Barriers to Adequate Pain Treatment

Pain is a common problem for people living with HIV disease. The onset of pain as a clinical problem varies throughout the disease process and increases with disease advancement. Nurses caring for patients with HIV disease need to understand the etiologies, clinical implications, and treatment interventions associated with pain syndromes.

The prevalence of pain in patients with HIV disease ranges from 50% to 90%, depending on disease stage and other comorbidities.[1] However, pain syndromes often are untreated or undertreated, resulting in physiological and psychological deterioration of the patient, said Debra Trimble, RN, MS, FNPC, Thomas Street Clinic, Houston, Texas. Trimble and colleagues identified several common barriers to pain treatment, including system barriers, reluctance of healthcare providers to treat pain, patient and family fears of developing an addiction, and legal issues (ie, providers having to deal with the US Drug Enforcement Agency).

People living with HIV face many psychosocial stresses and may experience social ostracism because of their risk-associated behavior, such as men who have sex with men and injection drug users. They often do not receive appropriate healthcare. Nurses are in the unique position to advance the treatment of pain syndromes in HIV disease by combining their clinical skills as primary care providers with their role as patient advocate.

Subtherapeutic treatment of pain is often a result of inadequate assessment. Although psychological, social, and spiritual factors can influence the manifestation of pain, organic etiologies need to be considered. Evaluation of pain should always be made on the assumption that organic factors are contributing to the pathophysiology of the pain.

An initial pain assessment should be performed with every new patient report of pain, and it should focus of the site (cause) of the complaint. Ongoing pain assessments should be performed at regular intervals after implementing a treatment plan and with each new patient report of pain.

The initial assessment should include: a detailed history, including intensity assessment; a physical examination, including appropriate laboratory studies; a psychosocial assessment; and a diagnostic workup to determine the causes of the pain. The mnemonic “ABCDE” can be used as a routine approach to pain assessment:

A — Ask about pain regularly and assess pain systematically.

B — Believe the patient and family in their reports of pain and what relieves it.

C — Choose pain control options that are appropriate for the patient, family, and setting.

D — Deliver an intervention in a timely, logical, and coordinated fashion.

E — Empower patients and their families.

This approach enables patients to control their pain to the greatest extent possible.

Dangerous Interactions
Unfortunately, the treatment of chronic pain in HIV disease has been complicated recently by old and emerging issues with “street drugs” and dependency.

The combination of recreational drugs and antiretroviral therapy can be a “deadly cocktail,” said Jean Clermont-Drolet, RN, Street Nurse for MIELS-Quebec, Quebec City, Canada. Often, people use more than 1 street drug at a time to help counteract the different effects, he said. For example, someone who is highly agitated after taking an amphetamine (”speed” or “meth”) may try to balance that by taking a narcotic to “calm” them down. Therefore, when patients present in emergency rooms with drug-related problems, nurses should not assume they are under the influence of just 1 drug, but rather should do a comprehensive evaluation and assessment.

Clermont-Drolet reviewed the principles of harm reduction, a practice model that does not judge behavior. This model is based on various stages of readiness to change; it meets the person “where they are” in their readiness to change behavior. The behavioral change does not have to be total abstinence as in the 12-step approach. Instead, it can be gradual and may include reducing the amount of substance being used or only using the substance under specific times and conditions.[2]

Another significant issue is the wide variability in “purity” of recreational drugs, Clermont-Drolet said. Street drugs are frequently mixed with a white crystalline powder, such as baking soda, which can alter the purity of the drug from 2% to as much as 98%. This practice, called “cutting,” is fairly standard as it increases the amount of the illegal drug and enhances profits for drug dealers.

Clermont-Drolet discussed some widely used antiretroviral drugs and how they can alter the amount of illegal drugs in the body and can lead to overdosing. Ritonavir (Norvir) is a protease inhibitor that is used to “boost” other anti-HIV medications. However, the boosting effect can also increase the level of recreational drugs. Employing the principles of harm reduction, caregivers should advise patients taking ritonavir to take only half the usual amount of any street drug, then gradually add more if needed, he said.

Another potentially serious interaction exists for patients on methadone maintenance, Clermont-Drolet said. Several agents, including ritonavir, lopinavir/ritonavir (Kaletra), and efavirenz (Sustiva), can decrease the circulating serum levels of methadone. Patients taking these HIV medications who need to be on methadone may need a higher dosage of methadone to prevent narcotic withdrawal.

A Growing Epidemic of Drug Abuse
Nurses need to be especially aware of the growing use of crystal methamphetamine, known simply as “meth,” said Julie Gumowski, RN, BSN, Research Nurse from the National Institutes of Health (NIH). Meth is second only to marijuana in rate of abuse, she said, and there are more than 35 million meth users in the world today.[3]

Meth can cause a state of euphoria that can last for hours to days, depending on how it is ingested, Gumowski explained. Meth can be smoked, injected, inhaled (”snorting”), or inserted rectally (”booty bumps”). Meth masks the body’s need for sleep and food but increases sexual desire, which can lead to “marathon” sexual sessions with multiple partners. This can lead to increased transmission of HIV and other sexually transmitted diseases.

