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History of Substance Abuse Not a Barrier to Opioid Use

History of Substance Abuse Not a Barrier to Opioid Use

NEW YORK--Pain is highly prevalent in patients with HIV disease. Yet clinicians are often afraid to prescribe opioids when the patient is a former substance abuser, William Breitbart, MD, said at a conference on chemical dependency and pain management.

The conference was sponsored by Memorial Sloan-Kettering Cancer Center, where Dr. Breitbart is chief of the Psychiatry Service.

Dr. Breibart, who has conducted a series of studies of the management of pain in AIDS, reminded clinicians that they have an obligation to treat pain, even when patients have a history of drug abuse.

Only 6% of AIDS patients with severe pain are prescribed a strong opioid like morphine, Dr. Breitbart noted, even though the World Health Organization analgesic ladder suggests strong opioids for all patients with severe pain.

"Substance abusers with AIDS are among the fastest growing segment of the epidemic. They are also among the most undertreated for pain. Fears of contributing to drug abuse behavior and causing re-addiction contribute to physician reluctance to prescribe opioids," he said.

One of the most frequent complaints Dr. Breitbart hears from AIDS patients with a history of drug abuse is that clinicians do not believe their reports of pain or assume they are exaggerated or concocted to obtain drugs of abuse.

Interpreting Pain

As with cancer pain, it is important to appreciate that pain in HIV disease is a complex multidimensional experience and not just a physical or nociceptive phenome-non, Dr. William Breitbart said in his symposium presentation .

"The ultimate report of pain intensity that you hear from the patient is a consequence of many interactions," he said. Factors that may impact on pain intensity reports include cognition or the meaning of pain; emotional factors such as fear, anxiety, and depression; social environmental factors such as social support and financial security; and substance abuse issues.

In Dr. Breitbart's experience, patients with AIDS-related pain who interpreted their pain as meaning that their HIV disease was progressing reported higher levels of pain than patients who saw no connection between their pain and their disease status.

"This makes one appreciate the need to apply both somatic therapies like analgesics and psychosocial therapies in the treatment of AIDS-related pain," he said.

To ascertain whether there was evidence of lies or exaggeration about pain, he compared the reports of pain of AIDS patients with a history of drug abuse with those who had no such history. He found that on every variable--prevalence of pain, pain intensity, number of pains--there was no significant difference between the two groups. But there was a difference in how they were treated.

"Our patients with a history of drug abuse were much more likely to get no treatment, much less likely to get a strong opioid, and much more likely to be distressed, depressed, and hopeless," he said.

Dr. Breitbart suggested two principles as a guideline for the management of pain in AIDS patients with a history of drug abuse. The first is that substance abusers with HIV deserve pain relief regardless of whether they have a drug abuse history.

"We treat other medical problems regardless of drug abuse. The presence of injection drug use or substance abuse complicates the management of pain, but it does not relieve us of the obligation to treat pain," he said.

The second principle of pain management in these patients is to try and accept and respect reports of pain. "During your first interaction with a patient, you will not be able to tell whether the patient is exaggerating or lying about his pain," he said. "You will only get to know the true nature of their pain experience through a process that will take time and involves assessment, intervention, and responses to your interventions."

Dr. Breitbart advised clinicians to speak frankly to patients with a history of substance abuse about their concerns. Clinicians should also be clear with them about the goals and conditions of opioid therapy, and should consider the use of written contracts that establish a single prescriber.

Dr. Breitbart, who has treated several hundred patients with AIDS-related pain and a history of substance abuse, said that he had been fooled "a good dozen or so times. But if I were to allow that experience of being manipulated and fooled to stop me, I would not have been able to help the vast majority of those patients with pain."

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