In part 1 of this article, we discussed the prevalence of pain in patients with acquired immunodeficiency syndrome (AIDS) and human immunodeficiency virus (HIV)-related disease, and offered an overview of pain syndromes in this population. We then briefly explored the topics of pain in women and children with AIDS and the impact of pain on quality of life, before beginning a general discussion on pain management in AIDS patients. After assessment and measurement issues, we detailed three major pharmacotherapeutic approaches—the use of nonopioid analgesics, opioid analgesics, and adjuvant analgesics. Continuing the discussion of management, part 2 will address nonpharmacologic interventions, the undertreatment of pain in AIDS patients, and barriers to pain control, concluding with an extensive consideration of pain treatment in HIV-infected substance abusers.
Nonpharmacologic Interventions
A variety of physical and psychological therapies may prove useful in the management of HIV-related pain (Table 1). Physical interventions range from bed rest and simple exercise programs to the application of cold packs or heat to affected sites. Other nonpharmacologic interventions include whirlpool baths, massage, the application of ultrasound, and transcutaneous electrical nerve stimulation (TENS). Increasing numbers of AIDS patients have resorted to acupuncture to relieve their pain, with anecdotal reports of efficacy.
Several psychological interventions—including hypnosis, relaxation and distraction techniques such as biofeedback and imagery, and cognitive-behavioral techniques—have demonstrated potential efficacy in alleviating HIV-related pain. Where nonpharmacologic and standard pharmacologic treatments fail, anesthetic and even neurosurgical procedures (such as nerve block, cordotomy, and epidural delivery of analgesics) are additional options available to the patient who appreciates the risks and limitations of these procedures.
Undertreatment of Pain in AIDS
Reports of dramatic undertreatment of pain in AIDS patients have appeared in the literature.[1,2] These studies suggest that all classes of analgesics, particularly opioid analgesics, are underutilized in the treatment of pain in AIDS. Our group[3] has reported that less than 8% of individuals in our cohort of ambulatory AIDS patients reporting pain in the severe range (8-10 on a numerical rating scale of pain intensity) received a strong opioid, such as morphine(Drug information on morphine), as recommended by published guidelines.[4] In addition, 18% of patients with severe pain were prescribed no analgesics whatsoever, 40% were prescribed a nonopioid analgesic (eg, a nonsteroidal anti-inflammatory drug [NSAID]), and only 22% were prescribed a "weak" opioid (eg, acetaminophen in combination with oxycodone(Drug information on oxycodone)).
Utilizing the Pain Management Index,[5] a measure of adequacy of analgesic therapy derived from the Brief Pain Inventory’s record of pain intensity and strength of analgesia prescribed, we further examined adequacy of pain treatment. Only 15% of our sample received adequate analgesic therapy, based on the Pain Management Index. This degree of undermedication of pain in AIDS (85%) far exceeds published reports of 40% undermedication of pain (using the Pain Management Index) in cancer populations. Larue and colleagues[6] found that, in France, 57% of patients with HIV disease reporting moderate to severe pain did not receive any analgesic treatment at all, and only 22% received a weak opioid.
While opioid analgesics are underutilized, it is clear that adjuvant analgesic agents such as the antidepressants are also dramatically underutilized.[1,2,6,7] Breitbart and colleagues[7] found that less than 10% of AIDS patients reporting pain received an adjuvant analgesic drug (eg, antidepressants, anticonvulsants), despite the fact that approximately 40% of the sample had neuropathic pain. This class of analgesic agents is a critical component of the World Health Organization (WHO) analgesic ladder, particularly in managing neuropathic pain, and is vastly underutilized in the management of HIV-related pain.
Barriers to Pain Management in AIDS
A number of different factors, including patient, clinician, and health-care system-related barriers, have been proposed as potential influences on the widespread undertreatment of pain in AIDS (see Table 2).[7-10] Sociodemographic factors reported to be associated with undertreatment of pain in AIDS include gender, education, and a history of substance abuse.[3] Women, less-educated patients, and patients who reported injection drug use as their HIV-transmission risk factor are significantly more likely to receive inadequate analgesic therapy for HIV-related pain.
Breitbart and colleagues[9] surveyed 200 ambulatory AIDS patients using a modified version of the Barriers Questionnaire (BQ),[11] which assesses a variety of patient-related barriers to pain management (resulting in patient reluctance to report pain or take opioid analgesics). Results of this study demonstrated that patient-related barriers (as measured by BQ scores) were significantly correlated with undertreatment of pain (as measured by the Pain Management Index) in AIDS patients with pain. Additionally, BQ scores were significantly correlated with higher levels of psychological distress and depression, indicating that patient-related barriers contributed to undertreatment of pain and poorer quality of life.
The most frequently indicated BQ items were those concerning the addiction potential of opioids, side effects and discomfort related to opioid administration, and misconceptions about tolerance. Although there were no age, gender, or HIV-transmission risk factor associations with BQ scores, nonwhite and less-educated patients scored higher on the questionnaire. Examination of additional AIDS-specific patient-related barriers[8,9] revealed that 66% of patients were trying to limit their overall intake of medications (ie, pills) or utilize nonpharmacologic interventions for pain, 50% of patients could not afford to fill a prescription for analgesics or had no access to pain specialists, and about 50% were reluctant to take opioids for pain because of concern that family, friends, or physicians would assume they were misusing or abusing these drugs.
In a survey of approximately 500 AIDS care providers,[10] clinicians (primarily physicians and nurses) rated the barriers to pain management that they perceived to be the most important in the care of AIDS patients. The most frequently noted barriers were those regarding lack of knowledge about pain management or access to pain specialists, and concerns regarding the use and addiction potential of opioid drugs in the AIDS population. The top five barriers indicated by AIDS clinicians were (1) lack of knowledge regarding pain management (51.8%), (2) reluctance to prescribe opioids (51.5%), (3) lack of access to pain specialists (50.9%), (4) concern regarding drug addiction and/or abuse (50.5%), and (5) lack of psychological support/drug treatment services (43%).
Patient reluctance to report pain and patient reluctance to take opioids were less commonly indicated barriers, noted by about 24% of respondents.[10] In contrast, past surveys of oncologists rated patient reluctance to report pain or take opioids as two of the top four barriers. Like AIDS care providers, oncologists frequently noted a reluctance to prescribe opioids, even to a population of cancer patients with a significantly lower prevalence of past or present substance abuse disorders. Both oncologists and AIDS care providers report that they have inadequate knowledge of pain management and pain assessment skills.
A 52-year-old man presented with an erythematous lesion in the axilla of unknown duration. Surgical excision was performed. What is your diagnosis?
