Page 213 Guide to Pain Management in Low-Resource Settings

Management of Pain in HIV/AIDS 201

cultures and lack of response to potent intravenous an- pain, abdominal pain, chest pain, arthralgias and myal-
tibiotic therapy. gias, and painful dermatological conditions.
3) Psychological pain. Loss of the will to continue
Are the principles of pain management
fi ghting and resignation to the possibility of death. Th e
diff erent in HIV?
loss of both parents, the tragic way she received her di-
agnosis, and the lateness of her presentation, together Th e principles of pain management in HIV are similar
with her severe ill health and opportunistic infection, to those in other medically ill patients. At each visit,
comprise a daunting load for a young psyche. Th e temp- both in the outpatient and inpatient facility, it is useful
tation to give up hope must certainly be strong. Th e to take “pain vital signs” to assess the degree of pain and
need for a strong, loving family support system with ex- the response to the current analgesic program (also see
ternal psychosocial intervention is crucial. Fortunately, the Brief Pain Inventory).
Abigail has very loving aunts who visited her daily and • Ask patients if they have experienced pain in the
caring school friends who sent cards and gifts during last week.
her hospital stay. Th e palliative care psychologist was • Ask them to describe the intensity of pain: mild,
also able to counsel and encourage her and her family moderate, or severe.
and provide them with the extra care they needed at • Ask them to tell you what it feels like: burning,
this diffi cult time. shooting, dull, or sharp.
4) Drug side eff ects. Tilidine is a strong opioid. • Find out what makes it better or worse.
Opioid analgesics are known to cause sedation and • Ask them to rate the pain (at its worst and at its
mood changes (euphoria or dysphoria.) Tilidine itself best) on a 0–10 numerical scale.
can also cause dizziness, drowsiness, and confusion. • Ask them to rate their quality of life on a 0–10 scale.
According to the WHO analgesic ladder, strong opi- • Ask about sadness, fatigue, and depression.
oids should be reserved for pain that does not respond After obtaining the history, a careful medical
to less strong analgesia. Th ey should not be used as a examination will help elucidate the causative factors.
fi rst-line analgesic, except postoperatively or where Th e baseline assessment can be used as an indicator as
clear pathology requiring strong analgesia is required, to whether the analgesia is eff ective or not.
such as pancreatitis.
Do women with HIV infection have more pain?
How to manage pain in HIV-infected adults Women experience pain diff erently from men due to
Th e pain syndromes seen in HIV-infected adults may be biological, psychological, and social factors. Men and
directly related to HIV infection, immunosuppression, women respond diff erently to pharmacological and
or HIV therapy. Pain can be divided into two categories: nonpharmacological treatments. Women with pain are
nociceptive or neuropathic. Th e most common syn- often underdiagnosed and undertreated. Th ey may not
dromes reported in HIV-positive adults include painful have the information or education to understand that
peripheral neuropathies, as well as pain caused by ex- their painful conditions may be part of HIV disease.
tensive Kaposi’s sarcoma, headache, oral and pharyngeal Culture also infl uences pain experience.

Table 3
Common sources of pain in HIV/AIDS
Cutaneous/Oral Visceral Deep Somatic Neurological/Headache
Kaposi’s sarcoma Tumors Rheumatological Headaches: HIV-related (encephalitis, meningitis, etc.)
Oral cavity pain Gastritis disease Headaches: HIV-unrelated (tension, migraine)
Herpes zoster Pancreatitis Back pain Iatrogenic (zidovudine-related)
Oral/esophageal Infection Myopathies Peripheral neuropathy
candidiasis Biliary tract Herpes neuritis
disorders Neuropathies associated with ddI, D4T toxicities,
alcohol, nutritional defi ciencies.
*Modifi ed from Carr DB. Pain in HIV/AIDS: a major health problem. IASP/EFIC (press release). Available at
www.iasp-pain-org.