Assessment of Pain

Pain is often treated subtherapeutically because of inadequate assessment. While psychological, social, and spiritual factors influence the manifestation of pain, organic etiologies need to be considered as a contributing factor. Evaluation of pain should always be made on the assumption that organic factors are contributing to the pathophysiology of the pain.1

Initial pain assessment should be performed with every new patient report of pain and should focus on the site of the complaint. Ongoing pain assessment should be performed at regular intervals after a treatment plan is implemented and with each new patient report of pain. Pain is a frequent complication of HIV disease even in the era of HAART. Peripheral neuropathy can result in advanced stages of disease and as a serious side effect of certain antiretroviral agents, notably the "D" drugs.2

Initial assessment of pain should include a detailed history, including intensity assessment; physical examination, including appropriate laboratory studies; psychosocial assessment; and diagnostic workup to determine the causes of the pain. The mnemonic "ABCDE" can be used to as a routine approach to pain assessment (see Table 1).

The patient's level of coping skills and cognition are often associated with their level of pain and pain control. Pain is best understood within a multidimensional framework since numerous factors influence its manifestation.

Pathophysiology and Clinical Presentation of Pain

Pain assessment and interventions in people living with HIV/AIDS should always be considered in the light of the patient's immune status. Patients with HIV infection without significant immune compromise usually do not develop life-threatening opportunistic infections or neoplasms. Pain in this population of patients can usually be diagnosed and the causative factor can be treated (eg, herpes zoster). However, onset of pain in the immune-compromised patient can herald a major event (eg, new onset of headache may be indicative of cryptococcal meningitis) that needs immediate treatment.

Pain in HIV disease, including procedure-related pain, can also be iatrogenic or can be associated with terminal stages of illness.

Pain etiologies in HIV disease can be assessed and treated systematically. Generally, treating the underlying causative factor can greatly alleviate pain. However, this does not dismiss the need for adequate analgesia.

 

Gastrointestinal Pain

Numerous opportunistic infections and HIV-related neoplasms can present clinically as pain referable in the gastrointestinal tract. Oral manifestations in HIV are important to diagnose because of their significant morbidity and their relatively early appearance in the disease stage.

Oral lesions occur in the vast majority of patients with HIV/AIDS, and many patients will develop oropharyngeal candidiasis. Kaposi's sarcoma (KS) lesions can be located anywhere in the oral mucosa but are predominately located on the palate and the gingiva. Oral KS is typically not painful unless lesions are infected or ulcerated.3

Other common sources of oral cavity pain are necrotizing gingivitis, dental abscesses, and oral ulceration caused by infection with herpes simplex virus (HSV), cytomegalovirus (CMV), Epstein-Barr virus (EBV), cryptococcal infection, histoplasmosis, or lymphoma. HSV is the common causative agent of treatable aphthous ulcers that can be recurrent and that can be a very painful complication of HIV disease. The etiology of apthous ulcers remains unclear; however, the drug thalidomide has shown some efficacy for intractable ulcers.

Primary treatment should included antiviral therapy for CMV and herpes simplex, and antifungal therapy for Candida. In addition, site-specific use of antacid or viscous xylocaine may provide symptomatic relief.

Esophageal pain occurs in approximately one-third of patients with advanced HIV disease; it often signals the onset of symptomatic HIV progression. Patients present with mild to profound dysphagia and odynophagia, and these symptoms can greatly reduce food intake and contribute to clinical wasting syndrome and generalized debilitation.

Ulcerative esophageal disease is typically associated with infection by CMV or HSV. However, patients with esophageal distress and low CD4 counts have been most often identified as having Candida albicans as the causative factor. Empiric treatment with oral antifungal therapy should be attempted. If the patient does not respond to treatment, an upper endoscopic evaluation should be performed.

Abdominal pain has been studied extensively and is frequently found as a major complaint in persons living with HIV/AIDS. The etiology of abdominal pain needs to be evaluated in relationship to its clinical presentation. Cramping is often associated with cryptosporidial diarrhea, Shigella, Salmonella and Campylobacter enteritis and CMV ileitis or colitis. Treatment of the causative agent will generally relieve the associated pain.

Acalculous cholecystitis is a common presentation for people living with HIV/AIDS. Classic right upper quadrant or epigastric pain is the usual clinical presentation. Immune-compromised patients may develop gallbladder disease from Crytosporidium or CMV. In addition, MAI and KS have been identified in several patients.

Drug-induced pancreatitis can often result from the use of antiretroviral agents such as didanosine (ddI), dideoxycytidine (ddC), and intravenous pentamidine. Acute abdominal pain and tenderness with elevated serum amylase typically accompany pancreatitis. Discontinuing the aggravating agent and providing supportive therapy will usually resolve the condition.

Anorectal pain needs scrupulous evaluation in men who have sex with menÑindeed, anorectal disease is becoming a major clinical issue in this patient group. Pain is often associated with perirectal abscesses, CMV proctitis, fissure-in-ano and HSV infection.

The etiology of pain in HIV disease is multifactorial, and all complaints need to be investigated. Clinicians need to understand the need not only for pain identification but also for adequate analgesia and symptom relief.

See Dr. Ferri's bio on page 85.

References

     1.   Jacox A, Carr D, Payne R, et al. Management of Cancer Pain. Clinical Practice Guidelines No. 9. Agency for Health Care Policy and Research, US Department of Health and Human Services, Public Health Services. Rockville, MD: AHCPR Publication No. 94-0592. 1994

     2.   FJ Jr, Pardo CA, Verma A. Human immunodeficiency virus and the Peripheral Nervous System Workshop. Arch Neurol. 2001;58:.

     3.   Belitsos PC. Management of HIV-associated esophageal disease. AIDS Clinical Care. 1995;3:19-21.