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

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 4: PainTable 4-12: AIDS Clinicians’ Ratings of Barriers to Pain Management# Barrier Percent26 picas1. Lack of knowledge regarding pain management 51.82. Reluctance to prescribe opioids 51.53. Lack of access to pain specialists 50.94. Concern regarding drug addiction and/or abuse 50.55. Lack of psychological support/drug treatment services 43.06. Patient reluctance to report pain 24.07. Patient reluctance to take opioids 24.0IVSource: Breitbart W, Kaim M, Rosenfeld B. Clinicians’ perceptions of barriers to pain management in AIDS. J Pain SymptomManage 18:203-12, 1999.Managing pain in AIDS patients with a history of substance use is a particularly challengingproblem that HIV providers will face with increasing frequency. Table 4-13 identifies basic interventionsfor pain management in substance users. For more information, see Chapter 11: Substance UseProblemsTable 4-13: An Approach to Pain Management in Substance Users with HIV Disease1. Substance users with HIV disease deserve pain control; we have an obligation to treatpain and suffering in all of our patients.2. Accept and respect the report of pain.3. Be careful about the label substance abuse; distinguish between tolerance, physicaldependence and addiction (psychological dependence or drug abuse).4. Not all substance users are the same; distinguish between active users, individuals inmethadone maintenance, and those in recovery.5. Individualize pain treatment.6. Utilize the principles of pain management outlined for all patients with HIV disease andpain (WHO Ladder).7. Set clear goals and conditions for opioid therapy: set limits, recognize drug abuse behaviors,make consequences clear, use written contracts and establish a single prescriber.8. Use a multidimensional approach: pharmacologic and nonpharmacologic interventions,attention to psychosocial issues, team approach.CONCLUSION■ Pain in AIDS, even in this era of protease inhibitors and decreased AIDS death rates, is a clinicallysignificant problem contributing greatly to psychological and functional morbidity. Pain can beadequately treated and so must be a focus of palliative care of the person living with HIV/AIDS.U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 117