Pain Syndromes
William Breitbart
Psychiatrists and psychologists are still actively involved in many aspects of the care of patients with acquired immunodeficiency syndrome (AIDS), and so it is necessary for us to be aware of such important quality of care and quality of life issues as pain in AIDS. With the introduction of highly active antiretroviral therapy (HAART) (i.e., combination therapies including protease inhibitors) the face of the AIDS epidemic, particularly for those who can avail themselves of and/or tolerate these new therapies, is indeed changing. Even with advances in AIDS therapies, pain continues to be an important psychiatric and supportive care issue for patients with human immunodeficiency virus (HIV) disease. As the epidemiology of the AIDS epidemic changes in the United States, the challenge of managing pain in patients with AIDS with a history of substance abuse is becoming an ever-growing challenge. Studies have documented that pain in individuals with HIV infection or AIDS is highly prevalent, diverse, and varied in syndromal presentation; associated with significant psychological and functional morbidity; and alarmingly undertreated.1,2,3,4,5,6,7,8,9,10,11,12 Pain management needs to be more integrated into the total care of patients with HIV disease. Responses from a self-referred sample of outpatients with AIDS indicate that patients with AIDS experience many distressing physical and psychological symptoms, along with a high level of distress.13 This chapter describes the prevalence and types of pain syndromes encountered in patients with HIV disease and reviews the psychological and functional impact of pain, as well as the barriers to adequate pain treatment in this population. Finally, principles of pain management, with particular emphasis on the management of pain in HIV-infected patients with a history of substance abuse, are outlined.
Prevalence of Pain
Estimates of the prevalence of pain in HIV-infected individuals have been reported to range from 30% to over 90%, with the prevalence of pain increasing as disease progresses,4,5,6,7,8,12,14,15,16 particularly in the latest stages of illness.
Studies suggest that approximately 30% of ambulatory HIV-infected patients in early stages of HIV disease (pre-AIDS; Category A or B disease) experience clinically significant pain, and as many as 56% have had episodic painful symptoms of less clear clinical significance.5,7,12
In a prospective cross-sectional survey of 438 ambulatory patients with AIDS in New York City, 63% reported frequent or persistent pain of at least 2 weeks’ duration at the time of assessment.5 The prevalence of pain in this large sample increased significantly as HIV disease progressed, with 45% of patients with AIDS with Category A3 disease reporting pain, 55% of those with Category B3 disease reporting pain, and 67% of those with Category C1, 2, or 3 disease reporting pain. Individuals in this sample of ambulatory patients with AIDS also were more likely to report pain if they had other concurrent HIV-related symptoms (e.g., fatigue, wasting), had received treatment for an AIDS-related opportunistic infection, or if they had not been receiving antiretroviral medications (e.g., AZT, ddI, ddC, d4t).
In a prospective cross-sectional survey of 438 ambulatory patients with AIDS in New York City, 63% reported frequent or persistent pain of at least 2 weeks’ duration at the time of assessment.5 The prevalence of pain in this large sample increased significantly as HIV disease progressed, with 45% of patients with AIDS with Category A3 disease reporting pain, 55% of those with Category B3 disease reporting pain, and 67% of those with Category C1, 2, or 3 disease reporting pain. Individuals in this sample of ambulatory patients with AIDS also were more likely to report pain if they had other concurrent HIV-related symptoms (e.g., fatigue, wasting), had received treatment for an AIDS-related opportunistic infection, or if they had not been receiving antiretroviral medications (e.g., AZT, ddI, ddC, d4t).
In a study of pain in hospitalized patients with AIDS in a public hospital in New York City, over 50% of patients required treatment for pain, with pain being the presenting complaint in 30% and the second most common presenting problem after fever.8 In a French multicenter study, 62% of hospitalized patients with HIV disease had clinically significant pain.7 Schofferman and Brody16 reported that 53% of patients with far-advanced AIDS cared for in a hospice setting had pain; Kimball and McCormick15 reported that up to 93% of patients with AIDS in their hospice experienced at least one 48-hour period of pain during the last 2 weeks of life.
