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Hawaii Anesthesiology Update 2008
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 Home : Professionals : Pain Reports : Pain Report No. 4
Dannemiller Memorial Educational Foundation
An Update on Issues, Research and Treatment Trends
Volume 1, Number 4

Editorial Board
Neil M. Ellison, MD
Rebecca Finley, PharmD
Judy Paice, PhD, RN

Supported by an unrestricted educational grant from Purdue Pharma L.P.
Guidelines for Comprehensive Assessment of Cancer Pain
Only guidelines produced or updated within the past five years can be considered current, according to The National Guideline Clearinghouse (NGC). The NGC is a database of evidence-based clinical practice guidelines produced by the U.S. government's Agency for Healthcare Research and Quality (AHRQ) with the support of the American Medical Association (AMA) and the American Association of Health Plans (AAHP).1,2

Though somewhat dated, the American Society of Clinical Oncologists' (ASCO's) 1992 guidelines on cancer pain, the Agency for Health Care Policy and Research (AHCPR) guidelines on cancer pain of 1994 [The AHCPR being a previous incarnation of the AHRQ], and the American Society of Anesthesiologists' 1996 guidelines continue to be reference resources.

What up-to-date guidelines on the assessment of cancer pain are available now? The National Comprehensive Cancer Network's (NCCN's) clinical practice guidelines on cancer pain were published in 2000. Whereas many clinical practice guidelines, such as the 1994 AHCPR Cancer Pain Guidelines, are "evidence based," the NCCN guidelines represent a consensus of its expert panel of authors regarding their views of currently accepted approaches to treatment. The NCCN guidelines panel represents each of the 18 member United States cancer centers that have allied to form the NCCN.3

The NCCN guidelines call for the screening of "all patients with cancer" for the presence of pain "every time they are seen." Reassessment should be conducted at specified intervals.3 Pain intensity can be quantified on a 0 to 10 scale. One of the four different types of scales for rating pain intensity can be used, and these are reproduced within the guidelines' text.3

If a patient is experiencing pain, a formal pain assessment should be considered in most circumstances in order to determine the etiology of the pain. This may include a detailed pain history, physical examination, appropriate laboratory and imaging studies, an evaluation of the patient's general medical condition, and an appraisal of important psychosocial factors.3 While the pain assessment is being conducted, analgesia should not be withheld; however, it may be inappropriate to provide only opioids to control the pain for the patient, if other therapies are more appropriate and can treat the source of pain. For example, a patient may be suffering from an impending epidural cord compression, a fracture or impending fracture of a weight-bearing bone, bowel obstruction, local infection, brain metastases, or another underlying condition that causes pain. In such situations, the underlying condition must be treated directly. In addition, analgesia should be provided.3

When pain is severe, greater than 7 on a 0 to 10 scale, initiation of aggressive pain management therapies is indicated. This entails "rapidly escalating doses of short-acting opioids, a bowel regimen, anti-emetics as needed, and psychosocial support." Patients reporting pain intensity of 7 or less can receive less intense treatment. The patient whose pain registers between 4 and 6 is started on short-acting opioids or adjuvant analgesic drugs. Patients whose pain is 3 or less usually achieve adequate relief with either acetaminophen, NSAIDS, or short-acting opioids. In some circumstances, there may be a relative contraindication to the use of acetaminophen or NSAIDs, such as fear of masking a fever in a neutropenic patient or potential drug interactions with these agents, and it may be more reasonable to initiate therapy with low doses of a short-acting opioid. A persistent problem in pain medicine, one much discussed in the literature, is the reluctance of many health professionals and patients to use opioid medications. The NCCN guidelines are unequivocal in recommending that opioid medications should be given if a certain level of pain is present, unless specific mitigating factors exist.3

Psychosocial support must be available for each patient, according to the guidelines. In partial ful- fillment of this directive, health professionals are encouraged to advocate adequate pain management, offer emotional support, furnish specific educational material to the patient and the patient's family, and teach pain coping skills.3

To obtain copies of the NCCN guidelines, telephone 1-888-909-NCCN or log on to www.nccn.org/.3