Although meth use was once confined primarily to certain populations, such as men who have sex with men, it has now spread to all sections of society, from “soccer moms” to business executives, Gumowski said. It is found in both rural and urban areas, and in all populations. Meth is “cheap to make with ingredients readily available at the local hardware store,” she noted. Also, the recipe for making meth can be found on numerous Web sites.

Short-term medical complications of meth use include central nervous system excitation, such as increased alertness, energy, and activity. Tremors and vertigo can also occur. Cardiac complications include tachycardia and hypertension; myocardial infarction and stroke have also been seen as the result of meth use.

The short-term complications are exacerbated by long-term effects. Neurodegeneration occurs and impairment of motor and learning function can take place, as well as symptoms of bruxism (habitual grinding of the teeth) and skin changes that present as obsessive scratching and skin sores. Gumowski also noted that when meth is smoked, the corrosive nature of the smoke is so extensive that it can actually penetrate tooth enamel, leading to significant periodontal disease. Portions of the teeth may break off, producing a condition commonly referred to as “meth mouth.”

In addition to the medical complications of meth use, many users experience psychiatric effects, Gumowski said. Patients can experience episodes of violent behavior, paranoia, anxiety, confusion, and insomnia. Depression and mood swings are also common and tend to persist and lead to severe depression, sometimes resulting in suicidal behavior.

As the meth epidemic grows, there is high demand for treatment. Unfortunately, treatment centers are in very short supply, Gumowski said, and the relapse rate for meth abuse can be a high as 92%.

Gumowski concluded that nurses need to be vigilant about assessing for meth use in all populations. It is important to treat acute symptoms and to encourage patients to enter a drug rehabilitation program.

References
1. Trimble D, Sandoval DM, Benavides J. Unmet need: chronic pain management in the HIV clinic. Program and abstracts of the Association of Nurses in AIDS Care 18th Annual Meeting; November 17-20, 2005; Orlando, Florida.

2. Clermont-Drolet J. Street drugs and antiretroviral therapy (ART): what every nurse must know. Program and abstracts of the Association of Nurses in AIDS Care 18th Annual Meeting; November 17-20, 2005; Orlando, Florida.

3. Gumowski J. Sharing crystal methamphetamine: the new epidemic associated with HIV. Program and abstracts of the Association of Nurses in AIDS Care 18th Annual Meeting; November 17-20, 2005; Orlando, Florida.

Copyright © 2006 Medscape.

A “Push-Pull” Struggle
Political, social, and clinical issues were examined by some of the most outstanding leaders in AIDS care today at the recent annual conference of the Association of Nurses in AIDS Care. The conference theme was “Celebrating the Magic of Caring: HIV/AIDS Nursing — A Commitment to Excellence.”

One of the most pressing issues in AIDS care today is the evolving nature of the global AIDS pandemic and how world leaders are responding to the crisis. There are 40 million people living with HIV infection throughout the world, with 90% of them living in resource-poor countries. Although HIV may have become a more chronic and treatable disease in the Western world, the number of annual deaths from HIV infection worldwide has not changed much since the beginning of the epidemic. Nearly 3 million people die annually, a figure equivalent to the entire population of Chicago.[1]

While the AIDS crisis in the Western world may “appear to be under control,” the global pandemic continues to ravage most of the world. Several keynote speakers looked at the significant AIDS issues facing healthcare providers in the United States and around the world.

Kristine Gebbie, DrPH, RN, FAAN, was the first National AIDS Policy Coordinator appointed by President Bill Clinton and is now Associate Professor of Nursing and Director of the Center for Health Policy at the Columbia University School of Nursing. She opened the conference with a presentation whose theme would run throughout the conference.[2]

Gebbie looked at the “push-pull” issue of providing either treatment or prevention interventions. Many governments still struggle over whether to fund treatment vs prevention programs at home and around the world, she said. Nurses cannot let this issue become an “either or” debate, she said, because they are in an ideal position to bridge that gap and help promote funding for both treatment and prevention.

In order to keep the debate from becoming polarized, nurses should make sure any policy discussion includes at least one person who is living with HIV/AIDS, she said. “It is important that [AIDS] policy not be talked about in the abstract.”

Both prevention and treatment policies need to be discussed together. They should not be separate issues but should exist in a combined dialogue. “We don’t have a national health policy,” Gebbie said, “but we do have ongoing entitlement programs [such as Medicare and Medicaid]. Yet, every year the money for prevention still remains a year-to-year issue.”

Gebbie talked about how, nearly 3 decades into the AIDS crisis, there is still a reluctance to talk frankly about HIV/AIDS issues around the world. This can lead to increased stigma and can isolate people. HIV/AIDS issues cannot be tackled if there is still a hesitation to talk about the issues at hand. “We need a social dialogue to attack this epidemic from a global perspective,” she said.

Gebbie recalled a recent trip to Africa where she witnessed nurses washing out disposable gloves and hanging them on clotheslines so they could be reused. She was appalled by this and wondered how we could expect to change the course of worldwide HIV infection if nurses were being forced to wash “disposable” gloves.