Larue et al.17 demonstrated that patients with AIDS being cared for by hospice at home had prevalence rates and intensity ratings for pain that were comparable to, and even exceeded, those of cancer patients. Breitbart et al.4 reported that ambulatory patients with AIDS in their New York City sample reported a mean pain intensity on average of 5.4 (on the 0 to 10 numerical rating scale of the Brief Pain Inventory) and a mean pain “at its worst” of 7.4. In addition, as with pain prevalence, the intensity of pain experienced by patients with HIV disease increases significantly as disease progresses. Patients with AIDS who are experiencing pain, like their counterparts with cancer pain, typically describe an average of 2.5 to 3 concurrent pains at a time.4,6
Frich and Borgbjerg18 concluded that the incidence of disturbing pain in AIDS is high, specifically in the extremities, gastrointestinal tract, and head. In a study of 95 patients with AIDS, the overall incidence of pain was 88% and 69% of the patients suffered from pain that interfered with daily activity to a degree described as moderate to severe.18 In patients with AIDS who are approaching end of life, 93% of patients report experiencing pain and discomfort at some time during the last 2 weeks of life.15 This percentage may be even higher if some pain and discomfort went unrecognized. Most patients experienced at least one 48-hour period of pain and discomfort during the last 2 weeks of life; furthermore, 88% received some sort of opioid analgesia with the majority experiencing some relief afterward.15
Pain Syndromes
Pain syndromes encountered in AIDS are diverse in nature and etiology. Pain syndromes seen in HIV disease can be categorized into three types (Table 17.1): (a) those directly related to HIV infection or consequences of immunosuppression, (b) those due to AIDS therapies, and (c) those unrelated to AIDS or AIDS therapies.2,3,6 In studies to date, approximately 45% of pain syndromes encountered are directly related to HIV infection or consequences of immunosuppression; 15% to 30% are due to therapies for HIV- or AIDS-related conditions, as well as diagnostic procedures; and the remaining 25% to 40% are unrelated to HIV disease or its therapies.6 The most common pain syndromes reported in studies to date include painful sensory peripheral neuropathy, pain due to extensive Kaposi’s sarcoma, headache, oral and pharyngeal pain, abdominal pain, chest pain, arthralgias and myalgias, and painful dermato-logic conditions.5,6,8,10,12,14,16,17,19 In a sample of 151 ambulatory patients with AIDS who underwent a research assessment, which included a clinical interview, neurologic examination, and review of medical records,6 the most common pain diagnoses included headaches
(46% of patients, 17% of all pains); joint pains (arthritis, arthralgias, etc., 31% of patients; 12% of pains); painful polyneuropathy (distal symmetric polyneuropathy, 28% of patients; 10% of pains); and muscle pains (myalgia, myositis, 27% of patients; 12% of pains). Other common pain diagnoses included skin pain (Kaposi’s sarcoma, infections, 25% of patients; 30% of homosexual males in the sample had pain from extensive Kaposi’s sarcoma lesions); bone pain (20% of patients), abdominal pain (17% of patients); chest pain (13%); and painful radiculopathy (12%). Patients in this sample had a total of 405 pains (averaging 3 concurrent pains), with 46% of patients diagnosed with neuropathic pain, 71% with somatic pain, 29% with visceral pain, and 46% with headache (classified separately because of controversy as to pathophysiology). When pain type was classified by pains (as opposed to patients) 25% were neuropathic pains, 44% were nociceptive-somatic, 14% were nociceptive-visceral, and 17% were idiopathic type pains. Patients in this study with lower CD4+ cell counts were significantly more likely to be diagnosed with polyneuropathy and headache. Hewitt et al.6 demonstrated that although pains of a neuropathic nature (e.g., polyneuropathies, radiculopathies) certainly make up a large proportion of pain syndromes encountered in patients with AIDS (Table 17.2), pains of a somatic and/or visceral nature are also extremely common clinical problems.
(46% of patients, 17% of all pains); joint pains (arthritis, arthralgias, etc., 31% of patients; 12% of pains); painful polyneuropathy (distal symmetric polyneuropathy, 28% of patients; 10% of pains); and muscle pains (myalgia, myositis, 27% of patients; 12% of pains). Other common pain diagnoses included skin pain (Kaposi’s sarcoma, infections, 25% of patients; 30% of homosexual males in the sample had pain from extensive Kaposi’s sarcoma lesions); bone pain (20% of patients), abdominal pain (17% of patients); chest pain (13%); and painful radiculopathy (12%). Patients in this sample had a total of 405 pains (averaging 3 concurrent pains), with 46% of patients diagnosed with neuropathic pain, 71% with somatic pain, 29% with visceral pain, and 46% with headache (classified separately because of controversy as to pathophysiology). When pain type was classified by pains (as opposed to patients) 25% were neuropathic pains, 44% were nociceptive-somatic, 14% were nociceptive-visceral, and 17% were idiopathic type pains. Patients in this study with lower CD4+ cell counts were significantly more likely to be diagnosed with polyneuropathy and headache. Hewitt et al.6 demonstrated that although pains of a neuropathic nature (e.g., polyneuropathies, radiculopathies) certainly make up a large proportion of pain syndromes encountered in patients with AIDS (Table 17.2), pains of a somatic and/or visceral nature are also extremely common clinical problems.