In 1998, the American Geriatric Society's (AGS's) Clinical Practice Committee issued guidelines on the management of chronic pain that review the assessment of cancer pain. An updated version of these guidelines is to be released in May, according to Pamela Ingham, Communications Manager, American Geriatric Society. See the AGS Web site at www.americangeriatrics.org/.4

If patients express an interest in learning more about the assessment of cancer pain, the health professional may direct them to the Cancer Pain Treatment Guidelines for patients issued jointly by the NCCN and the American Cancer Society (ACS). This document represents a "translation" of the NCCN's guidelines for professionals into language and approach appropriate for the general public. This guideline may be obtained at www.cancer.org and www.nccn.org or by telephoning either of the following numbers: 1-800-ACS-2345 or 1-888-909-NCCN.5

An additional valuable resource for patients is the PDQ for patients. The text on pain assessment and management, which is in the section on supportive care, is adapted from the peer-reviewed PDQ for health professionals. It contains sections on the Patient Self-Report and on Assessment of the Outcomes of Pain Management. This is not a guideline, but does merit consideration in this context. See http://cancernet.nci.nih.gov/.6

Excellent guidelines are available on pain assessment. The American Pain Society will be releasing a clinical practice guideline on cancer pain in 2002. Health professionals should make sure they are using up-to-date guidelines and should be diligent in applying the recommendations.

References
  1. National Guidelines Clearinghouse. About the National Guidelines Clearing House. Available at http://www.guideline.gov/STATIC/about.asp?view=about/Accessed on October 17, 2001.
  2. National Guideline Clearinghouse. Inclusion criteria: definition of clinical practice guideline. Available at http://www.guideline.gov/. Accessed on October 17, 2001.
  3. National Comprehensive Cancer Network (NCCN). NCCN Practice guidelines for cancer pain, version 2000. Rockledge, PA, National Comprehensive Cancer Network, 2000.
  4. Personal communication, November, 2001.
  5. National Comprehensive Cancer Network (NCCN), American Cancer Society (ACS). Cancer pain: treatment guidelines for patients. Version 1. January 2001
  6. CancerNet: A service of the National Cancer Institute: Pain (PDQ): Supportive Care – Patients. Available at http://cancernet.nci.nih.gov/. Accessed on October 15, 2001.

The Impact of Palliative Care on Quality of Life (QOL)
Writing in Palliative Care and Rehabilitation of Cancer Patients, authors Brady and Cella maintain that "QOL is THE outcome in palliative care."1 What does this statement mean? What is quality of life (QOL)? What is palliative care and how is our perspective on palliative care changing?

QOL is defined as "the extent to which one's usual or expected physical, emotional, social, and spiritual well-being are affected by a medical condition or its treatment." So, QOL is subjective in that it represents the patient's point of view. In addition, QOL is multidimensional and encompassing, is not bounded by any subspecialty of medicine or any narrow dogma. Furthermore, QOL cannot be directly correlated with symptoms — patients with several severe symptoms may enjoy excellent quality of life, while patients with a few, mild-to-moderate symptoms may have poor quality of life. QOL is affected by such factors as support received from family and friends. Of course, it is also very much affected by the quality of medical care each patient receives.1

A somewhat different definition of QOL has also been advanced. According to this view, QOL should be evaluated in terms of the difference between the expectations envisioned by the patient and family at diagnosis and what actually happens to the patient. Patients who realistically understand that their disease and treatment are likely to involve difficult events and discomfort usually maintain better quality of life once these problems appear. Patients with less realistic expectations often have a lesser QOL. This definition of QOL serves to remind healthcare professionals of the importance of addressing patients' symptoms and also educating them in a way that brings expectations closer to reality.1

Palliative medicine is that aspect of medicine concerned with the relief of suffering.2, 3 This definition is undergoing a process of re-conceptualization and redefinition. Palliative medicine has been defined as "the study and management of patients with progressive, far advanced disease for whom the prognosis is limited and the focus of care is quality of life." Does this mean that palliative care is something that should primarily be given to patients who are no longer receiving curative or lifeprolonging therapy?3

