Patient-related barriers to pain management in ambulatory AIDS patients

HIV-associated neuropathic pain: epidemiology, pathophysiology and management

Peripheral neuropathy is associated with numerous systemic illnesses including HIV infection. Neuropathic pain constitutes approximately 25-50% of all pain clinic visits. Distal symmetrical polyneuropathy (DSP) is the most common form of peripheral neuropathy in individuals with HIV infection. DSP is distinguished from other forms of neuropathy on the basis of history and neurological examination. The pain associated with DSP can be debilitating. Therefore, it is important to diagnose HIV-associated DSP properly and treat the neuropathic pain in order to improve quality of life. We review the clinical manifestations, epidemiology, pathophysiology and management strategies for HIV-associated DSP.

Working Through the Pain

OBJECTIVES

A large percentage of employees experience persistent pain while at work. This situation can become costly to employers with large amounts of lost production-time, absenteeism, and long-term disability. The link or transition between working through (ignoring) pain and disabling pain is unknown. This paper presents the results of a controlled study examining the impact of persistent pain on performance in a working population. Benefits of early detection are discussed.

METHODS

This was a controlled, repeated measures study using 3 types of measures: questionnaires (pain, pain anxiety, daily memory, and attention mistakes); actigraphic monitoring to assure the absence of sleep deprivation; and the Performance Assessment Battery, a computer-based series of tests. Participants were studied during 3 time periods (9:00 AM, 3:00 PM, and 9:00 PM).

RESULTS

Forty participants (20 pain, 20 controls) were studied. For all tasks, pain participants were slower than controls with significant findings on 2 tasks and less accurate with significant differences on 1 task.

DISCUSSION

Unlike other studies that either induced pain or used persons with complex pain conditions, this study used participants with a low level of pain intensity and had a majority still engaged in full-time employment. Our results found that people with persistent low-level pain demonstrate a reduction in performance compared with controls. Our study revealed that using a sensitive tool to detect minor performance deficits could indicate pain interference. The early detection of pain interference would provide an opportunity for prevention programs to have a pre-emptive effect on work-related musculoskeletal disorders.

Access and equity in HIV/AIDS palliative care: a review of the evidence and responses

The high prevalence of pain and other symptoms throughout the HIV disease trajectory, the need for management of side effects related to antiretroviral therapy, the continuing incidence of cancers and new emerging co-morbidities as a result of extended life expectancy under new therapeutic regimes, and the ongoing need for terminal care all prove the curative versus palliative dichotomy to be inappropriate. Although there is evidence for both need and effectiveness of palliative care in HIV patient care, access is often poor and care less than optimal. This review aimed to identify evidence of barriers and inequalities in HIV palliative care in order to inform policy and service development. Biomedical databases were searched using a specific strategy, and evidence extracted into the barrier and inequity categories of patient, clinician, service and disease factors. A model of the barriers and inequalities is presented from the evidence. Recommendations are made from the evidence for promoting access and outcomes through integrated palliative care from diagnosis to end-of-life, alongside antiretroviral therapy when initiated. Service responses that have attempted to increase access to palliative care are presented.

Patient-related barriers to pain management: the Icelandic Barriers Questionnaire II

The Barriers Questionnaire-II (BQ-II) is used to evaluate eight attitudinal barriers to cancer pain management. The purpose of this study was to evaluate the psychometric properties of the Icelandic BQ-II (IBQ-II). Icelandic adults (n=244) completed the IBQ-II, the Brief-Pain-Inventory, and demographic questions. Half the responders were male (52%), and 42.8% had pain on the day of data collection. Participants had a mean (SD) age of 34.73 (11.78) years and education of 15.08 (3.69) years. Factor analysis of the IBQ-II supported three factors. The alpha was 0.90. The mean (SD) IBQ-II total score was 2.32 (0.78), on a scale of 0 to 5, with higher scores indicating stronger barriers. IBQ-II total scores were inversely related to education (r=-0.21; P<0.01), and positively related to least pain (r=0.24; P<0.05), average pain (r=0.23; P<0.05), and pain interference with life activities (r=0.22; P<0.05) for those who had pain. There is support for reliability, validity, and feasibility of the IBQ-II.

Validity of the brief pain inventory for use in documenting the outcomes of patients with noncancer pain

OBJECTIVES

The Brief Pain Inventory (BPI) is a short, self-administered questionnaire that was developed for use in cancer patients. While most empirical research with the BPI has been in pain of that etiology, the questionnaire is increasingly evident in published studies of patients with non-cancer pain. The current research addresses the need for formal evaluation of the reliability and validity of the BPI for use in non-cancer pain patients.

