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In the era of highly active antiretroviral therapy, HIV-infected
patients live longer and healthier lives, which makes relief of
pain associated with the complications of HIV infection an important factor
in improving the quality of life. Relief of acute pain is important
not only because pain relief affects the quality of life of caregivers
as well as the individual suffering pain, but also because unrelieved
pain can become chronic pain, which is much more difficult to manage because
a vicious cycle that sustains pain develops.1,2
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Acute pain may be classified in various ways, but is usually
more or less directly related to some pathologic condition, although
the intensity of the pain experienced may be out of proportion to the
physiologic cause. When unrelieved acute pain has become chronic
pain (often called “benign” when it is not associated
with malignancy), special management considerations not found in
acute pain become important.
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A variety of studies have found the prevalence of pain in patients
with HIV disease to vary from 40% to 60%, with
even higher rates of pain found in inpatient settings and in patients
near the end of life.3–5 Although different
risk groups (eg, men who have sex with men, intravenous drug users,
women) have different degrees of unrelieved pain, in general pain
in HIV-infected individuals is underdiagnosed and undertreated.
In one survey, only 7.3% of 110 patients with AIDS who reported “severe” pain
received a strong opioid according to treatment guidelines, whereas
11.8% received no analgesic and 39.1% received
a nonsteroidal anti-inflammatory drug.6
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A French study7 found that doctors underestimated
pain severity in more than half (52%) of AIDS patients
and that only a fifth (21%) received a strong opioid, whereas
57% received no analgesic treatment. This is somewhat higher
than a recent estimate based on a meta-analysis of 15 studies that
found a median point prevalence of chronic pain of 15% (range
2% to 40%) in adults.8
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Many studies show that the intensity of pain in HIV disease is
comparable to that experienced by cancer patients. However, a patient
with AIDS often experiences several painful syndromes simultaneously.
Table 48-1 lists some causes of HIV-related pain.
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Painful syndromes may be nociceptive, neuropathic, or idiopathic.
Nociceptive (somatic or visceral) pain, which is mediated by pain
receptors, accounts for the majority of painful syndromes reported
by ambulatory AIDS patients. Nociceptive pain is usually effectively
relieved by conventional analgesics. Although non-opioid analgesics ...