Leading authorities are increasingly and emphatically answering, No, to this question. There is no reason palliative care should be held in abeyance while curative or specific disease directed therapy is ongoing. "The palliation of symptoms should," according to Ann Berger, M.D., Chief, Pain and Palliative Care Service, Warren Grant Magnuson Clinical Center, National Institutes of Health (NIH), "be addressed immediately upon diagnosis." Palliative care "is not really end-of-life care," she explained.4

"Palliative care includes the spiritual and the activities of clergy, pharmacologic interventions, recreation therapy and massage, nutrition, and other modalities important for the patient's quality of life," according to Dr. Berger.

It includes the positive contribution made by family, friends, clergy, and even the patient. It includes the management of nausea, dyspnea, depression, pain and other frequently described symptoms. It also encompasses such issues as fatigue, worry, loss of appetite, sexual problems, and why certain patients remain resilient and optimistic in the face of severe illness. "Our focus is really living until you die," writes Dr. Berger. "...living every moment, living every day."4

The Oxford Textbook of Palliative Medicine, 2nd edition, takes a similar position. Clinch et al., explain that the provision of palliative care is directed to the goal furnished by QOL. From the day a diagnosis is established and through months or years of medical interventions, much in the patient's life and medical treatment may change. But optimizing QOL should always remain the target that is in the health professional's sights. (Clinch, 1998, 83) They describe QOL as including "(1) physical function, (2) emotional or psychological function, (3) social function, (4) symptoms of disease or its treatment."5

Each inspanidual health professional and each team of professionals must decide their personal comfort level and values in regard to these complex issues. QOL provides an "expanded horizon" that serves to direct attention to overall patient benefit rather than exclusively on a disease entity.5

From this point of view, treating symptoms is also a way of managing patients' anxiety about their illness. As Dr. Berger remarked to one of her patients, "If we don't take away your symptoms you are going to worry that the disease has come back, and that will affect your quality-of-life." So the single act of treating the symptom permitted her to address both the symptom itself and the associated concerns related to the symptom.4

Of course, quality-of-life is a fundamental goal for a dying patient, as well. "Death is inevitable, but severe suffering is not," Kathleen M. Foley, M.D., has said. In 1981 at the Memorial Sloan-Kettering Cancer Center, Dr. Foley founded the first pain service in an American cancer center. She is currently director of the Open Society Institute's Project on Death in America.2 She recently co-authored the important document, Improving Palliative Care for Cancer: Summary and Recommendations of the National Cancer Policy Board and National Research Council.6

Recently she discussed one of her patients who had widely-metastasized breast cancer and increasing pain. "Her greatest fear was that she would die in uncontrollable pain. I went over with her how we could manage her pain, and simply telling her what the options were and that the expertise was available to her was profoundly comforting and reduced her fear of death." Treating the patient's symptom permitted Dr. Foley to address both the symptom itself and the fear of death. Improved QOL was achieved.2

It is also essential to keep in mind that palliative medicine is not just for cancer patients. "We should be giving the same priority to patients with congestive heart failure and with neurologic conditions, such as stroke, A.L.S., Alzheimer's and multiple sclerosis," Dr. Foley said.2

The question may be asked, how can QOL be best assessed? Formal QOL scales are available but are used more in research than actual practice. In the clinic, simple questions may get the answers that are needed in a more expeditious fashion. For example, "Does the pain influence your relationship with others?" and "Would it make your life better if this or that symptom were controlled?" can be questions used to initiate a QOL discussion.

One important step on the path to achieving better patient QOL is for palliative care to find its way into educational curricula. Many students are still not being taught about palliative care. And some nursing textbooks "are just as woefully inadequate as the ones for medical students," Dr. Foley reports. Those for social work students "don't do a better job either."2 Currently, efforts are underway to educate faculty at medical, nursing, and pharmacy schools regarding the importance of palliative care and to provide sample curricular materials.

