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An Overview
Pain treatment in HIV is similar to treatment in cancer. Pain is a symptom commonly experienced by patients with HIV infection, even in the absence of an opportunistic cancer such as Kaposi's sarcoma.354a The principles of pain assessment and treatment in the patient with HIV are not fundamentally different from those in the patient with cancer and should be followed for patients with HIV.
The prevalence of pain in HIV-infected individuals varies depending on stage of disease, care setting, and study methodology. Estimates of the prevalence of pain in HIV-infected individuals generally range from 40 to 60 percent with prevalence of pain increasing as disease progresses.64; 411; 276; 425 Thirty-eight percent of ambulatory HIV-infected patients reported significant pain in a prospective study of current pain prevalence.64 Fifty percent of patients with AIDS reported pain while only 25 percent of those with earliest stages of HIV infection had pain. Patients had an average of two or more pains at one time. A recent review of ambulatory HIV-infected men425 demonstrated that 28 percent of those who were asymptomatic seropositive, 55.6 percent of those with AIDS-related complex, and 80 percent of those with AIDS reported one or more painful symptoms over a 6-month period. A study of pain in hospitalized patients with AIDS revealed that over 50 percent of patients required treatment for pain; with pain being the presenting complaint in 30 percent (second only to fever.) 276 411 report that 53 percent of patients with far-advanced AIDS cared for in a hospice setting had pain. The most common pain syndromes reported in studies to date include painful peripheral sensory neuropathy, pain due to extensive Kaposi's sarcoma, headache, pharyngeal and abdominal pain, arthralgias and myalgias, as well as painful dermatologic conditions.64; 276; 411; 425
HIV-related peripheral neuropathy is often a painful condition, affecting up to 30 percent of people with AIDS,99 and is characterized by a sensation of burning, numbness, or anesthesia in the affected extremity. Several antiviral drugs, such as didanosine or zalcitabine, chemotherapy agents used to treat Kaposi's sarcoma (vincristine), as well as phenytoin and isoniazid, can also cause painful peripheral neuropathy.
Reiter's syndrome, reactive arthritis, and polymyositis are painful conditions reported in early HIV infection.252 Other painful rheumatologic manifestations of HIV infection include various forms of arthritis (painful articular syndrome, septic arthritis, psoriatic arthritis), vasculitis, Sjogren's syndrome, polymyositis, zidovudine (AZT) myopathy, and dermatomyositis.136
Conditions associated with chronic or intermittent pain include intestinal infections with Mycobacterium avium-intracellulare and cryptosporidium, which cause cramping and intermittent abdominal pain; hepatosplenomegaly, resulting in abdominal distention and pain; oral and esophageal candidiasis, causing pain while the patient is eating and swallowing; and severe spasticity associated with encephalopathy, which causes painful muscle spasms.
HIV-related conditions that cause acute pain in children include meningitis and sinusitis, which result in severe headaches; otitis media; shingles; cellulitis and abscesses; severe candida dermatitis; and dental caries.
The patient with HIV disease faces many stressors during the course of illness including dependency, disability, and fear of pain and painful death. Such concerns are universal; the level of psychological distress, however, is variable and depends on social support, individual coping capacities, personality, and medical factors, such as the extent or stage of illness. In a study of pain in ambulatory HIV-infected patients,62 depression was significantly correlated with the presence of pain. In addition to being significantly more distressed and depressed, those with pain (40 percent) were twice as likely to have suicidal ideation as those without pain (20 percent). HIV-infected patients with pain were more functionally impaired, were more depressed, were more likely to be unemployed or disabled, and reported less social support.
Children with HIV infection often come from multiproblem families.52 Many families have more than one infected member, and multiple losses from AIDS in one family are common. These issues affect how families deal with the disease and the pain it causes. Parental guilt, which often results in denial of the disease, can also cause denial of a child's pain and resistance to adequate pain management.
Fears of addiction and concerns regarding drug abuse affect both patient compliance and clinician management of opioid analgesics and often lead to the undermedication of HIV-infected patients in pain. Also problematic is the management of pain in the growing segment of HIV-infected people who are actively using illicit drugs.
The issue of drug abuse is also problematic in the pediatric HIV population. Many children with HIV infection live in families where intravenous drug abuse is or was a problem. Either they have parents who are actively using drugs or are recovered from drug abuse, or they live with extended family who have had experiences with their drug-abusing relatives. In these environments, questions arise about the safety of prescribing opioids for the child. Extended-family members are often anxious about the use of opioids for a child whose parent was a drug addict, fearing that the child will also become addicted. These fears and concerns should be anticipated and discussed, and explicit plans such as those discussed earlier should be put into place to minimize the risk of drug diversion.
The general management of pain in children with HIV is the same as that for children with cancer. The assessment of pain in HIV-infected children may be complicated by the frequency of encephalopathy and related developmental delays. It is often difficult to determine whether an encephalopathic infant or toddler who cannot talk is in pain. Observations of a child's response to a trial of pain medication may be the best means of assessing such a child's pain.
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