METHODS

Approximately 250 patients with arthritis or low back pain (LBP) self-administered a number of generic and condition-specific health status measures (including the BPI) in the clinic of their primary care provider at 2 time points: the initial clinic visit and the first visit following treatment.

RESULTS

The reliability of BPI data collected from non-cancer pain patients was comparable to that reported in the literature for cancer patients and sufficient for group-level analyses (coefficient alphas were greater than 0.70). The factor structure of the BPI was replicated in this sample and the relationship of the BPI to generic measures of pain was strong. The BPI exhibited similar relationships to general and condition-specific measures of health as did a generic pain scale (SF-36 Bodily Pain). Finally, the BPI discriminated among levels of condition severity and was sensitive to change in condition over time in arthritis and LBP patients.

DISCUSSION

Results support the validity of the BPI as a measure of pain in patients without cancer and, in particular, as a measure of pain for arthritis and LBP patients.

Barriers to caregiver administration of pain medication in hospice care

Barriers to adequate pain management in hospice and palliative care settings are an important area of investigation. In this study, a Caregiver Pain Medicine Questionnaire (CPMQ) was developed and psychometrically tested. The CPMQ is a 22-item self-report instrument that measures concern about reporting pain, concern about administering analgesics, and difficulty administering analgesics. One hundred fifty-one caregivers of patients admitted to three Chicagoland hospice agencies participated; these individuals were family members, hired caregivers in the home, or staff nurses in skilled care facilities. While only a small percentage of the caregivers expressed concern about communicating information about the patient's pain, more than a quarter were concerned about addiction, tolerance, and side effects from medications. A fourth of the caregivers had difficulty administering medications because of fear of doing something wrong and difficulty deciding which or what amount of medications to give. Male caregivers and hired caregivers had greater concerns, both about reporting information about the patient's pain and administering medications. Greater concerns were also evident among less educated caregivers, caregivers who worked in blue-collar jobs, and caregivers who were homemakers or retired. Concerns of caregivers in the home were significantly greater than staff nurse caregivers in skilled care facilities only in the belief that pain could not be controlled and concern about addiction. Caregivers who had greater concern about addiction and tolerance, and more difficulty administering medications, rated the patient's pain as less completely controlled. These findings remind hospice staff members of the importance of assessing specific caregiver concerns about medication administration and devising appropriate strategies to address them.

Realizing Engel's vision: psychosomatic medicine and the education of physician-healers

Many of the exciting conceptual and scientific advances in the field of psychosomatic medicine are not taught in United States medical schools. This article, based on the Presidential Address given at the Annual Meeting of the American Psychosomatic Society in Phoenix, Arizona in March 2003, reviews the rationale for integrating psychosomatic medicine into medical curricula, identifies educational needs, proposes a core curriculum, and suggests how American Psychosomatic Society members can be instrumental in curriculum development and implementation.

Interventions to overcome clinician- and patient-related barriers to pain management

Barriers to optimal cancer pain management exist among clinicians and patients, and within the healthcare system. This article focuses on clinician- and patient-related barriers and the interventions that have been tested to overcome them. Although individual studies have shown promise in improving patient outcomes, overall the studies do not provide clear answers to guide practice. Further research is required to determine what components of educational interventions are necessary to facilitate optimal cancer pain management.

Factors associated with willingness to try different pain treatments for pain after a spinal cord injury

OBJECTIVE

To develop and establish the psychometric properties of a pain treatment willingness scale and identify factors associated with willingness to try specific pain treatments for spinal cord injury (SCI)-related pain.

DESIGN

As part of a larger study, a questionnaire was designed to assess willingness to use various pain medications and other types of pain treatments. This questionnaire, which included measures of pain severity, pain interference, mood, hope, and current use of pain treatments, was completed by persons with SCI recruited through the mail or in person.

SUBJECTS

One hundred fifteen persons completed the questionnaire (35% response rate). Seventy-two percent of the participants were men, mean age was 49.1 years, and average time elapsed since injury was 8 years.

RESULTS

Factor analysis indicated two factors-willingness to use opioids and willingness to use nonpharmacological treatment (i.e., physical therapy, relaxation methods and stress management, and alternative medicine). Internal consistency and convergent and divergent validity were established. Persons experiencing SCI-related pain were more willing to use pain treatments than those without current pain, and those who were currently using opioids reported greater willingness to use that treatment. Persons who reported SCI-related pain were more willing to use nonpharmacological treatments than opioid medications. Finally, participants demonstrated different degrees of willingness to use an opioid medication based on its name (i.e., "narcotic," "codeine," "morphine," "methadone").