Another area in which greater understanding of palliative care is needed is in the American health insurance system, including Medicare. This system should not force patients and families to make choices between active therapy and palliative care, Dr. Foley said.2 Coverage is often provided for aggressive third or fourth line chemotherapy with little expected benefit, but not for oral or transdermal analgesics which would greatly improve a patient's QOL.2

Currently, "the public does not trust its medical care system to provide adequate comfort in the face of severe illness."3 Orienting palliative medicine to the target of improved QOL is a way to start to gain that trust. Palliative care is "whole person care" and allows ample room for treatment of disease, while simultaneously insisting that treatment of disease should allow ample room for palliative care.3

The Dunlop and Max references have been included for the benefit of those wishing to conduct research in the field of palliative care.7-8

References
  1. Brady MJ, Cella D. Assessing quality of life in palliative care. In: von Gunten CF. Palliative Care and Rehabilitation of Cancer Patients. Boston, Kluwer Academic Publishers, 1999:203-216.
  2. Toufexis A. A conversation with Kathleen Foley: pioneer in the battle to avert needless pain and suffering. The New York Times. November 6, 2001, page F5.
  3. Von Gunten CF. Preface. In: von Gunten CF. Palliative Care and Rehabilitation of Cancer Patients. Boston, Kluwer Academic Publishers, 1999:i-xv.
  4. Berger A. "Pain and Palliative Care: More Than Just End-of-Life Care." An NIH Medicine for the Public Lecture, presented on September 25, 2002. Available at http://videocast.nih.gov. At this screen go to and click on the heading "Past Events," scroll and click on "Special Event / Press Conferences", click on # 5, scroll down to Berger program, click on "Real Player Logo")
  5. Clinch JJ, Dudgeon D, Schipper H. Quality of life assessment in palliative care. In: Doyle D, Hanks GWC, MacDonald N. Oxford Textbook of Palliative Medicine 2nd ed. New York, Oxford University Press, 1998:83-94.
  6. Foley KM, Gelbard, H. Improving Palliative Care for Cancer: Summary and Recommendations. National Academies Press, Washington, D.C., 2001.
  7. Dunlop R. Evaluation of palliative-care services. . In: Dunlop R. Cancer: Palliative Care London, Springer, 1998:137-153.
  8. Max MB, Portenoy RK. Pain research: designing clinical trials in palliative care. In: Doyle D, Hanks GWC, MacDonald N. Oxford Textbook of Palliative Medicine 2nd ed. New York, Oxford University Press, 1998:167-178.

Achieving Pain Relief in Osteoarthritis
Osteoarthritis (OA) may be characterized by tenderness, swelling, gross deformity, periarticular muscle atrophy, and loss of joint motion.1 Pain is the symptom of greatest concern to many OA patients, and pain complaints are the motivation for most OA patients who seek medical attention. Furthermore, many patients consider treatment effective if they achieve substantial pain relief.2 Osteoarthritis is a multifactorial and complex disease. In this brief article, it will be possible to present only a broad overview of current OA pain management strategies.

Exercise: Clinical trials have shown that physical exercise may reduce pain and improve function. Nevertheless, many health professionals do not sufficiently appreciate the importance of exercise for these patients.3-6 The benefits of an exercise program include improved range of motion, reduced pain, reduced shock to the joint during exercise, and lessened stress on the affected joint. Exercise permits many OA patients to better accomplish or resume activities of daily living.

The health professional should not only advise OA patients to exercise but also develop means to monitor their performance. During subsequent visits, the professional should diligently inquire about compliance.5 Many patients can develop an exercise program with minimal instruction, although selected patients require a supervised program. Exercise may be more effective if a degree of pain relief is first achieved via another modality, such as pharmacotherapy.