“There has just got to be enough money to send appropriate sterile gloves throughout the world,” she demanded.

Culturally Appropriate Interventions
Gebbie’s comments were echoed and expanded upon in another major address by Todd Summers, Senior Policy Officer for Global Health at the Bill and Melinda Gates Foundation, and a former member of the President’s AIDS Advisory Council.

“Nurses are the voices of people living with HIV/AIDS,” Summers said. With 14,000 new infections occurring daily, it is important for nurses to tell the stories of their patients, he said.

Like Gebbie, Summers lamented the fact that there is an ongoing “treatment vs prevention” funding debate. He, too, emphasized that the debate is artificial and should not be seen as an “either or” issue.

People in resource-poor countries have been willing and able to take antiretroviral therapy successfully, Summers continued. He challenged any skeptics to check out the World Health Organization’s “3 by 5 Initiative”, where the target goal was to get 3 million people on antiretroviral therapy by the end of 2005. At the “3 by 5″ Web site, readers can listen to stories and see pictures of men, women, and children whose lives have been radically changed by taking antiretroviral therapy.

Summers concluded that prevention interventions can and do work in the developing world. However, they must be culturally appropriate for targeted audiences.

Summers also championed the role of nurses in AIDS care worldwide. “The majority of AIDS care throughout the world is done by nurses,” he said. “Studies have demonstrated that nurses provide as good healthcare as, or even better than, that of physicians.”[3]

Unfortunately, there is a considerable “brain drain” of nurses from poorer nations to the Western world, he said, leaving many HIV/AIDS patients without proper healthcare. “This is not a simple problem,” he warned. “Many nurses leave their native country to come to the United States to be able to send money home to provide for their families.”

Summers also sounded the alarm for the need to examine global issues of gender inequality that still exists in the 21st century. Many women are still considered “property” around the world. Many women are still considered “minors,” which forces them to get their husband’s permission to take an HIV test or receive other basic medical care. Worldwide, women fear violence, torture, and even death at the hands of their very own families.

The Bush administration’s “ABC” approach to HIV disease may be useful in certain pockets of the world, but it does not really work for women in the developing world, Summers said. The “ABC” model encourages people to abstain from sex; be faithful; or use condoms when abstinence is not a realistic option. “‘ABC’ sounds good but it does not work worldwide,” he said. “Many husbands are ’stepping out’ [having sex with other men or other partners]. We need to look at the ‘ABC’ approach since it may not be effective.”

Summers also noted that the “treatment vs prevention” issue may be a victim of its own success. “Once a person gets on antiretroviral therapy and stays there, the financial need for those on therapy goes up, and prevention funding goes down.”

Moving Beyond “Abstinence Education”
Terje Anderson, Executive Director of the National Association of People With AIDS (NAPWA), concluded the keynote remarks by focusing on domestic HIV/AIDS issues. “It would be a really good idea if we had an AIDS policy [in the United States],” he said. “We really don’t have one.”[4]

Current practices for fighting HIV/AIDS are disjointed and are not based on science, he said. For instance, when school programs are allowed to provide only abstinence education as a prevention strategy, that is simply “not the truth,” he said. Although abstinence is a good option for some people, he added, it is not realistic for all people. Several other strategies have been scientifically proven to reduce HIV risk, including the consistent use of condoms. When prevention programs fail to provide all the scientific information available to youth, they are withholding vital life-saving information, he said.

In fact, when the message to youth is to be “abstinent until married,” a significant number of at-risk youth are marginalized, he added. Specifically, gay and lesbian youth, who have very limited access to legal marriage, may interpret the message as not applying to them.

Anderson, who is openly HIV positive himself, also addressed the need to provide comprehensive care to people living with HIV, and not just medications. He recalled his own youth when he was homeless and was injecting heroin. The notion that taking antiretroviral therapy would somehow change his life seemed remote. What he needed was support, housing, and food.

Treatment of HIV infection has become “completely medicalized,” he said. “We need a social response as well. We need business, faith-based, and other responses to this disease. Our social response to HIV/AIDS and our response to [Hurricane] Katrina were the same. Apparently, some people are not as important as others. This is an epidemic about human rights, and we cannot have some people written off.”

References
World Heath Organization. The World Health Report 2005. Available at: http://www.who.int/whr/en/. Accessed December 2, 2005.
Gebbie K. Care and prevention: conflict or complement. Program and abstracts of the Association of Nurses in AIDS Care 18th Annual Meeting; November 17-20, 2005; Orlando, Florida.
Wilson IB, Landon BE, Hirschhorn LR, et al. Quality of HIV care provided by nurse practitioners, physician assistants, and physicians. Ann Intern Med. 2005;143:729-736. Abstract
Anderson T, Summers T. The inside track on HIV/AIDS policy. Program and abstracts of the Association of Nurses in AIDS Care 18th Annual Meeting; November 17-20, 2005; Orlando, Florida.

Copyright © 2006 Medscape.

National Public Radio (WGBH Boston) February 2006

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