CONCLUSIONS

Willingness to use a specific pain treatment may be a key factor mediating the behavior of using that specific treatment. Assessment of patient attitudes toward various treatments options, particularly regarding opioid medications, is warranted to optimize treatment adherence. Once the factors that determine these attitudes are identified, interventions to increase willingness to use nonpharmacological or opioid treatments can be designed and evaluated.

Patient-related barriers to fatigue communication: initial validation of the fatigue management barriers questionnaire

Fatigue is a highly prevalent and distressing symptom of cancer and its treatment. However, cancer patients often fail to communicate with their oncologists about fatigue. In this study, we attempted to identify the patient-related barriers to communication about fatigue, as cited by patients. Two hundred patients were sampled across the Community Cancer Care, Inc. (CCC) network of Indiana using the Cancer Behavior Inventory-Brief scale (CBI-B), the Zung Self-Rating Depression Scale (ZSDS), the Functional Assessment of Cancer Inventory-Fatigue scale (FACT-F), and the Fatigue Management Barriers Questionnaire (FMBQ), a questionnaire devised by experts in the field of cancer-related fatigue. There were no significant correlations between the instrument scores and demographic variables. Scores on the instruments did not differ significantly based on whether the patient was from a rural or urban site. One hundred thirty-two patients (66%) reported that they had never spoken to their doctor about fatigue. The most frequently reported reasons for this lack of patient communication about fatigue included the doctor's failure to offer interventions (47%), patients' lack of awareness of effective treatments for fatigue (43%), a desire on the patient's part to treat fatigue without medications (40%), and not wanting to complain to the doctor (28%). Patients reported that medical staff offered a mean of 11.63 recommendations for dealing with fatigue. The FMBQ was found to correlate significantly with self-efficacy (CBI-B, r = -0.20, P < 0.01) and correlate weakly with the number of recommendations made (r = -0.15, P < 0.05). The FMBQ was noted to have acceptable internal consistency (alpha = 0.88) and validity and may prove to be a useful instrument for understanding why patients do not communicate about fatigue. Multiple barriers contribute to why cancer patients do not comment about fatigue but may be overcome if physicians screen and assess for this symptom.

Patient-related barriers to pain management: the Barriers Questionnaire II (BQ-II)

Patients' beliefs can act as barriers to optimal management of cancer pain. The Barriers Questionnaire (BQ) is a tool used to evaluate such barriers. Here, the BQ has been revised to reflect changes in pain management practices, resulting in the Barriers Questionnaire-II (BQ-II), a 27-item, self report instrument. This paper presents the results from two studies where the psychometric properties of the BQ-II were evaluated. In the first study, the responses of 27 nurses trained in pain management were compared to responses of a convenience sample of 12 patients with cancer. The results indicated that patients with cancer had higher mean scores on the BQ-II than did nurses trained in pain management. In the second study, a convenience sample of 172 patients with cancer responded to the BQ-II and a set of pain and quality of life (QOL) measures. A factor analysis supported four factors. Factor one, physiological effects, consists of 12 items addressing the beliefs that side effects of analgesics are inevitable and unmanageable, concerns about tolerance, and concerns about not being able to monitor changes in one's body when taking strong pain medications. Factor two, Fatalism, consists of three items addressing fatalistic beliefs about cancer pain and its management. Factor three, Communication, consists of six items addressing the concern that reports of pain distract the physician from treating the underlying disease, and the belief that 'good' patients do not complain of pain. The fourth and final factor, harmful effects, consists of six items addressing fear of becoming addicted to pain medication and the belief that pain medications harm the immune system. The BQ-II total had an internal consistency of 0.89, and alpha for the subscales ranged from 0.75 to 0.85. Mean (SD) scores on the total scale was 1.52 (0.73). BQ-II scores were related to measures of pain intensity and duration, mood, and QOL. Patients who used adequate analgesics for their levels of pain had lower scores on the BQ-II than did patients who used inadequate analgesics. The BQ-II is a reliable and valid measure of patient-related barriers to cancer pain management.