TABLE 17.1 Pain Syndromes in AIDS Patients | |
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Women and Pain
The author’s group at Memorial Sloan-Kettering Cancer Center has reported on the experience of pain in women with AIDS.6,20 Although preliminary, our studies suggest that women with HIV disease experience pain more frequently than men with HIV disease and report somewhat higher levels of pain intensity. This may be, in part, a reflection of the fact that women with AIDS-related pain are twice as likely to be undertreated for their pain compared to men.4 Women with HIV disease have unique gynecologic pain syndromes specifically related to opportunistic infectious processes and cancers of the pelvis and genitourinary tract.21 Women with AIDS were significantly more likely to be diagnosed with radiculopathy and headache in one survey.6
TABLE 17.2 Neuropathies Encountered in HIV/AIDS-Infected Patients | |
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Children and Pain
Children with HIV infection also experience pain.22 HIV-related conditions in children that are observed to cause pain include meningitis and sinusitis (headaches); otitis media; shingles; cellulitis and abscesses; severe candida dermatitis; dental caries; intestinal infections, such as Mycobacterium avium intracellulare (MAI) and Cryptosporidium; hepatosplenomegaly; oral and esophageal candidiasis; and spasticity associated with encephalopathy that causes painful muscle spasms. (The reader is referred to the Chapters 25 and 38 on palliative care in children.)
Impact of Pain on Quality of Life
Pain, in patients with HIV disease, has a profound negative impact on physical and psychological functioning and overall quality of life.7,11 In a study of the impact of pain on psychological functioning and quality of life in ambulatory AIDS patients,11 depression was significantly correlated with the presence of pain. In addition to being significantly more distressed, depressed, and hopeless, those with pain were twice as likely to have suicidal ideation (40%) as those without pain (20%). HIV-infected patients with pain were more functionally impaired.11 Such functional interference was highly corrlated to levels of pain
intensity and depression. Patients with pain were more likely to be unemployed or disabled and reported less social support. Larue et al.7 reported that HIV-infected patients with pain intensities greater than 5 (on a 0 to 10 NRS) reported significantly poorer quality of life during the week preceding their survey than patients without pain. Pain intensity had an independent negative impact on HIV patients’ quality of life, even after adjustment for treatment setting, stage of disease, fatigue, sadness, and depression. Singer et al.12 also reported an association between the frequency of multiple pains, increased disability, and higher levels of depression. Psychological variables, such as the amount of control people believe they have over pain, emotional associations and memories of pain, fears of death, depression, anxiety, and hopelessness, contribute to the experience of pain in people with AIDS and can increase suffering.11,23 Our group also reported that negative thoughts related to pain were associated with greater pain intensity, psychological distress, and disability in ambulatory patients with AIDS.24 Those patients with AIDS who felt that pain represented a progression of their HIV disease reported more intense pain than those who did not see pain as a threat. Vogel et al.13 assessed 504 ambulatory patients with AIDS to measure symptom distress, physical and psychosocial functioning, and demographic and disease-related factors. As opposed to those who reported sexual contact as a means of transmission, patients who reported intravenous (IV) drug use as route of HIV transmission indicated higher levels of distress and physical symptom distress.13 Furthermore, Vogel et al.13 showed that both the number of symptoms and symptom distress were highly associated with psychological distress and poorer quality of life.
intensity and depression. Patients with pain were more likely to be unemployed or disabled and reported less social support. Larue et al.7 reported that HIV-infected patients with pain intensities greater than 5 (on a 0 to 10 NRS) reported significantly poorer quality of life during the week preceding their survey than patients without pain. Pain intensity had an independent negative impact on HIV patients’ quality of life, even after adjustment for treatment setting, stage of disease, fatigue, sadness, and depression. Singer et al.12 also reported an association between the frequency of multiple pains, increased disability, and higher levels of depression. Psychological variables, such as the amount of control people believe they have over pain, emotional associations and memories of pain, fears of death, depression, anxiety, and hopelessness, contribute to the experience of pain in people with AIDS and can increase suffering.11,23 Our group also reported that negative thoughts related to pain were associated with greater pain intensity, psychological distress, and disability in ambulatory patients with AIDS.24 Those patients with AIDS who felt that pain represented a progression of their HIV disease reported more intense pain than those who did not see pain as a threat. Vogel et al.13 assessed 504 ambulatory patients with AIDS to measure symptom distress, physical and psychosocial functioning, and demographic and disease-related factors. As opposed to those who reported sexual contact as a means of transmission, patients who reported intravenous (IV) drug use as route of HIV transmission indicated higher levels of distress and physical symptom distress.13 Furthermore, Vogel et al.13 showed that both the number of symptoms and symptom distress were highly associated with psychological distress and poorer quality of life.
