Pain in the HIV-Infected Substance User

I. INTRODUCTION

Recommendation:

Clinicians should not withhold treatment for pain because a patient has a history of substance use. Rather, standard pain assessment and treatment protocols should be followed.

The sensation of pain is a fundamental protective physiologic response. Most often, it is a signal that tissue damage has occurred and that steps should be taken to avert further damage and foster healing. When pain is prolonged or intense, it can reduce quality of life and psychological functioning.¹ This chapter addresses the treatment of pain in HIV-infected substance users and special considerations for opioid use.

HIV-infected individuals are at increased risk for developing certain painful conditions, particularly neuropathy, which can be due to medications, diabetes, or the underlying HIV infection itself. Additionally, some opportunistic infections are painful, such as chronic herpes simplex virus or varicella zoster virus.

One study of ambulatory patients with AIDS reported that more than 60% of patients said they had current frequent or persistent pain, many with severe pain and associated dysfunction.² In another study, patients reported an average of 2.7 seemingly distinct pain-related problems, such as headaches, joint pain, polyneuropathy, and muscle pain, thus indicating they had multiple pain syndromes.³

Yet pain in HIV-infected substance users is greatly undertreated. In one study, AIDS patients with a history of substance abuse received adequate analgesic therapy in only 8% of cases compared to 20% of AIDS patients without a history of substance abuse.⁴ In this study, clinicians did not make distinctions of whether the patients were actively using drugs, in methadone maintenance, or on drug-free rehabilitation when deciding to withhold analgesics (e.g., opioids).

Literature on the management of pain has focused primarily on pain management in the HIV-infected patient in general, with little guidance on pain management in the HIV-infected substance user.⁵ In addition to the painful conditions listed above, persons with a history of substance use are also at increased risk for trauma, abscess, and chronic pancreatitis.