The impact of PTSD on pain experience in persons with HIV/AIDS

Pain is a common and pervasive symptom for persons infected with the human immunodeficiency virus (HIV). Individuals with persistent pain are known to be at heightened risk for posttraumatic stress disorder (PTSD), an anxiety disorder that manifests itself following exposure to a traumatic event. Moreover, research suggests that patients with persistent pain who develop PTSD often experience greater pain intensity and pain-related disability than those who do not develop PTSD. The purpose of this study was to assess the relation of PTSD to pain intensity and pain-related interference in HIV-infected persons suffering from persistent pain. Study participants included 145 ambulatory persons living with HIV/AIDS (PWHAs) who were enrolled in a randomized clinical trial assessing the impact of a pain communication intervention. Participants completed a series of self-report measures including the Stressful Life Events Checklist (SLE), the Posttraumatic Stress Disorder Checklist-Civilian (PCL-C), the Mental Health Inventory (MHI), and the Brief Pain Inventory (BPI). On average, participants reported being exposed to 6.3 different types of trauma over the course of their lifetime, of which receiving an HIV diagnosis was rated as being among the most stressful. Over half (53.8%) merited a PTSD diagnosis according to the PCL-C. Those with PTSD reported having significantly higher pain intensity and greater pain-related interference in performance of daily activities (i.e., working, sleeping, walking ability and general activity), and affect (i.e., mood, relations with other people, enjoyment of life) over time than those who did not meet the diagnostic criteria. Possible explanations for these findings are discussed along with implications for clinical care.

The prevalence of pain in pediatric human immunodeficiency virus/acquired immunodeficiency syndrome as reported by participants in the Pediatric Late Outcomes Study (PACTG 219)

OBJECTIVES

As the life expectancy of children with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) increases, quality-of-life outcomes are of increasing concern. The prevalence of pain in adults with AIDS ranges from 40% to 60%, depending on stage of illness. There is limited research concerning pain in HIV-infected children and youth.

DESIGN

The General Health Assessment for Children was administered to caregivers of HIV-infected children and youth enrolled in the Pediatric Late Outcomes Study (PACTG 219), a prospective cohort study. Pain is assessed over the previous month with 7 questions. For the purpose of this analysis, we defined pain as the presence of pain of at least moderate intensity. Participants were observed from January 1, 1996, to December 31, 1999.

RESULTS

A total of 985 HIV-positive participants had a baseline pain evaluation in 1995. The prevalence of pain remained relatively constant during each year of observation, averaging 20%. Lower CD4+ T-lymphocyte percentage, female gender, and an HIV/AIDS-related diagnosis were highly associated with an increased risk of reported pain. Pain was also independently associated with increased risk of death. After adjusting for CD4 percentage, use of combination therapy including protease inhibitors, comorbid diagnoses, and other sociodemographic characteristics, individuals reporting pain were over 5 times more likely to die than those not reporting pain (hazard ratio = 5.07; 95% confidence interval = 3.23-7.95).

CONCLUSIONS

Pain is a frequently encountered symptom in children and youth with HIV disease and is also associated with increased mortality. These findings emphasize the importance of pain management in this population.

Obtaining informed consent for clinical pain research: patients' concerns and information needs

Investigators who conduct clinical pain research are required to obtain voluntary informed consent from patients. However, little is known about what information patients expect when they decide whether to enroll in such studies. It is important that investigators understand these information needs so they can effectively and clearly describe the research risks and potential benefits that matter to potential subjects. By understanding these needs for information, investigators may also be better able to anticipate patients' concerns and to recruit subjects more efficiently. This study was designed to define information needs that patients have when they decide whether to participate in clinical pain research. This paper describes these information needs, and identifies clinical and demographic variables associated with specific needs.

Variations in perceived pain associated with emotional distress and social identity in AIDS

This article examines associations between self-perceptions of pain and associated pain distress to gender, ethnicity and religion, health care, health status, and emotional distress. Data were collected through interviews collected in participants' homes. Participants were 151 adults with diagnoses of advanced human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS). Time since diagnosis, health status, health care, ethnicity, gender, religion, and emotional distress were examined as mediators of pain symptoms, pain distress, and anticipatory pain. Almost all participants (83%) reported AIDS-related pain in the last 3 months. Unexpectedly, pain was negatively associated with time since diagnosis with AIDS. Pain symptoms and pain distress tended to vary by ethnicity, with Latinos expressing more symptoms and pain distress than African Americans. Anticipatory pain varied significantly by gender and religion, with women, Catholics, and Protestants anticipating pain more than men and non-Christians. Anxiety, depression, and general emotional distress were significantly associated with pain symptoms (r = 0.44, 0.33, 0.47) and pain distress (r = 0.34, 0.31, 0.34). Health status and health care were unrelated to pain symptoms, pain distress, or anticipatory pain. Pain is a common problem for people living with HIV/AIDS. Self-reported pain is associated with cultural factors and changes in illness status. Clinicians' attention to patients' emotional distress, depression, and anxiety may assist in interventions for pain management.