Management of Pain
Assessment Issues
The initial step in pain management is a comprehensive assessment of pain symptoms. The health professional working in the AIDS setting must have a working knowledge of the etiology and treatment of pain in AIDS. This would include an understanding of the different types of AIDS pain syndromes, as discussed previously, as well as a familiarity with the parameters of appropriate pharmacologic treatment. A close collaboration of the entire health care team is optimal when attempting to adequately manage pain in the patient with AIDS. A careful history and physical examination may disclose an identifiable syndrome (e.g., herpes zoster, bacterial infection, or neuropathy) that can be treated in a standard fashion.25,26 A standard pain history27,28 may provide valuable clues to the nature of the underlying process and indeed may disclose other treatable disorders. A description of the qualitative features of the pain, its time course, and any maneuvers that increase or decrease pain intensity should be obtained. Pain intensity (current, average, at best, at worst) should be assessed to determine the need for weak versus potent analgesics and as a means to serially evaluate the effectiveness of ongoing treatment. Pain descriptors (e.g., burning, shooting, dull, or sharp) will help determine the mechanism of pain (somatic, nociceptive, visceral nociceptive, or neuropathic) and may suggest the likelihood of response to various classes of traditional and adjuvant analgesics (nonsteroidal anti-inflammatory drugs [NSAIDs], opioids, antidepressants, anticonvulsants, oral local anesthetics, corticosteroids, etc.).29,30,31 Additionally, detailed medical, neurologic, and psychosocial assessments (including a history of substance use or abuse) must be conducted. Where possible, family members or partners should be interviewed and included in the pain management treatment plan. During the assessment phase, pain should be aggressively treated; pain complaints and psychosocial issues are subject to an ongoing process of reevaluation.27
Pain Measurement/Assessment Tools
An important element in assessment of pain is the concept that assessment is continuous and needs to be repeated over the course of pain treatment. The use of readily available, simple and clinically validated pain self-report measures or tools can make this process simpler and more reliable. There are essentially four aspects of pain experience in AIDS that require ongoing assessment and evaluation, which can be aided by these tools: (a) pain intensity, (b) pain relief, (c) pain-related functional interference (e.g., mood state, general, and specific activities), and (d) monitoring of intervention effects.
Three commonly used self-report pain intensity assessment tools include a simple descriptive pain intensity scale, a 0 to 10 numeric pain intensity scale, and the Visual Analog Scale (VAS) for Pain Intensity. A Pain Faces scale is used in children and in non–English speaking or illiterate populations. The Memorial Pain Assessment Card (MPAC)32 is a helpful clinical tool that allows patients to report their pain experience. The MPAC consists of visual analog scales that measure pain intensity, pain relief, and mood. The Brief Pain Inventory (BPI) is another pain assessment tool that has been widely used in cancer and AIDS pain research and clinical settings.33 The BPI has a useful Pain Interference Subscale that assesses pain’s interference in seven domains of quality of life and function. There are many other pain assessment tools available for adults and children.
There are four aspects of pain experience in AIDS that require ongoing evaluation: (a) pain intensity, (b) pain relief, (c) pain-related functional interference (e.g., mood state and general and specific activities), and (d) monitoring of intervention effects (analgesic drug side effects and abuse). Several readily available pain assessment tools are easily adapted to the clinical setting. These include the Brief Pain Inventory and the MPAC.
