The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 4: Pain• HIV-associated myopathy or polymyositis• Necrotizing non-inflammatory myopathy in association with zidovudineand without zidovudine26 picas• Pyomyositis• Microsporidiosis myositisPolymyositis may occur at any stage of HIV infection; it is thought to be the result of direct viralinfection of muscle cells 40 and may present with a sub-acute onset of proximal muscle weakness andmyalgia. 45 Electromyographic evidence of myopathy, a raised serum creatinine kinase, and biopsyevidence of polymyositis are common in symptomatic patients. Drugs used in the treatment of HIVdisease may also be associated with the development of myalgia 26 and myositis. 46, 52 Zidovudine hasbeen particularly implicated; symptoms frequently improve following discontinuation of zidovudinetherapy. 10IVOVERVIEW OF PAIN MANAGEMENT IN HIV/AIDS■ Optimal management of pain requires a multidisciplinary approach. The initial assessment shouldshed light on etiology and contributing factors as well as establish a baseline from which to monitorthe impact of therapy. Pain assessment tools for noting the intensity of pain, time, dose, and impactof medications are discussed below. Clear communication between provider and patient/family isimportant to monitor the impact of any intervention (see Chapter 21: Patient-Clinician Communication).WHO Pain LadderChoice of analgesic agents should follow the World Health Organization’s pain ladder(see Figure 4-1):• Non-narcotic analgesics are the first step, for mild pain• Weak opioids are the second step, for moderate pain• Strong opioids are the third step, for severe painIt is important that providers be comfortable with the use of one or two medications in each analgesicstep (see Tables 4-6, 4-7 and 4-8), including management of side effects; conversion from one step,or level, to another; drug interactions (see Chapter 27: Pharmacologic Interactions of Clinical Significance);and dosing schedules.Adjuvant treatments are important components of the pain ladder and have key roles in AIDS, particularlyin management of neuropathic pain.Assessment IssuesDame Cicely Saunders introduced the concept of total pain in the early years of the hospicemovement in the United Kingdom. 53 This approach emphasizes the need to keep in mind psychological,social, and spiritual aspects as well as physical aspects when approaching a patient in pain.Therefore, a close collaboration of the entire health care team is optimal when attempting to adequatelymanage pain in the AIDS patient.The initial step in pain management is a comprehensive assessment of pain symptoms. A healthprofessional in the AIDS setting must have a working knowledge of the etiology and treatment of painin AIDS, including an understanding of the different types of AIDS pain syndromes discussed as wellas a familiarity with the parameters of appropriate pharmacologic treatment.U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 95