by Mark Cichocki, RN
August 2007
Unfortunately, pain is a common companion of HIV. Pain can occur at all stages of the disease; each individual is different. As HIV progresses so does the incidence and strength of pain. A study of HIV patients at St. Paul’s Hospital in British Columbia, Canada found that over 50 percent of HIV+ people had pain.
Pain occurs for many reasons:
- A symptom of HIV
- A symptom of other illness or infections
- A side effect of HIV drugs
Regardless of the reason, pain must be identified, assessed, and then treated in order to maintain quality of life.
The first step in pain management is identifying the type of pain. The most common types of pain include the following:
-
Peripheral Neuropathy: Pain as a result of sensory nerve
damage, mostly in the feet, hands and face. It is described as numbness,
tingling, or burning sensations. The nerve damage can be a result of HIV drugs
or other medical conditions such as diabetes.
-
Abdominal Pain: There are many reasons an HIV+ person would
experience abdominal pain.
- A side effect of some HIV drugs.
- Inflammation of the pancreas (pancreatitis) caused by some medicines
- HIV-related abdominal infections caused by bacteria or parasites
- Bladder and urinary tract infections (especially in women)
- Menstruation or conditions of the uterus, cervix or ovaries
- Diseases of the intestinal tract such as irritable bowels
-
Headache: This pain can be mild to intense. Causes of mild headaches
include muscle tension, stress, HIV drug side effects, and sometimes viral
illness. Moderate headaches can be caused by sinus or tooth infections. Severe
headaches can be caused by brain tumors, bleeding in the brain, or
infection.
-
Post-Herpetic Pain: Herpes is a family of viral infections common to
HIV+ people. Once infected, herpes stays for life. Post herpetic pain is
present even after the herpes sores have healed. There are several types of
Herpes:
- Chickenpox: which causes open, itching sores on the body
- Herpes Simplex (HSV-2, or genital herpes): which causes painful sores in the genital area
- Herpes zoster (HSV-1 or “cold sores”): causes painful sores near the lips
- Shingles: which is similar to chickenpox but causes painful sores along
nerve pathways
-
Joint and Muscle Pain: This pain can be mild to severe and related
to conditions such as arthritis, any kind of injury, lack of exercise, or just
aging. It can also be a side effect of some HIV drugs and high cholesterol
medications.
- Others: Painful skin rashes, chest pain caused by lung infections such as TB, bacterial pneumonia and PCP pneumonia (Pneumocystis pneumonia). Mouth pain can be caused by mouth ulcers (“canker sores”) or severe fungal infections (thrush).
Once the type of pain is identified the next step is to assess its
characteristics. There are three primary goals of pain assessment:
-
Define the severity of the pain:
This can be accomplished in several ways.
- Your healthcare provider will ask you to assign a number to your pain, one being very little pain to ten, being the worst.
- Pictures can describe pain. A smiling face represents little or no pain, while a crying face represents severe pain.
- There may come a time when you are having pain but do not want to complain.
You may feel reporting your pain will in some way inconvenience your provider.
In that case your medical provider watches your body language, facial
expressions, and your vital signs.
-
Pain medication selection: All pain cannot be treated the same way.
The severity, cause and type of pain, and projected duration of pain, and any
history of substance abuse all play a role in selecting medication.
- Does the Pain Medication Work? Frequent pain assessment is necessary to see if pain medications are working. People can become resistant to pain medications.
Once the type and characteristics of pain are identified, treatment must be selected. There are many options for pain relief:
Non-medicinal: Meaning pain relief without medicines.
- heat and cold therapy
- massage
- relaxation techniques
- physical therapy
- hypnosis
- mental imagery (focusing on a pleasing mental picture, also known as visualization)
While these may be enough to relieve pain, they are usually used along with pain medications.
Non-opioid: Meaning pain relief by medicines that do not contain
narcotics (opiates).
