute;sito Vizca\u0026iacute;no S, Casanova-Moll\u0026agrave; J, Escoda L, Gal\u0026aacute;n S, Mir\u0026oacute; J. Neuropathic pain in cancer patients treated with bortezomib. Neurologia (Engl Ed). 2018 Jan-Feb;33(1):28-34. English, Spanish. doi: 10.1016/j.nrl.2016.05.008. \u003c/li\u003e\n\u003cli\u003eIto T, Handa H. Molecular mechanisms of thalidomide and its derivatives. Proc Jpn Acad Ser B Phys Biol Sci. 2020;96(6):189-203. doi: 10.2183/pjab.96.016. \u003c/li\u003e\n\u003cli\u003eBanach M, Jurczyszyn A, Skotnicki A. Polekowa neuropatia obwodowa u pacjent\u0026oacute;w ze szpiczakiem plaZmocytowym leczonych talidomidem [Thalidomide induced peripheral neuropathy in multiple myeloma patients]. Przegl Lek. 2015;72(11):629-35. \u003c/li\u003e\n\u003cli\u003eMorawska M, Grzasko N, Kostyra M, Wojciechowicz J, Hus M. Therapy-related peripheral neuropathy in multiple myeloma patients. Hematol Oncol. 2015 Dec;33(4):113-9. doi: 10.1002/hon.2149. Epub 2014 Nov 14. Erratum in: Hematol Oncol. 2016 Jun;34(2):117. doi: 10.1002/hon.2291. \u003c/li\u003e\n\u003cli\u003eSichetti D, Bandieri E, Romero M, Di Biagio K, Luppi M, Belfiglio M, Tognoni G, Ripamonti CI; for ECAD Working Group. Impact of setting of care on pain management in patients with cancer: a multicentre cross-sectional study. Ann Oncol. 2010 Oct;21(10):2088-2093. doi: 10.1093/annonc/mdq155. \u003c/li\u003e\n\u003cli\u003eShen WC, Chen JS, Shao YY, Lee KD, Chiou TJ, Sung YC, Rau KM, Yen CJ, Liao YM, Liu TC, Wu MF, Lee MY, Yu MS, Hwang WL, Lai PY, Chang CS, Chou WC, Hsieh RK. Impact of Undertreatment of Cancer Pain With Analgesic Drugs on Patient Outcomes: A Nationwide Survey of Outpatient Cancer Patient Care in Taiwan. J Pain Symptom Manage. 2017 Jul;54(1):55-65.e1. doi: 10.1016/j.jpainsymman.2017.02.018. \u003c/li\u003e\n\u003cli\u003eFujii A, Yamada Y, Takayama K, Nakano T, Kishimoto J, Morita T, Nakanishi Y. Longitudinal assessment of pain management with the pain management index in cancer outpatients receiving chemotherapy. Support Care Cancer. 2017 Mar;25(3):925-932. doi: 10.1007/s00520-016-3482-x. \u003c/li\u003e\n\u003cli\u003eDonati CM, Zamagni A, Zamfir AA, Aristei C, Cammelli S, Zamagni C, Paolinelli S, Buwenge M, Rossi R, Maltoni M, Morganti AG, Cilla S. Exploring pain management in breast cancer: key findings from the ARISE study. Front Oncol. 2025 Mar 12;15:1536709. doi: 10.3389/fonc.2025.1536709. \u003c/li\u003e\n\u003cli\u003eShrestha S, Sapkota S, Teoh SL, Kc B, Paudyal V, Lee SWH, Gan SH. Comprehensive assessment of pain characteristics, quality of life, and pain management in cancer patients: a multi-center cross-sectional study. Qual Life Res. 2024 Oct;33(10):2755-2771. doi: 10.1007/s11136-024-03725-w. \u003c/li\u003e\n\u003cli\u003eGreco MT, Roberto A, Corli O, Deandrea S, Bandieri E, Cavuto S, Apolone G. Quality of cancer pain management: an update of a systematic review of undertreatment of patients with cancer. J Clin Oncol. 2014 Dec 20;32(36):4149-54. doi: 10.1200/JCO.2014.56.0383. Epub 2014 Nov 17. \u003c/li\u003e\n\u003cli\u003eApolone G, Corli O, Caraceni A, Negri E, Deandrea S, Montanari M, Greco MT; Cancer Pain Outcome Research Study Group (CPOR SG) Investigators. Pattern and quality of care of cancer pain management. Results from the Cancer Pain Outcome Research Study Group. Br J Cancer. 2009 May 19;100(10):1566-74. doi: 10.1038/sj.bjc.6605053. \u003c/li\u003e\n\u003cli\u003eHolly L. Geyer, Halena Gazelka, Ruben Mesa; How I treat pain in hematologic malignancies safely with opioid therapy. Blood 2020; 135 (26): 2354\u0026ndash;2364. doi: https://doi.org/10.1182/blood.2019003116.\u003c/li\u003e\n\u003cli\u003eYu C, Cai T, Zhou T, Zeng N, Liang X, Pan G, Ouyang W, Yuan C. Classification of symptom subtypes in patients with multiple myeloma during treatment: a cross-sectional survey study in China. BMJ Open. 2023 Mar 14;13(3):e066467. doi: 10.1136/bmjopen-2022-066467. \u003c/li\u003e\n\u003cli\u003eNiscola P, Tendas A, Scaramucci L, Giovannini M, De Sanctis V. Pain in blood cancers. Indian J Palliat Care. 2011 Sep;17(3):175-83. doi: 10.4103/0973-1075.92333.\u003c/li\u003e\n\u003cli\u003ePaice JA, Moreira J. Pain Syndromes of Hematologic Malignancies. In: Ullrich, C.K., Roeland, E.J. (eds) Palliative Care in Hematologic Malignancies and Serious Blood Disorders. Springer, Cham. 2023. https://doi.org/10.1007/978-3-031-38058-7_13.