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inhibited by methadone, thereby increasing its bioavailability and possibly toxicity (McCance‐
Katz et al, 1998 Level III‐3).
Patients with a history of substance abuse
HIV/AIDS patients with diagnosed mood/anxiety or substance‐use disorders report much
higher levels of pain than HIV/AIDS patients without these comorbidities or the general
population (Tsao & Soto, 2009 Level III‐2). Those with a history of substance abuse are also more
likely to receive inadequate analgesia and suffer greater psychological distress (Breitbart et al,
1997 Level III‐2). Two cohort studies showed that that even though HIV‐positive patients with a
history of problematic drug use report higher ongoing use of prescription analgesics
specifically for pain, these patients continue to experience persistently higher levels of pain,
relative to non‐problematic users (Tsao et al, 2007 Level III‐2; Passik et al, 2006 Level III‐2).
Patients in a methadone maintenance program, who also suffered from HIV/AIDS related pain,
gained improved analgesia without adverse effects by use of additional methadone
(Blinderman et al, 2009 Level IV).
The principles of pain management in these patients are outlined in Section 11.8.
Key messages
1. High concentration capsaicin patches, smoking cannabis and lamotrigine are effective in
treating neuropathic pain in patients with HIV/AIDS (N) (Level II).
2. Nucleoside reverse transcriptase inhibitor (NRTIs)‐induced neuropathic pain in HIV/AIDS
patients is treatable with acetyl‐L‐carnitine (ALCAR) (N) (Level II).
3. HIV/AIDS patients with a history of problematic drug use report higher opioid analgesic
use, but also more intense pain (N) (Level III‐2).
The following tick boxes represent conclusions based on clinical experience and expert
opinion.
Neuropathic pain is common in patients with HIV/AIDS (U).
In the absence of specific evidence, the treatment of pain in patients with HIV/AIDS should
CHAPTER 9 Interaction between antiretroviral and antibiotic medications and opioids should be
be based on similar principles to those for the management of cancer and chronic pain (U).
considered in this population (U).
9.7
The scope of acute cancer pain
9.7.1 ACUTE CANCER PAIN
Acute pain in the cancer patient may signify an acute oncological event including pathological
fracture or microfracture, spinal cord or nerve compression, visceral obstruction or cutaneous
ulceration due to tumour. Cancer pain may become acute in the presence of infection, and
during diagnostic or therapeutic interventions. Anticancer therapies, including surgery,
chemotherapy, hormonal therapy and radiotherapy, may be associated with both acute and
chronic pain of a nociceptive or neuropathic nature.
Acute pain in the cancer patient requires urgent assessment and treatment. A thorough
evaluation of the patient should include a full history and examination, and mechanism‐based
assessment of pain and, where indicated, appropriate investigations to determine the
280 Acute Pain Management: Scientific Evidence
