Pain Management in PWA'S

Pain Management in PWA'S

Being Alive Newsletter; December 1992
Michael Gottlieb, MD

Ten years into the epidemic, doctors and researchers are just now beginning to address the complications of AIDS which result in pain, and how to best manage that pain. The relatively primitive state of medical knowledge and practice in this area was apparent to me as I listened to a symposium on pain management in AIDS at the recent national meeting of the American Pain Society of which I am a member. In the medical profession, we have an obligation with respect to pain: "To cure sometimes, to relieve often, to comfort always." In the case of pain and AIDS, there is evidence that we may be falling short of these goals.

There are two major implications of uncontrolled pain in PWAs. One is the negative impact of uncontrolled pain on basic functioning and enjoyment of life. The other is the deleterious effect of uncontrolled pain on immune function, a fact supported by basic research in psychoneuroimmunology (the study of the linkage of the brain and the immune system). One researcher summed this up dramatically with the statement "Pain kills."

In one study of outpatients with HIV/AIDS discussed at the symposium, remarkably few patient who said they had pain were receiving pain medications. In the same study, the presence of pain correlated with depression and thoughts of suicide, and interfered with work, relaxation, sleep and enjoyment of life.

Another study discussed the care given to patients in a municipal hospital in New York where 61% of the patients complained of pain at hospital admission and in 33% the pain lasted for the duration of the hospital stay. Pain was the second most common reason for hospital admissions. While 69 % of the patients were former injecting drug users, the complaint of pain and patient requests for medication or type of medication did not correlate at all with this factor. One startling finding was that acetaminophen (Tylenol), a relatively weak pain reliever, was often the only drug prescribed for some patients.

At the symposium, the speakers pointed to the fact that problems can result from doctors' reluctance to prescribe narcotic pain medications to people with a prior history of substance abuse. The concepts of physical dependence and addiction (severe drug abuse) are frequently misunderstood. Refusing to prescribe narcotic pain medications to former addicts who are in pain often leads the patients to engage in aberrant drug-seeking behaviors. In medically ill patients with pain and past drug use, a realistic goal should be to restore the patient to his or her baseline state rather than aim for abstinence.

All of the speakers agreed that there was an urgent need to address pain management issues associated with AIDS and its complications. One thing you can do is to let your physician know about your pain and what works for you. This can result in better communication with your own doctor over issues of pain and pain medication and finding the best medication or technique for a specific pain syndrome (e.g. neuropathy).

(Michael Gottlieb, MD, is in private practice in Sherman Oaks and West Hollywood and can be reached at 818.501.2600.)
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©1992. AEGIS.