In rare instances, exercise can aggravate OA. For example, bicycle riding may make symptoms of chondromalacia patella worse and hyperextension of the spine may make lumbar facet OA worse.3-6

Weight loss for obese patients: Overweight patients should be counseled about weight loss. Research has demonstrated that obesity can exacerbate arthritic conditions.3,5

Canes, shoes, and other assistive devices: Canes, crutches, walkers, proper shoes, and orthotic shoes may provide benefit to OA patients. Health professionals should be aware, however, that the mere mention of these devices may be met with resistance from patients unwilling to acknowledge that they have some degree of disability or need for assistance.3, 5

Occupational retraining: If a patient's occupation requires bending, repetitive motions, or musculoskeletal stress, occupational trauma may affect OA patients. Changes in work habits may be required.3

Thermal modalities: Heat, cold, or alternating heat and cold can be beneficial. Each patient should be permitted to determine which of these modalities to use.3

Pharmacotherapy: The physical modalities already described provide sufficient management tools for some patients. Not everyone with OA requires medication. Many patients do, however, and the pharmacotherapeutic armamentarium available to manage OA pain is considerable.

Acetaminophen provides benefit, although whether or not acetaminophen remains as effective as NSAIDS after months or years of use is controversial.7 NSAIDS are commonly prescribed for OA. Smaller doses of these agents than are required for antiinflammatory effects may be used to achieve pain relief in OA. The side effects of NSAIDs should be carefully monitored. Geriatric patients are particularly susceptible to NSAID toxicities. COX-2 inhibitors may be a good choice for certain patients.3, 5

Topical agents may be effective. A number of these agents are available, and the efficacy of capsaicin as therapy for OA has been demonstrated in double blind trials.3, 5 Antispasmodics may be effective for patients with muscle pain and spasm, although trials have demonstrated greatest efficacy where administration is by injection.3 Intra-articular hyaluronic acid injection also provides pain relief, although compliance with the regimen of injections may be problematic. (Brandt, 2001, 1425-1426) Intra-articular injection of depocorticosteroids is another therapy that provides benefit. By convention no more than 4 injections of this drug should be administered to an inspanidual joint per year. The literature does not support oral corticosteroids in OA therapy.3, 5, 7

Opioid medications occupy an important role in the management of moderately severe and severe OA pain in selected patients2, 3 Some OA patients using opioid medications have achieved improved work performance associated with pain relief.2 Long acting opioids can improve compliance by enhancing the ease of drug administration. Tricyclic antidepressants may be used effectively in conjunction with opioids to enhance pain relief.3

Psychosocial factors: For the management of OA pain to be effective, it is essential that the health professional provide reassurance, counseling, and education. Such face-to-face contact need not be time consuming but should be clear and unambiguous. This psychological component is important because, as research has shown, patients who understand OA and are willing to be actively involved in its management are more compliant and better able to adapt to the effects of the disease. Patients in greatest need of such counseling are those who are older, unmarried, non-Caucasian, have lower income levels, and have attended fewer years of school. These are also the types of patient most likely to become disabled with OA. Telephone support to selected OA patients may be useful. Research has demonstrated benefit even when the telephone call comes from a trained, non-health care provider.3, 5

Complementary and alternative therapies, including diet: Cognitive and behavioral therapies, such as relaxation, biofeedback, meditation, imagery, and stress management approaches may be used. Some of these modalities have been studied more thoroughly than others.5, 8 Acupuncture may be effective, and research is ongoing.2, 9 The value of chiropractic manipulation remains controversial. Homeopathy has not, however, demonstrated efficacy for OA.5, 8

Studies have suggested that maintaining a normal serum vitamin D level and ingestion of more than 119 mg per day of vitamin C may reduce risk of OA progression.7, 9 Diet therapies may benefit a minority of patients, for example those with demonstrable food allergies. However, no diet therapy has achieved a consensus of support from "mainstream medicine" as being appropriate for the vast majority of arthritis patients.8, 9

Well-designed trials have demonstrated that oral chondroitin sulfate provides a significant number of patients with prolonged, if delayed, improvement. However, other studies of chondroitin sulfate have been less conclusive. Glucosamine sulfate has shown benefit in clinical trials, as well.3

A significant number of arthritis patients use prayer, faith, and a combination of religious and spiritual approaches in addressing OA. Although the subject has been inadequately studied, some evidence of benefit from these approaches exists. In part, religious and spiritual approaches may help patients adjust to and cope with the effects of the disease.9

