History of Substance Abuse Not a Barrier to Opioid Use

NEW YORK--Pain is highly prevalent in patients with HIV disease. Yetclinicians are often afraid to prescribe opioids when the patient is aformer substance abuser, William Breitbart, MD, said at a conference onchemical dependency and pain management.

The conference was sponsored by Memorial Sloan-Kettering Cancer Center,where Dr. Breitbart is chief of the Psychiatry Service.

Dr. Breibart, who has conducted a series of studies of the managementof pain in AIDS, reminded clinicians that they have an obligation to treatpain, even when patients have a history of drug abuse.

Only 6% of AIDS patients with severe pain are prescribed a strong opioidlike morphine, Dr. Breitbart noted, even though the World Health Organizationanalgesic ladder suggests strong opioids for all patients with severe pain.

"Substance abusers with AIDS are among the fastest growing segmentof the epidemic. They are also among the most undertreated for pain. Fearsof contributing to drug abuse behavior and causing re-addiction contributeto physician reluctance to prescribe opioids," he said.

One of the most frequent complaints Dr. Breitbart hears from AIDS patientswith a history of drug abuse is that clinicians do not believe their reportsof pain or assume they are exaggerated or concocted to obtain drugs ofabuse.

Interpreting Pain

As with cancer pain, it is important to appreciate that pain in HIVdisease is a complex multidimensional experience and not just a physicalor nociceptive phenome-non, Dr. William Breitbart said in his symposiumpresentation .

"The ultimate report of pain intensity that you hear from the patientis a consequence of many interactions," he said. Factors that mayimpact on pain intensity reports include cognition or the meaning of pain;emotional factors such as fear, anxiety, and depression; social environmentalfactors such as social support and financial security; and substance abuseissues.

In Dr. Breitbart's experience, patients with AIDS-related pain who interpretedtheir pain as meaning that their HIV disease was progressing reported higherlevels of pain than patients who saw no connection between their pain andtheir disease status.

"This makes one appreciate the need to apply both somatic therapieslike analgesics and psychosocial therapies in the treatment of AIDS-relatedpain," he said.

To ascertain whether there was evidence of lies or exaggeration aboutpain, he compared the reports of pain of AIDS patients with a history ofdrug abuse with those who had no such history. He found that on every variable--prevalenceof pain, pain intensity, number of pains--there was no significant differencebetween the two groups. But there was a difference in how they were treated.

"Our patients with a history of drug abuse were much more likelyto get no treatment, much less likely to get a strong opioid, and muchmore likely to be distressed, depressed, and hopeless," he said.

Dr. Breitbart suggested two principles as a guideline for the managementof pain in AIDS patients with a history of drug abuse. The first is thatsubstance abusers with HIV deserve pain relief regardless of whether theyhave a drug abuse history.

"We treat other medical problems regardless of drug abuse. Thepresence of injection drug use or substance abuse complicates the managementof pain, but it does not relieve us of the obligation to treat pain,"he said.

The second principle of pain management in these patients is to tryand accept and respect reports of pain. "During your first interactionwith a patient, you will not be able to tell whether the patient is exaggeratingor lying about his pain," he said. "You will only get to knowthe true nature of their pain experience through a process that will taketime and involves assessment, intervention, and responses to your interventions."

Dr. Breitbart advised clinicians to speak frankly to patients with ahistory of substance abuse about their concerns. Clinicians should alsobe clear with them about the goals and conditions of opioid therapy, andshould consider the use of written contracts that establish a single prescriber.

Dr. Breitbart, who has treated several hundred patients with AIDS-relatedpain and a history of substance abuse, said that he had been fooled "agood dozen or so times. But if I were to allow that experience of beingmanipulated and fooled to stop me, I would not have been able to help thevast majority of those patients with pain."