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTABLE 1: Socio-demographic characteristics of patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eVariables\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eMyeloma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eNon-myeloma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eP- value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u0026lt;58\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u0026ge;58\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGender\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEducation\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePerformance status\u003c/p\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eOn therapy (chemotherapy)\u003c/p\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNP score\u003c/p\u003e\n \u003cp\u003e(myeloma vs non-myeloma)\u003c/p\u003e\n \u003cp\u003e\u0026le;12\u003c/p\u003e\n \u003cp\u003e\u0026ge;13\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNPRS\u003c/p\u003e\n \u003cp\u003e0 (no pain)\u003c/p\u003e\n \u003cp\u003e1-3 (mild pain)\u003c/p\u003e\n \u003cp\u003e4-6 (moderate pain)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWorst pain (WP) in 4 weeks\u003c/p\u003e\n \u003cp\u003e0 (no pain)\u003c/p\u003e\n \u003cp\u003e1-3 (mild pain)\u003c/p\u003e\n \u003cp\u003e4-6 (moderate pain)\u003c/p\u003e\n \u003cp\u003e7-10 (severe pain)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBody mass index (BMI)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eUnderweight (Below 18.5)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNormal (18.5\u0026ndash;24.9)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eOverweight (25.0\u0026ndash;29.9)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eObesity (30.0 and above\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSmoking\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNever\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePrevious\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;Alcohol\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNever\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePrevious\u003c/p\u003e\n \u003cp\u003eOccasional\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e08\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e08\u003c/p\u003e\n \u003cp\u003e05\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e02\u003c/p\u003e\n \u003cp\u003e02\u003c/p\u003e\n \u003cp\u003e02\u003c/p\u003e\n \u003cp\u003e07\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e00\u003c/p\u003e\n \u003cp\u003e05\u003c/p\u003e\n \u003cp\u003e06\u003c/p\u003e\n \u003cp\u003e02\u003c/p\u003e\n \u003cp\u003e00\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003cp\u003e00\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e05\u003c/p\u003e\n \u003cp\u003e08\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e01\u003c/p\u003e\n \u003cp\u003e09\u003c/p\u003e\n \u003cp\u003e03\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e00\u003c/p\u003e\n \u003cp\u003e01\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e02\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e00\u003c/p\u003e\n \u003cp\u003e09\u003c/p\u003e\n \u003cp\u003e03\u003c/p\u003e\n \u003cp\u003e01\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003cp\u003e00\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e07\u003c/p\u003e\n \u003cp\u003e04\u003c/p\u003e\n \u003cp\u003e02\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e03\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003cp\u003e09\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e02\u003c/p\u003e\n \u003cp\u003e02\u003c/p\u003e\n \u003cp\u003e08\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e01\u003c/p\u003e\n \u003cp\u003e01\u003c/p\u003e\n \u003cp\u003e09\u003c/p\u003e\n \u003cp\u003e09\u003c/p\u003e\n \u003cp\u003e03\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003e03\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003cp\u003e02\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e09\u003c/p\u003e\n \u003cp\u003e03\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e03\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e07\u003c/p\u003e\n \u003cp\u003e02\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e02\u003c/p\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e05\u003c/p\u003e\n \u003cp\u003e00\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003cp\u003e02\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e05\u003c/p\u003e\n \u003cp\u003e03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.968\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.617\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.044\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.288\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.047\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.509\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.402\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.884\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNP \u0026ndash; neuropathic pain\u003c/p\u003e\n\u003cp\u003eTABLE 2: The characteristics of pain and frequency of analgesia use in the patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eCharacteristic\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eFrequency\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003ePercentage\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eNPRS\u003c/p\u003e\n \u003cp\u003emean \u0026plusmn; SD \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.86 \u0026plusmn;1.79\u003c/p\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e0 (no pain)\u003c/p\u003e\n \u003cp\u003e1-3 (mild pain)\u003c/p\u003e\n \u003cp\u003e4-6 (moderate pain)\u003c/p\u003e\n \u003cp\u003e7-10 (severe pain)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWorst pain (WP) in 4 weeks\u003c/p\u003e\n \u003cp\u003e0 (no pain)\u003c/p\u003e\n \u003cp\u003e1-3 (mild pain)\u003c/p\u003e\n \u003cp\u003e4-6 (moderate pain)\u003c/p\u003e\n \u003cp\u003e7-10 (severe pain)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNP score\u003c/p\u003e\n \u003cp\u003e\u0026le;12\u003c/p\u003e\n \u003cp\u003e\u0026ge;13\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAnalgesic score\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e3\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eParacetamol\u003c/p\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNSAIDs\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWeak Opiate\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStrong opiate\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003cp\u003e05\u003c/p\u003e\n \u003cp\u003e01\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e03\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e09\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e01\u003c/p\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003cp\u003e09\u003c/p\u003e\n \u003cp\u003e08\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003cp\u003e04\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e08\u003c/p\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003cp\u003e13.9\u003c/p\u003e\n \u003cp\u003e02.8\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e08.4\u003c/p\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e72.2\u003c/p\u003e\n \u003cp\u003e27.8\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e02.8\u003c/p\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003cp\u003e22.2\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e88.9\u003c/p\u003e\n \u003cp\u003e11.1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e72.2\u003c/p\u003e\n \u003cp\u003e27.8\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e38.9\u003c/p\u003e\n \u003cp\u003e61.1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e22.2\u003c/p\u003e\n \u003cp\u003e77.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNPRS \u0026ndash; numeric pain rating scale; NSAIDs \u0026ndash; non-steroidal anti-inflammatory drugs\u003c/p\u003e\n\u003cp\u003eTABLE 3: Association between analgesic use and presence of haematological cancer and pain (chi-square/ Fischer test)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eVariable\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eMM presence\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eNP presence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eWP in 4 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eParacetamol\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNSAIDs\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWeak Opiate\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStrong Opiate\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCo-analgesic\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAnalgesic score\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.609\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.043\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.040\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.293\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.223\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.107\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.017\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.473\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.008\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.058\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.250\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.009\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNSAIDs \u0026ndash; non-steroidal anti-inflammatory; MM \u0026ndash; multiple myeloma; NP \u0026ndash; neuropathic pain; WP \u0026ndash; worst pain.