Surgery: May be appropriate for patients with severe pain or major functional impairment who have not responded well to other therapeutic modalities.3, 5 Joint lavage, arthroscopy, and arthroplasty can be considered.7

OA has a major impact upon the functioning and quality of life of millions of people. Achieving pain relief is very important for patients.2 As Landi et al., writes in the Archives of Internal Medicine, "A failure to make all reasonable efforts to treat pain successfully should be considered one of the most important indicators of poor quality of health care."10

The American Pain Society will soon release evidence-based guidelines for the management of pain associated with osteoarthritis and rheumatoid arthritis. These guidelines have been developed by a multidisciplinary panel of experts and have undergone review by a large number of practitioners. Information about the guidelines can be obtained at the APS website: www.ampainsoc.org/.

References
  1. Brandt KD. Osteoarthritis. In: Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL. Harrison's Principles of Internal Medicine. 15th ed. New York: McGraw-Hill, 2001: 1987-1994.
  2. Goldenberg DL. Chronic pain management. In: Ruddy S, Harris ED, Jr, Sledge CB. Kelley's Textbook of Rheumatology 6th ed. Philadelphia, W. B. Saunders, 2001: 753-761.
  3. Lozada CJ, Altman RD. Management of osteoarthritis. In: Koopman WJ. Arthritis and Allied Conditions: A Textbook of Rheumatology 14th ed. Philadelphia, Lippincott Williams & Wilkins, 2001: 2246-2258.
  4. Brander VA, Chang RW. Rehabilitation for persons with arthritis and rheumatic disorders. In: Koopman WJ. Arthritis and Allied Conditions: A Textbook of Rheumatology 14th ed. Philadelphia, Lippincott Williams & Wilkins, 2001: 943- 963.
  5. Brandt KD. Management of osteoarthritis. In: Ruddy S, Harris ED, Jr, Sledge CB. Kelley's Textbook of Rheumatology 6th ed. Philadelphia, W. B. Saunders, 2001: 1419-1430.
  6. Biundo JJ, Jr, Rush PJ. Rehabilitation of patients with rheumatic diseases. In: Ruddy S, Harris ED, Jr, Sledge CB. Kelley's Textbook of Rheumatology 6th ed. Philadelphia, W. B. Saunders, 2001: 763-774.
  7. Ratiner B, Gramas DA, Lane NE. Osteoarthritis. In: Weisman MH, Weinblatt ME, Louie JS. Treatment of the Rheumatic Diseases: Companion to Kelley's Textbook of Rheumatology Philadelphia, W.B. Saunders, 2001: 461-485.
  8. Panush RS. Diets, other complementary and alternative therapies, and the rheumatic diseases. . In: Koopman WJ. Arthritis and Allied Conditions: A Textbook of Rheumatology 14th ed. Philadelphia, Lippincott Williams & Wilkins, 2001:968-980.
  9. Conn DL, Hollister JR, Arnold. Alternative care for arthritis and related musculoskeletal diseases. In: Ruddy S, Harris ED, Jr, Sledge CB. Kelley's Textbook of Rheumatology 6th ed. Philadelphia, W. B. Saunders, 2001: 739-751.
  10. Landi F, Onder G, Cesari M, et al. Pain management in frail, community-living elderly patients. Arch Intern Med. 2001;161:2721-2724.

Management of Pain in Patients with HIV/AIDS
HIV/AIDS is not only a potentially devastating disease but also one in which pain continues to be "under-appreciated, under-recognized, and under-treated."1, 2 Whether as a result of the AIDS infection itself, as a result of AIDS-related illnesses, or due to unrelated causes, AIDS patients may experience peripheral neuropathy, headache, abdominal pain, muscular pain, joint pain, radiculopathy, pain-causing skin disorders, oropharyngeal pain, chest pain and other types of pain.1, 3, 4 The frequency and intensity of pain tends to increase as the disease advances, similar to the experience of patients with cancer. Patients with advanced AIDS frequently experience pain most of the time.1

