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 approachesthe 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
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 interventionsincluding hypnosis, relaxation and
distraction techniques such as biofeedback and imagery, and cognitive-behavioral
techniqueshave 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.
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 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, as recommended by published guidelines. 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).
Utilizing the Pain Management Index, 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 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 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
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
factors reported to be associated with undertreatment of pain in AIDS include
gender, education, and a history of substance abuse. 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 surveyed 200 ambulatory AIDS patients using a
modified version of the Barriers Questionnaire (BQ), 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, 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
Patient reluctance to report pain and patient reluctance to take opioids were
less commonly indicated barriers, noted by about 24% of respondents. 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
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