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
As with cancer pain, it is important to appreciate that pain in HIV
"The ultimate report of pain intensity that you hear from the patient
In Dr. Breitbart's experience, patients with AIDS-related pain who interpreted
"This makes one appreciate the need to apply both somatic therapies
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,"
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."