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Current Perspectives on Pain in AIDS

Current Perspectives on Pain in AIDS

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 (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 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.

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