Barriers to the analgesic management of cancer pain: a comparison of attitudes of Taiwanese patients and their family caregivers

The purposes of this study were as follows: (1) to compare the attitudes which were considered to be barriers to cancer pain management held by Taiwanese cancer patients and their family caregivers; (2) to determine if these barriers were related to patient hesitancy to take analgesics and/or family caregiver hesitancy to administer analgesics: and (3) to determine if attitudinal barriers by patients and/or family caregivers predicted the adequacy of analgesics that patients used. A total of 159 dyads of oncology outpatients and their primary family caregivers (n = 318) participated in this study. The instruments completed by patients consisted of the Barriers Questionnaire-Taiwan form, the Brief Pain Inventory-Chinese version, the ECOG performance status scale, and a demographic and medication questionnaire. Family caregivers completed the Barriers Questionnaire-Taiwan form and a demographic questionnaire. The data in this study revealed that patients and family caregivers had attitudinal barriers to pain management and these concerns were positively correlated between patients and caregivers. Patient concerns were related to their hesitancy to take analgesics and, similarly, caregiver concerns were related to their hesitancy to administer analgesics. Most importantly, patient and caregiver concerns had an impact on how the patients' pain was managed: (1) patients and their family caregivers with higher levels of concerns used inadequate analgesics as compared to patients using adequate analgesics; (2) family caregiver barriers (concerns) were a significant predictor of inadequate management of cancer pain (after controlling for demographic and disease variables). Therefore, educational interventions for overcoming these barriers for both patients and their family caregivers may have potential for improving the management of cancer pain in Taiwan.

HIV/AIDS-related Pain as a Chronic Pain Condition: Implications of a Biopsychosocial Model for Comprehensive Assessment and Effective Management

This paper reviews the current literature focusing on pain in HIV/AIDS, including prevalence, pathophysiology, substance abuse, treatment issues, and psychosocial contributions. In light of the high prevalence of pain among individuals with HIV/AIDS, attention is paid to the negative psychosocial impacts of pain in this population and to psychosocial barriers to optimal HIV/AIDS-related pain treatment. The paper conceptualizes HIV/AIDS pain as chronic pain. Subsequently, a biopsychosocial model of chronic pain assessment and treatment is applied. A multidimensional framework is presented for appropriate assessment and treatment of HIV/AIDS patients with pain, and specific recommendations and guidelines are offered for assessment and multimodal treatment of HIV/AIDS-related pain informed by the model.

Complementary and alternative therapies to manage HIV-related symptoms

Persons with HIV infection report substantial use of complementary and alternative medical (CAM) therapies for symptom management. Anecdotal reports from patients indicate that CAM approaches are helpful; however, there is limited scientific information on the safety and efficacy of these therapies in the HIV population. The purpose of this review is to critically appraise the scientific evidence for selected CAM therapies that are used by HIV-infected persons to manage three common symptoms: nutritional alterations, pain, and depression.

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

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 about 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.

Clinicians' perceptions of barriers to pain management in AIDS

A growing body of literature has demonstrated the widespread undertreatment of pain in patients with AIDS. While clinician-related barriers to cancer pain management have been studied, to date there has been no systematic attempt to survey clinician-related barriers to the management of pain in patients with AIDS. We surveyed AIDS health care providers' attitudes towards pain management, as well as their perception of the barriers to adequate pain management in patients with HIV disease. Subjects were 492 AIDS care providers attending continuing education symposia on the clinical management of pain in patients with AIDS in 5 major U.S. cities (New York, Philadelphia, San Francisco, Los Angeles, and Miami). Results indicated that the most frequently endorsed barriers to pain management were those regarding lack of knowledge about pain management or access to pain management experts, and concerns regarding potential substance abuse or addiction. Experience in the management of pain in patients with AIDS was inversely correlated with endorsement of barriers related to pain management expertise and concern regarding potential substance abuse. More experienced clinicians were significantly less likely to cite these factors as barriers to pain management. More knowledgeable respondents were significantly more likely to identify barriers to pain management and individuals with more conservative attitudes towards pain management were significantly more likely to cite substance abuse issues or medical concerns as barriers to pain management.