As of January 1, 2001 the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established new pain management standards for accreditation. These standards include the following statements: (a) individuals served have the right to appropriate assessment and referral for a provision of management of pain and (b) pain must be assessed in all individuals.1
Other sources of help in meeting the pain standards include “Building an Institutional Commitment to Pain Management: The Mayday Resource Manual for Improvement,” an excellent compilation of resource material to promote institutional support of pain management; all of the sample resource tools are available on a disc.2
Multimodal Approach
Federal guidelines developed by the Agency for Health Care Policy and Research (AHCPR) for the management of cancer pain also address the issue of management of pain in AIDS and state: “The principles of pain assessment and treatment in the patient with HIV positive/AIDS are not fundamentally different from those in the patient with cancer and should be followed for patients with HIV-positive/AIDS.”29 In contrast to pain in cancer, pain in HIV disease may more commonly have an underlying treatable cause.10 Readers are also directed to an excellent resource for general palliative care in patients with HIV disease and AIDS in the form of Health Resources and Services Administration’s A Clinical Guide to Supportive & Palliative Care for HIV/AIDS.34
Optimal management of pain in AIDS is multimodal and requires pharmacologic, psychotherapeutic, cognitive-behavioral, anesthetic, neurosurgical, and rehabilitative approaches. A multidimensional model of AIDS pain, which recognizes the interaction of cognitive, emotional, socioenvironmental, and nociceptive aspects of pain suggests a model for multimodal intervention.
Pharmacotherapies for Pain
The World Health Organization (WHO)30 has devised guidelines for analgesic management of cancer pain that the AHCPR has endorsed for the management of pain related to cancer or AIDS.29 These guidelines, also known widely as the “WHO Analgesic Ladder,” have been well validated.35 This approach advocates selection of analgesics based on severity of pain, as well as the type of pain (i.e., neuropathic versus non-neuropathic pain). For mild-to-moderate pain, nonopioid analgesics such as NSAIDs and acetaminophen are recommended. For pain that is persistent and moderate to severe in intensity, opioid analgesics of increasing potency (such as morphine) should be utilized. Adjuvant agents, such as laxatives and psychostimulants, are useful in preventing and treating opioid side effects, such as constipation and sedation, respectively. Adjuvant analgesic drugs, such as the antidepressant analgesics, are suggested for use, along with opioids and NSAIDs, in all stages of the analgesic ladder (mild, moderate, or severe pain), but have their most important clinical application in the management of neuropathic pain.
This WHO approach, although not yet validated in AIDS, has been recommended by the AHCPR and clinical authorities in the field of pain management and AIDS.8,10,12,16,29,36,37
Clinical reports describing the successful application of the principles of the WHO Analgesic Ladder to the management of pain in AIDS, with particular emphasis on the use of opioids, have also appeared in the literature.9,15,16,38,39,40,41
Nonopioid Analgesics
The nonopioid analgesics (Table 17.3) are prescribed principally for mild-to-moderate pain or to augment the analgesic effects of opioid analgesics in the treatment of severe pain. The use of NSAIDs in patients with AIDS must be accompanied by heightened awareness of toxicity and adverse effects. NSAIDs are highly protein-bound, and the free fraction of available drug is increased in patients with AIDS who are cachectic, wasted, and hypoalbuminic, often resulting in toxicities and adverse effects. Patients with AIDS are frequently hypovolemic, on concurrent nephrotoxic drugs, and experiencing HIV nephropathy and so are at increased risk for renal toxicity related to NSAIDs. The antipyretic effects of the NSAIDs may also interfere with early detection of infection in patients with AIDS.
The major adverse effects associated with NSAIDs include gastric ulceration, renal failure, hepatic dysfunction, and bleeding. The nonacetylated salicylates, such as salsalate, sodium salicylate, and choline magnesium salicylate, theoretically have fewer gastrointestinal side effects and might be considered in cases in which gastrointestinal distress is an issue. Prophylaxis for NSAID-associated gastrointestinal symptoms include histamine H2-antagonist drugs (cimetidine 300 mg tid to qid or ranitidine 150 mg bid), misoprostol 200 mg qid, omeprazole 20 mg daily, or an antacid). Patients should be informed of these symptoms, issued guaiac cards with reagent, and taught to check their stool weekly. NSAIDs effect kidney function and should be used with caution. NSAIDs can cause a decrease in glomerular filtration, acute and chronic renal failure, interstitial nephritis, papillary necrosis, and hyperkalemia.42 In patients with renal impairment, NSAIDs should be used with caution, because many (i.e., ketoprofen, feroprofen, naproxen, and carpofen) are highly dependent on renal function for clearance. The risk of renal dysfunction is greatest in patients with advanced age, preexisting
renal impairment, hypovolemia, concomitant therapy with nephrotoxic drugs, and heart failure. Prostaglandins modulate vascular tone, and their inhibition by the NSAIDs can cause hypertension and interference with the pharmacologic control of hypertension.43 Caution should be used in patients receiving -adrenergic antagonists, diuretics, or angiotensin-converting enzyme inhibitors. Several studies have suggested that there is substantial biliary excretion of several NSAIDs, including indomethacin and sulindac. In patients with hepatic dysfunction, these drugs should be used with caution. NSAIDs, with the exception of the nonacetylated salicylates (e.g., sodium salicylate, choline magnesium trisalicylate), produce inhibition of platelet aggregation (usually reversible, but irreversible with aspirin). NSAIDs should be used with extreme caution, or avoided, in patients who are thrombocytopenic or who have clotting impairment.
