Challenges in pain management among persons with AIDS in a long-term-care facility

Opiate-resistant pain has been studied in cancer for many years; however, its existence in end-stage acquired immunodeficiency syndrome (AIDS) has captured little attention. This paper examines the existence, prevalence, and characteristics of opiate-resistant pain among persons with AIDS receiving end of life care at Bailey-Boushay House, an AIDS-skilled nursing facility in Seattle, WA.

A retrospective chart review of consecutive discharges during 1996 to 1999 examined patients near the end of life with advanced AIDS who had used opioid patient-controlled analgesia (PCA) for pain relief. The patients were divided into a control group (n = 97) and an opiate-resistant group (ongoing, severe pain with morphine use of greater than 100 mg/hr in an alert patient with no response to doubling doses, n = 12). The two groups were compared on the basis of current diagnosis of depression, history of injection drug abuse, peripheral neuropathy, or central nervous system involvement.

Out of a total of 740 AIDS admissions during the study period, 226 patients were admitted for terminal care. Of these, 109 utilized a PCA for pain control for at least a day before death. Twelve (1.6% of all admissions, 5% of terminal patients, 11% of PCA users) experienced opiate-resistant pain. No associations with injection drug abuse, central nervous system involvement, depression, or peripheral neuropathy were found.

Opiate-resistant pain is rare and can be relieved by aggressive use of adjuvants for pain treatment. There are no distinguishing characteristics that are predictive of this pain syndrome among AIDS patients near the end of life. The recognition of,prompt attention to, opiate-resistant pain remains a challenge for medical providers.