A major accomplishment in AIDS research during the past 6 years has been the investigation of the adequacy of pain management. Researchers from the Memorial Sloan-Kettering Cancer Center published a study exploring the pain affecting 366 ambulatory AIDS patients. Two hundred twenty- six reported "persistent or frequent" pain over a 2-week period. Nearly 85% of patients were receiving inadequate analgesic therapy, based on the Pain Management Index. Of the 110 patients reporting "severe" pain, fewer than 8% had been given a "strong" opioid, such as morphine. Only 10% of the patients were receiving adjuvant analgesic medications, such as antidepressants. Pain relief was, on average, most deficient for women, less educated patients, and users of injected drugs.3 The researchers concluded that "these results demonstrate the alarming degree of undertreatment of pain in ambulatory patients with AIDS, and indicate the need to improve the management of AIDS-related pain in this under-served population."3

A study of 438 ambulatory AIDS patients published by the same team of researchers found that more than 60% of the patients experienced "frequent or persistent pain" and that those patients who reported pain had an average of 2.5 distinct pains. Mean pain intensity averaged 5.4 on the Brief Pain Inventory (BPI) scale; mean pain "at its worst" on the BPI averaged 7.4.5 Another study published by the same researchers revealed that patients with pain had greater impairment in functional ability and greater physical symptom distress than patients without pain. The presence of pain contributed to depression, hopelessness, and diminished quality of life. Furthermore, as pain intensity increased, degree of impairment and distress increased.5, 6

These same researchers also identified pain syndromes prevalent in AIDS patients. A study of 274 ambulatory patients, 151 (55%) of whom consented to a detailed assessment, determined that headache, joint pain, pain associated with polyneuropathy, and muscle pain were each present in more than 25% of patients assessed. Polyneuropathy and headache were more common in patients with lower CD4+ cell counts; headache and radiculopathy were more common in female patients. Although the researchers documented a range of pain syndromes, they also noted that many AIDS patients did not suffer from any specific pain syndrome that could be diagnosed.4

Memorial Sloan-Kettering researchers studied the credibility of pain reports by ambulatory AIDS patients. They examined 516 patients, 270 (52.3%) reporting HIV transmission through injection drug use (IDU) and 246 (47.7%) reporting other modes of transmission. No significant differences between the IDU and non-IDU group appeared in pain prevalence, pain intensity, or pain-related functional interference. Patients, though, with an IDU history "were significantly more likely to receive inadequate analgesic medications" and to report "lower levels of pain relief and a greater degree of psychological distress." The researchers state that providers should trust the validity of reports of pain of ambulatory AIDS patients, regardless of history of injection drug use, "at least in research settings."7

By early 1998, further research confirmed that "pain is dramatically undertreated among patients with AIDS and that opioids in particular are rarely prescribed."8

Assessing patient-related barriers to pain management, the Memorial Sloan-Kettering investigators studied 199 ambulatory AIDS patients. The patients expressed concern as to the addiction potential of medications, the physical discomfort accompanying injections, and side effects of analgesic opioid medications such as nausea and constipation. The researchers conclude that patient barriers "may add to the already considerable likelihood of under-treatment of AIDS-related pain."8

Clinician-related barriers also appear to impede the provision of pain relief to patients with AIDS. Surveying 492 AIDS care providers, Breitbart and colleagues found that lack of knowledge about pain management, inadequate access to pain management experts, and concerns about substance abuse and addiction were the most frequently identified impediments. The less experienced a provider was in managing pain in patients with AIDS, the more likely she or he was to "endorse barriers related to pain management expertise and concern regarding potential substance abuse."9

To examine the symptom distress of ambulatory patients more globally, the Global Distress Index (GDI) was administered to 504 ambulatory patients with AIDS. The most prevalent of listed symptoms experienced by these patients were worrying (86%), fatigue (85%), sadness (82%), and pain (76%). Under-treatment of AIDS associated pain is often accompanied by under-treatment of other symptoms. "Both the number of symptoms and symptom distress were highly associated with psychological distress and poorer quality of life."10 (See Table 1.)

