The article by Dr. William Breitbart and Lucia DiBiase offers an excellent in-depth review of our current knowledge of the epidemiology, pharmacologic, and nonpharmacologic interventions in the field of pain management in patients with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS).
Epidemiologic surveys suggest that pain is highly prevalent and frequently undertreated in both cancer and HIV/AIDS patients.[1-3] Studies have strongly indicated, however, that the problem of pain undertreatment is far worse in the HIV/AIDS population. Pain management needs to be a fundamental priority in the provision of care and relief of suffering for these patients. In order to address this priority, health-care providers should familiarize themselves with the pain syndromes prevalent in HIV/AIDS and principles of pain management.
Adjuvant Analgesics
Many different adjuvant analgesics are used to treat pain in the HIV/AIDS population. Neuropathic pain syndromes associated with disease progression or treatment-related side effects are the most prevalent pain complications in HIV/AIDS patients, and they pose a daunting challenge for management. In clinical practice, unsuccessful trials are frequently attributed to the incomplete duration of the trial, inadequate dose titration, overly rapid titration producing dose-limiting side effects, issues of nonadherence, and/or unrealistic expectations held by patient or clinician.
The authors have presented an extensive list of drugs that have potential benefit in the treatment of neuropathic pain. In light of the extensive number of adjuvant medications, it is recommended that felbamate(Drug information on felbamate) (Felbatol) use be avoided because of the possibility of aplastic anemia and hepatic failure.[4]
Opioid Pharmacology
Breitbart and DiBiase provide an excellent, comprehensive guide to opioid selection for the management of pain in patients with HIV/AIDS. It would have been worthwhile, however, to devote an additional paragraph to the use of methadone(Drug information on methadone) for pain management. It appears that the recent increase in the use of methadone for pain management may be related to its low cost and efficacy in patients for whom opioid trials have been inadequate. Despite the paucity of efficacy studies, an opioid rotation to methadone is recommended for patients who experience dose-limiting side-effects on other opioids.
A 70-year-old man with a history of localized prostate cancer treated with whole-pelvis radiation therapy with a boost to the prostate, in conjunction with androgen deprivation therapy 7 years prior, presented with lower back pain. A bone scan revealed an area of activity in the sacrum. What is the most likely diagnosis?