renal impairment, hypovolemia, concomitant therapy with nephrotoxic drugs, and heart failure. Prostaglandins modulate vascular tone, and their inhibition by the NSAIDs can cause hypertension and interference with the pharmacologic control of hypertension.43 Caution should be used in patients receiving -adrenergic antagonists, diuretics, or angiotensin-converting enzyme inhibitors. Several studies have suggested that there is substantial biliary excretion of several NSAIDs, including indomethacin and sulindac. In patients with hepatic dysfunction, these drugs should be used with caution. NSAIDs, with the exception of the nonacetylated salicylates (e.g., sodium salicylate, choline magnesium trisalicylate), produce inhibition of platelet aggregation (usually reversible, but irreversible with aspirin). NSAIDs should be used with extreme caution, or avoided, in patients who are thrombocytopenic or who have clotting impairment.
TABLE 17.3 Oral Analgesics for Mild-to-Moderate Pain in AIDS | ||||||||||||||||||||||||||||||||||||||||||||||||||
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Opioid Analgesics
Opioid analgesics are the mainstay of pharmacotherapy of moderate-to-severe intensity pain in the patient with HIV disease (Table 17.4). Several reports describing the safe and effective use of opioid drugs in the management of moderate-to-severe pain in populations of patients with HIV disease (including patients with a history of injection drug use as their HIV transmission factor) have begun to appear in the literature.15,37,38,39,40,43 Kaplan et al.44 conducted a multicenter study in which 44 patients with moderate-to-severe AIDS-related pain were treated with sustained-release oral morphine in an open-label prospective study of
patients treated for up to 18 days. Pain intensity decreased by 65% in the patients who completed treatment, quality of life was good in 80%, acceptability of therapy was 96%, 92% of side effects were resolved, and total morphine dose remained stable through the course of the study. In a pilot study, Newshan and Lefkowitz45 reported similar findings on the effectiveness and safety of the transdermal fentanyl patch in a small sample of patients with AIDS-related pain. With transdermal fentanyl, pain severity scores decreased, mean pain relief scores increased, and daily functioning measures improved significantly.45 Furthermore, Newshan and Lefkowitz45 reported transdermal fentanyl was effective for chronic pain in chemically dependant and nonchemically dependant AIDS patients. In persons with AIDS near the end of life, the use of opioid analgesia remains common practice. The medical records of 185 adult patients with AIDS who receiving hospice care were reviewed by Kimball and McCormick.15 Most patients (93%) experienced at least one 48- hour period of discomfort during the last 2 weeks of life; the majority (88%) received some form of opioid analgesia.15 Of these patients, 62% experienced some relief of pain thereafter.15
patients treated for up to 18 days. Pain intensity decreased by 65% in the patients who completed treatment, quality of life was good in 80%, acceptability of therapy was 96%, 92% of side effects were resolved, and total morphine dose remained stable through the course of the study. In a pilot study, Newshan and Lefkowitz45 reported similar findings on the effectiveness and safety of the transdermal fentanyl patch in a small sample of patients with AIDS-related pain. With transdermal fentanyl, pain severity scores decreased, mean pain relief scores increased, and daily functioning measures improved significantly.45 Furthermore, Newshan and Lefkowitz45 reported transdermal fentanyl was effective for chronic pain in chemically dependant and nonchemically dependant AIDS patients. In persons with AIDS near the end of life, the use of opioid analgesia remains common practice. The medical records of 185 adult patients with AIDS who receiving hospice care were reviewed by Kimball and McCormick.15 Most patients (93%) experienced at least one 48- hour period of discomfort during the last 2 weeks of life; the majority (88%) received some form of opioid analgesia.15 Of these patients, 62% experienced some relief of pain thereafter.15
TABLE 17.4 Opioid Analgesics for Moderate-to-Severe Pain in AIDS | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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