\u003c/p\u003e\n\u003cp\u003eTABLE 4: Logistic regression showing association between the independent variables and presence of multiple myeloma.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003ep-Value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eAge\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStrong opiate use\u003c/p\u003e\n \u003cp\u003eWeak opiate use\u003c/p\u003e\n \u003cp\u003ePS\u003c/p\u003e\n \u003cp\u003eNP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003cp\u003e0.030\u003c/p\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1.075\u003c/p\u003e\n \u003cp\u003e25.667\u003c/p\u003e\n \u003cp\u003e15.833\u003c/p\u003e\n \u003cp\u003e0.902\u003c/p\u003e\n \u003cp\u003e16.800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1.008 \u0026ndash; 1.147\u003c/p\u003e\n \u003cp\u003e2.621 \u0026ndash; 251.303\u003c/p\u003e\n \u003cp\u003e2.947 \u0026ndash; 85.075\u003c/p\u003e\n \u003cp\u003e0.822 \u0026ndash; 0.990\u003c/p\u003e\n \u003cp\u003e2.693 \u0026ndash; 104.822\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ePS \u0026ndash; performance status; NP \u0026ndash; neuropathic pain\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Haematological cancer, multiple myeloma, Cancer pain, neuropathic pain, pain management index","lastPublishedDoi":"10.21203/rs.3.rs-8441132/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8441132/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eOBJECTIVE\u003c/h2\u003e \u003cp\u003ePain is a very common complaint among haematological cancer patients. There is yet to be a study on the portrayal of pain experiences among haematological cancer patients in Nigeria. This main aim of this study is to do an appraisal of the clinical characteristic of pain issues in Nigerian haematological cancer.\u003c/p\u003e\u003ch2\u003eMETHODS\u003c/h2\u003e \u003cp\u003eThe 36 haematological cancer patients from the University of Ilorin Teaching Hospital were divided into myeloma or non-myeloma groups. Their Socio-demographics and clinical attributes were duly recorded. The painDETECT questionnaire (PDQ), the numeric pain rating scale (NPRS) and pain management index were deployed to evaluate their pain levels.\u003c/p\u003e\u003ch2\u003eRESULTS\u003c/h2\u003e \u003cp\u003eApproximately 67% study participants complained of pain at presentation, and 92% reported it as their worst in the past 4 weeks. A mean age of 58 years was reported among the patients. multiple myeloma was significantly associated with age (p\u0026thinsp;=\u0026thinsp;0.035) performance status (p\u0026thinsp;=\u0026thinsp;0.044), pain at presentation (p\u0026thinsp;=\u0026thinsp;0.047), worst pain in 4 weeks (p\u0026thinsp;=\u0026thinsp;0.013) and neuropathic pain (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In the multivariate analysis, performance status (b\u0026thinsp;=\u0026thinsp;0.902, p\u0026thinsp;=\u0026thinsp;0.03) and use of a strong opiate (b\u0026thinsp;=\u0026thinsp;25.667, p\u0026thinsp;=\u0026thinsp;0.005), weak opiate (b\u0026thinsp;=\u0026thinsp;15.833, p\u0026thinsp;=\u0026thinsp;0.001) and age (b\u0026thinsp;=\u0026thinsp;1.075, p\u0026thinsp;=\u0026thinsp;0.029) had significant association with multiple myeloma. The percentage of patients receiving inadequate pain therapy (PMI\u0026thinsp;\u0026lt;\u0026thinsp;0) was 22.2%.\u003c/p\u003e\u003ch2\u003eDISCUSSION\u003c/h2\u003e \u003cp\u003eThis research shows the characteristic of pain in haematological cancer patients in Nigeria. The findings highlight the unevenly raised frequency of neuropathic pain in multiple myeloma compared to other haematological cancer. In addition, the inadequacy of pain management was also exposed.\u003c/p\u003e","manuscriptTitle":"Pain Characteristics of Adult Haematological Cancer Patients at an Outpatient Clinic in Nigeria – a Cross-sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-06 14:29:51","doi":"10.21203/rs.3.rs-8441132/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3d43b0dd-ddf2-4703-bd4d-a31faa37d67d","owner":[],"postedDate":"January 6th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-06T14:29:54+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-06 14:29:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8441132","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8441132","identity":"rs-8441132","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}