AIDS Patients Undermedicated for Pain, Study Shows

NEW YORK--AIDS patients are vastly undermedicated for their pain,a new study from Memorial Sloan-Kettering Cancer Center has shown.

While it is well documented that cancer pain continues to be undertreated,there has been a paucity of data on the adequacy of pain treatmentin HIV disease. The new findings show that only 15% of AIDS patientsreceive adequate analgesic therapy, and only 6% of those reportingsevere pain receive a strong opioid, William Breitbart, MD, reportedat the annual meeting of the American Psychiatric Association.

Dr. Breitbart and coworkers evaluated the adequacy of analgesicmanagement of pain in 366 ambulatory AIDS patients, by using anestablished measure for pain assessment--the Pain Management Index(PMI)--and by determining the type and frequency of analgesicmedications prescribed for pain.

"Our data suggest a striking degree of undertreatment, whichmay reflect a lack of physician knowledge regarding pain and painmanagement in HIV disease," said Dr. Breitbart, associateattending psychiatrist. However, in some cases, such undertreatmentmay reflect patient related barriers to adequate treatment, headded. For example, some patients may prefer nonpharmacologicinterventions for their pain.

The frequency and intensity of AIDS-related pain is at least comparableto and possibly greater than that experienced by cancer patients,Dr. Breitbart said. The US government has established pain managementguidelines stating that the treatment of pain in HIV disease shouldbe fundamentally similar to that in cancer.

These guidelines support the use of the World Health Organization"analgesic ladder" approach for both populations, Dr.Breitbart said. With this approach, the selection of analgesicsis based primarily on the severity of reported pain. Non-opioidanalgesics--for example, nonsteroidal anti-inflammatory drugs(NSAIDs)--are recommended for mild pain, while opioid analgesicsare advocated for moderate to severe pain.

The opioids traditionally recommended for moderate pain includedrugs such as codeine or oxycodone, while those suggested forsevere pain include strong opioids such as morphine or hydromor-phone.Adjuvant analgesic drugs such as antidepressants may be combinedwith any of the traditional analgesics to treat residual painor neuropathic pain.

The Sloan-Kettering study showed that nearly 85% of patients wereclassified as receiving inadequate analgesic therapy based onthe PMI, Dr. Breitbart said. Less than 8% of the 110 patientswho reported severe pain were prescribed a strong opioid, as issuggested by the guidelines. In addition, only 10% of patientsreceived adjuvant analgesic drugs.

Women, less educated patients, and patients who reported injectiondrug use as their HIV transmission risk factor were most likelyto have received inadequate analgesic therapy.

Dr. Breitbart said that the results point up an alarming degreeof undertreatment of pain in ambulatory patients with AIDS andthus underscore the need to improve the management of AIDS-relatedpain in this underserved population.

He noted, however, that the findings should be interpreted withcaution given that the study methodology relied primarily on self-reportingat a single point in time, and reported medication regimens werenot confirmed by independent chart review or patient contact.