Are pain complaints more of a problem for the patients studied by the researchers from Memorial Sloan-Kettering than for other patients with this disease? A study of 95 AIDS patients in Copenhagen, Denmark identified an overall incidence of pain of 88%. Constant pain which interfered with activities of daily living was described as moderate to severe and affected 69% of the sample. Patients reported that their physicians did not take their pain seriously. The researchers noted that when patients believed they were receiving optimal treatment, even as their pain was under-treated, they were not dissatisfied. Furthermore, this belief impacted the patients' readiness to request adequate pain medication.11

Authoritative recommendations on the management of pain in HIV-positive patients suggest the following guidelines for the management of cancer pain:
  1. Applying the WHO analgesic ladder, health professionals should use acetaminophen or NSAIDS for most mild-to-moderate pain.
  2. Opioids are recommended for most moderate-to-severe pain. Long-acting opioids are preferred for around-the-clock pain, perhaps accompanied by adjuvant drugs.
  3. The constipation that may affect cancer patients receiving opioids does not as commonly affect AIDS patients. This is probably due to the frequent diarrhea experienced by AIDS patients caused by complications of the disease and its treatments.4
  4. Practitioners should be aware that drug pharmacokinetics may be altered by malabsorption and other conditions affecting patients with AIDS.
  5. A multidisciplinary approach to pain is recommended.
  6. Health professionals should actively engage in conversation with patients about issues such as guilt, depression and fear.1, 2
In the past, "the story of pain in AIDS has been a story of neglect," according to William Breitbart, MD, of Memorial Sloan-Kettering.12 Pain treatment should be adequate for quality of life and psychological well-being to be maintained for patients with AIDS.6 According to Paul Volberding, M.D., professor of medicine at the University of California, San Francisco, School of Medicine, offering adequate pain relief "is probably one of the main areas where we could really make a difference in the quality of life of AIDS patients."12

References
  1. Grothe T, Gottlieb M. Hospice care and symptom management. In: Merrigan TC, Jr., Bartlett JG, Bolognesi D. Textbook of AIDS Medicine 2nd ed. Baltimore, Williams & Wilkins, 1999: 923-934.
  2. Luckwitz JW. Management of painful medical diseases. In: Abram SE, Haddox JD. The Pain Clinic Manual 2nd ed. Philadelphia, Lippincott Williams & Wilkins, 2000: 261- 269.
  3. Breitbart W, Rosenfeld BD, Passik SD, McDonald MV, Thaler H, Portenoy RK. The undertreatment of pain in ambulatory AIDS patients. Pain 1996;65:243-249.
  4. Hewitt DJ, McDonald M, Portenoy RK, Rosenfeld B, Passik S, Breitbart W. Pain syndromes and etiologies in ambulatory AIDS patients. Pain 1997;70:117-123.
  5. Breitbart, McDonald MV, Rosenfeld B, et al. Pain in ambulatory AIDS patients. I: Pain characteristics and medical correlates. Pain 1996;68:315-321.
  6. Rosenfeld B, Breitbart W, McDonald MV, Passik SD, Thaler H, Portenoy RK. Pain in ambulatory AIDS patients. II: Impact of pain on psychological functioning and quality of life. Pain 1996;68:323-328.
  7. Breitbart W, Rosenfeld B, Passik S, Kaim M, Funesti-Esch J, Stein K. A comparison of pain report and adequacy of analgesic therapy in ambulatory AIDS patients with and without a history of substance abuse. Pain 1997;72:235-243.
  8. Breitbart W, Passik S, McDonald MV, et al. Patient-related barriers to pain management in ambulatory AIDS patients. Pain 1998;76:9-16.
  9. Breitbart W, Kaim M, Rosenfeld B. Clinicians' perceptions of barriers to pain management in AIDS. J Pain Symptom Manage 1999;18:203-212.
  10. Vogl D, Rosenfeld B, Breitbart W, et al. Symptom prevalence, characteristics, and distress in AIDS outpatients. J Pain Symptom Manage 1999;18: 253-262.
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