The Doctor is IN
By; Dr. Rami Rustim – July, 2102
In the early 1980s, HIV infection emerged as a rapidly progressive, terminal illness for which treatment was limited to the alleviation of pain and other symptoms at the end of life. The development of effective combination antiretroviral therapy (ART) in the mid-1990s transformed HIV from a terminal to a chronic condition. Advances in treatment have dramatically changed the lives of many patients, their loved ones, and their caregivers by restoring patients to health and delaying death, even restoring to some the expectation of having an average lifespan. However, as patients are living longer, new challenges have emerged, including treatment toxicities and drug resistance; increased rates of co-morbid diseases such as chronic liver and kidney disease, atherosclerosis, cancers, depression, and dementia; and issues of adherence to complex treatment regimens.
Pain Symptom Management
All good pain management begins with an adequate pain assessment. Patients with HIV disease are often reluctant to report pain to their healtchare providers, so it is important for those care-providers to ask about pain. Any complaint of pain should be followed up with a focused medical and neurological history, a physical examination, and a psychosocial assessment.
Pain in HIV disease is complex and multidimentional. The physical and psychological aspects of pain interact, and that interaction is ultimately expressed in the patient’s description of the nature and intensity of the pain, and the degree to which the pain impairs function. Whenever an HIV-positive patient reports pain, the clinician should obtain a description of the quantitative and qualitative features of the pain, its time course, and any maneuvers that increase or decrease the pain’s intensity. Patients should be asked to describe the pain as precisely as possible, because these descriptors can help the clinician determine the mechanism of pain — which can, in turn, predict how the pain may respond to the classes of analgesics.
Pain intensity can be assessed using simple 0-10 numerical scales, and these ratings — of how intense the patient’s pain is currently, on average, at best, and at worst can be useful in determining the potency of the analgesic required.
Clinician barriers in treating pain include inadequate knowledge of pain management, concerns regarding use of opioids, and lack of access to pain management specialists. Clinicians understandably worry about addiction in their patients with substance abuse histories. Despite these concerns, physicians and nurses have an ethical obligation to treat pain and should possess knowledge and skills in basic pain management.
It is important to look for and treat the underlying etiology of pain. For example, HIV infection itself is associated with significant neurotoxicity related to viral load levels.
(Figure 1) shows a “pain ladder” model developed by the World Health Organization (WHO) for progressive treatment of pain. The basis of the ladder is the 3-step approach, starting with non-opioids for mild pain, escalating to mild opioids for moderate pain, and moving to stronger opioids for severe pain until the pain is controlled. For anything but mild pain, medications should be given around the clock rather than on demand. Adjuvants, such as certain antidepressants, anticonvulsants, nonsteroidal antiinflammatory drugs (NSAIDs), and muscle relaxants, should be used as appropriate, depending on the type of pain ( Table 1).
Step 1: Mild Pain – TREATMENT: Nonopioid:
• Acetaminophen 600 mg orally every 4 hours
• Ibuprofen 400 mg orally every 4 hours. OR
Step 2: Moderate Pain
Add opioid around the clock: • Acetaminophen 325 mg + codeine 30 mg orally every 4 hours
OR • Acetaminophen 325 mg + codeine 60 mg orally every 4 hours. OR Acetaminophen 325 mg + oxycodone 5 mg orally every 4 hours
Step 3: Severe Pain
TREATMENT Start strong oral opioid around the clock: Morphine 15-30 mg orally every 4 hours, titrate to pain control
OR • Dilaudid 2-4 mg orally every 4 hours, titrate to pain control OR
• MS-Contin or other long acting opioid 30 mg orally every 8-12 hours
AND Use short acting opiate in addition for breakthrough pain Adjuvant Medications (can be added at any step)
• For neuropathic pain: tricyclic antidepressants, selective serotonin reuptake inhibitors, anticonvulsants such as gabapentin, carbamazepine, and topiramate
• For bony pain: corticosteroids
For muscle spasm: baclofen, cyclobenzaprine
How can pain relief for AIDS become more accessible?
Patient-doctor level: Many of the problems associated with a lack of adequate pain control are linked to negative perceptions of opioids held and perpetuated by patients, doctors, governmental authorities and international organisations. Therefore, reassuring and lobbying those involved about the medical value of opioids is necessary in order to overcome some of the barriers.