- Tylenol ® (acetaminophen)
- Non-steroidal anti-inflammatories (NSAIDs); examples include Advil ® and Motrin ® (ibuprofen)
- Steroids – examples include prednisone and hydrocortisone
- COX-2 inhibitors – these drugs block body chemicals that send pain messages to the brain. An example is Celebrex ® (celecoxib)
These pain medications are effective in relieving mild pain related to
inflammation or swelling. They can also cause some side effects:
- stomach upset (especially NSAIDs)
- altered blood clotting
- cardiac complications (especially with COX-2 inhibitors)
- liver toxicity (especially acetaminophen)
- stomach bleeding and ulcers (especially NSAIDs)
Non-opioids are available over-the-counter or by prescription.
Opioids / Narcotics
Opioids are the strongest pain relievers, available only by prescription. They treat moderate to severe pain, including acute (recent and sudden) and chronic (long-term) pain. Opioids are classified according to speed of action and duration of pain relief.
- immediate release opioids - act rapidly but don’t relieve pain for very long
- sustained-released opioids - take longer to act but pain relief is
sustained over longer periods
The type used depends on pain characteristics. Chronic pain requires sustained release drugs while acute pain requires rapid, shorter acting opioids.
Opioids are also classified by strength.
- Weak Opioids – relieve mild to moderate pain (less than a severity of 7 on
a 1 to 10 pain scale). These are usually mixed with non-opioids to improve
their action.
- hydrocodone
- codeine
- Tylenol ® with codeine (acetaminophen and codeine)
- Vicodin ® (hydrocodone and acetaminophen)
- Strong Opioids – relieve severe pain (pain with a designation of greater
than 7).
- morphine
- fentanyl
- methadone
- oxycodone
Adjuvant Therapy
These are medicines indicated for purposes other than pain relief but have
pain relieving properties.
- Anti-depressants – relieve pain related to the nervous system (neuropathic)
such as peripheral neuropathy. A prescription is needed for these drugs. An
example is Cymbalta ® (dulozetine).
- Anticonvulsants – used to treat seizures, these drugs are effective in
relieving the pain of peripheral neuropathy. An example is Neurontin ®
(gabapentin).
- Local Anesthetics – these drugs are topical (applied directly to the area of pain) or injectable (in the blood stream or spinal canal). They are effective in relieving tingling or burning type pain. An example would be Xylocaine ® (Lidocaine).
When you have pain, you need to know how to get immediate, safe pain relief.
- Never Ignore Your Pain – Pain is the body’s way to say there’s a problem.
Ignoring pain usually makes matters worse and can cause more damage in the long
run.
- Assess Your Pain – when pain occurs ask yourself:
- How long have I had the pain?
- Did it emerge gradually or sudden?
- Is the pain sharp or dull?
- What makes the pain worse?
- Does anything ease the pain?
- Is the pain localized or does it radiate to other areas?
- Are there other symptoms (e.g., numbness, cough, fever)?
- Notify Your Doctor – Pain should be reported to your doctor. Sharing your
pain assessment with the doctor will help identify the cause and how best to
treat it.
- Take Your Pain Medications – If pain medications are needed, make sure you
take them exactly as prescribed. Pain medications work best if they are taken
at the first hint of pain. Breaking the cycle of pain means taking medications
before your pain is at its worst.
- Be Responsible – Pain medications are very effective when they are taken as
prescribed. Taking them incorrectly or venturing away from what’s prescribed
can be dangerous. Opioids are addictive, meaning a physical and emotional
dependence of the drug can occur. Opioids can adversely affect breathing, level
of consciousness and judgment. In extreme cases abuse of opioids can be
fatal.
- If They Don’t Work Tell Your Doctor – If your pain medicine is not relieving your pain, talk to your doctor. It is possible you may have become resistant to the drugs. A dose or pain medication change may be needed.
Pain is a fact of life for those who are HIV+. However it must be and can be managed for you to maintain your quality of life. If you are having pain, talk to your doctor. He or she can work with you to find the cause, treat the pain, and help you get back to living.
| 1 | |
Brasseur, L. “Pain and HIV Infection: A French National Survey” |
| 2 | |
Great Ormand Hospital for Children “Pain Assessment” |
| 3 | |
Zarowny, D. “Incidence of Pain in Ambulatory HIV Patients” |
