Kaplan R, Slywka J, Slagle S, Ries K. . J of Pain & Symptom Manage, 2000; 19(4):265-273.

Prepared by: : Dr. Robin Fainsinger

Received during: Journal Rounds on the Tertiary Palliative Care Unit, Grey Nuns Hospital

Abstract:

To compare morphine dosage and effectiveness in AIDS patients with/without prior substance use and pain, a prospective, open-label case series lasting 3 - 18 days was conducted in both outpatients and inpatients at major pain service teaching programs. Forty-four patients, 13 with prior drug use history, who had pain associated with HIV infection or its treatment were administered sustained-release morphine (SRM) every 12 hours. The dose was titrated to pain relief for a period of ³ 3 consecutive days (associated with = 2 immediate-release morphine tablets per 24 hours), or until the patient discontinued from the study or completed 18 study days. Forty-four patients were enrolled (13 with a prior drug use history). Forty were evaluable for an intent-to-treat analgesia, including 11 with a drug use history. Twenty-four (6 users) completed this study. Former users and non-users were similar in demographics, baseline pain intensities, causes of pain, discontinuation, quality of life and acceptability of therapy. Pain intensity decreased by ³ 50% in both groups (P = 0.0001). To identify a stable dose, the dose of SRM more than doubled in former users and rose by 31% in non-users (mean final dose 177.4 mg and 84.9 mg, respectively) (P = 0.0018). Immediate-release morphine decreased in both; former users required more (P = 0.0006). These data suggest the utility of morphine for AIDS-related pain. Patients with a prior drug use history benefited but required substantially more morphine.

Comments:

Strengths/uniqueness: A good description of methods and results, with an acceptable definition of well controlled pain. There is a reasonable reporting of other outcomes such as quality of life and safety variables.

Weakness: The past history of drug use is not well defined. Presumably any past history was sufficient for inclusion, but this could include a range of use ending a month previously to many years ago, as well as varying frequency, duration, drugs used, or rehabilitation initiatives. We do not know how many patients were excluded from the study due to drug use within one month. The authors acknowledge the short study duration and small patient numbers as further problems. The open-label, non-randomized design is a further problem, but difficult to avoid in this patient population.

Relevance to Palliative Care: This study should increase our confidence in providing patients with a past history of drug use with appropriate opioid pain management. We can anticipate some of these patients will need higher doses to achieve stable pain control.

A pilot survey of aberrant drug-taking attitudes and behaviors in samples of cancer and AIDS patients.

Passik SD, Kirsh KL, McDonald MV, et al. J of Pain & Symptom Manage 2000; 19(4):274-286.

Prepared by: : Dr. Robin Fainsinger

Received during: Journal Rounds on the Tertiary Palliative Care Unit, Grey Nuns Hospital

Abstract:

The clinical assessment of drug-taking behaviors in medically ill patients with pain is complex and may be hindered by the lack of empirically derived information about such behaviors in particularly medically ill populations. To investigate issues surrounding the assessment of these behaviors, we piloted a questionnaire based on the observations of specialists in pain management and substance abuse. This preliminary questionnaire evaluated medication use, present and past drug abuse, patients' beliefs and the risk of addiction in the context of pain treatment, and aberrant drug-taking attitudes and behaviors. This instrument was piloted in a mixed group of cancer patients (N= 52) and a group of women with HIV/AIDS (N = 111). Reports of past drug use and abuse were more frequent than present reports in both groups. Current aberrant drug-related behaviors were seldom reported, but attitude items revealed that patients would consider engaging in aberrant behaviors, or would possibly excuse them in others, if pain or symptom management were inadequate. Aberrant behaviors and attitudes were endorsed more frequently by the women with HIV/AIDS than by the cancer patients. Patients greatly overestimated the risk of addiction in pain treatment. We discuss the significance of these findings and the need for cautious interpretation given the limitations of the methodology. This early experience suggests that both cancer and HIV/AIDS patients appear to respond in a forthcoming fashion to drug-taking behavior questions and describe attitudes and behaviors that may be highly relevant to the diagnosis and understanding management of substance use among patients with medical illness.

Comments:

Strengths/uniqueness: An initial effort to characterize drug related behaviors and attitudes in cancer and AIDS patients, by using a comprehensive pilot survey. Confirms a high frequency of abnormal drug behavior and attitudes in women with HIV/AIDS. The overestimation by all patients of the addiction risk reinforces the need for education.

Weakness:The questions on drug use do not capture the time elapse and duration of past behavior. The authors highlight the other limitations of small sample size, potential bias in questionnaire design and subjects' response, patients limited to an academic cancer centre or women with HIV/AIDS, and inability to do subgroup analysis.

Relevance to Palliative Care: This study highlights the wide potential variation in different palliative care populations in patterns of past and present aberrant drug-taking behaviors and the need for a clinically useful screening approach. The implications for psychosocial and pharmacological management of symptoms such as pain, as well as any underlying aberrant behavior, remains unclear.

Current Perspectives on Pain in AIDS (Second of Two Parts). Downloadable PDF File

Breitbart W, Dibiase L. Oncology 16:964-968, 2002.

Prepared by: : Dr. Debra Slade

Received during: Case Rounds, September 10, 2002

Abstract:

As active participants in the care of patients with acquired immunodeficiency syndrome (AIDS), oncologists need to be aware of the many facets of pain management in this population. This two-part article, which began in the June 2002 issue, describes the prevalence and types of pain syndromes encountered in patients with AIDS and reviews the psychological and functional impact of pain as well as the barriers to adequate pain treatment in this group and others with human immunodeficiency virus (HIV)-related disease. Finally, principles of pain management, with particular emphasis on controlling pain in HIV infected patients with a history of substance abuse, are outlined.

Comments:

Strengths/uniqueness:
A thorough review of treatment of pain at the end of life in HIV-infected patients and particularly for those continuing to abuse drugs. This paper includes a discussion of nonpharmacologic interventions (eg neurosurgical options) and stresses a multidimensional approach. The importance of carefully defining the pain syndrome is emphasized.

Weaknesses:
Although a multidimensional approach is stressed, it would have been very useful to know which counselling techniques have been found to be most effective with this population. Contracts are very commonly used with patients who continue to abuse drugs but are not specifically mentioned in the article. Consideration of the impact of a methadone maintenance program on the use of methadone in the treatment of
neuropathic pain syndromes in these patients would have been useful.

Relevance to Palliative Care:
As HIV-infection therapy advances, AIDS presents more as a chronic disease. Undoubtedly we will be seeing greater numbers of HIV-infected palliative patients dying of chronic AIDS-related illnesses or of causes more commonly found in the current palliative population. It is increasingly important to be able to recognize and manage specific concerns which affect this population.