In order to lessen fears about taking opioids, patients should be made aware that they can be administered often with very few pills. This is important considering the overall daily pill burden of people living with HIV. Patients should also know that side effects can be prevented and treated.
Overcoming the hesitancy by healthcare workers to supply pain relieving opioids to patients because of fear of addiction can be achieved through education in order to dispel myths about opioids, in particular morphine. Palliative care specialists should consult HIV specialists and addiction experts if they are worried about prescribing opioids to users of illicit drugs so that the patient receives adequate doses. Training on how to properly assess a patient’s need for opioids, and then administer and monitor opioids, is needed as this is lacking in the training of health care workers in many low- and middle-income countries around the world.
Countries where there is high HIV prevalence and a more urgent need for pain control often have less developed healthcare sectors and poorer infrastructure in general. This makes pain relief just one of many healthcare essentials that are poorly provided due to diminished levels of economic development. It can be argued that strengthening health systems in general would have the effect of alleviating many specific problems. However, there are many steps that could be more immediately effective.
Separating laws directed at curbing abuse and laws ensuring sufficient supply would enable handlers of opioids to not feel they are in potential violation of criminal law. As some palliative care specialists have stated, Too many legal obstacles for busy health professionals are a disincentive to use.
Countries should also submit reliable estimates of annual need to the International Narcotics Control Board to ensure they are granted a sufficient quota. Some countries’ estimates are so low that they would realistically cover less than 1 percent of those in need.
Relaxing the regulation surrounding narcotics provision could make effective pain relief much more accessible. Such liberalisation could include permitting a wider range of healthcare workers to prescribe and administer opioids; making necessary accreditation by professional bodies or governmental authorities easier and quicker; and increasing the duration of prescriptions. Normalising the medical use of opioids, through a relaxation of regulation, could make them less taboo and lead to more rational beliefs about them.
“Assessing the current policy bottlenecks, operating changes in national policies, regulations and laws, and disseminating these changes among regulators, procurement officials and health workers are crucial steps in ensuring the availability of essential controlled medicines to patients”.
Many of the obstacles to pain relief have been removed in Uganda where morphine is now promoted at all levels including in villages. Nurses are allowed to prescribe it, and within its hospice system, morphine can be prescribed in any dose and for any number of days. Palliative care was recognized by the government as an essential clinical service, and liquid morphine was added to its essential drugs list. Furthermore, no cases of narcotics abuse occurred at least during the first three years of government use and first twelve years of hospice use.
In Kerala, a state in South India, simplified regulations and licensing systems for controlled substances has allowed the state to greatly expand access to pain relief. Kerala is an exception in India (80 percent of all palliative care provided in India is delivered in Kerala), where most states apply stringent laws to curb the drug trade but have not taken steps to ensure that these laws do not obstruct access to palliative care.
The international drug control framework also needs to shift to greater emphasise the adequate provision of pain relief medications, rather than focusing on the potential for illicit drug trafficking and addiction. To achieve this, United Nations model laws could be amended to reflect the spirit of the Single Convention on Narcotic Drugs that recognizes the importance of pain relief.
To reduce fears that narcotics imported for medical purposes could seep into the black market, accountability processes that detail suppliers, recipients, quantities, and medical usage of opioids are necessary. The International Narcotics Control Board already requires countries to submit such information but it is believed a simplified, standardized process to make accountability easier would be effective in reducing worries about misuse
It is within the ability of current clinical practice to deliver a high degree of pain control to most patients with end-stage HIV disease — without sacrificing their sense of self and their ability to think and function. In some patients, more invasive techniques may be needed, including spinal narcotics and destructive nerve-block procedures. However, these patients are the exceptions to the rule. In the vast majority of cases, carefully considered titration of medication can result in a satisfactory outcome, one that ablates the patient’s pain and maintains his dignity and comfort.
Ref: 1- Pain & Policy Studies Group, Paul P. Carbone Comprehensive Cancer Center, School of Medicine and Public Health, University of Wisconsin (2009, January), ‘Do international model drug control laws provide for drug availability?
2- World Health Organization (2006), ‘The urgency of pain control in adults with HIV/AIDS