Pain Management Training: A Cognitive-Behavioral Approach to Treating HIV-Related Peripheral Neuropathy

Article excerpt

Approximately 1-2 million Americans are estimated to be infected with the human immunodeficiency virus (HIV). Peripheral neuropathic pain in ambulatory patients with HIV is prevalent and associated with significant psychological distress, social-vocational impairment and diminished quality of life. Alternatives to analgesics are needed for a variety of reasons including the fact that analgesics alone are not always successful in treating pain and many patients have fears regarding side effects, addiction, and tolerance. Pain Management Training (PMT), a manualized treatment developed by the authors, is designed to target HIV-related peripheral neuropathic pain and its related distressing symptoms. PMT employs a cognitive-behavioral approach to pain and suffering, with the primary goal of increasing the patient's sense of control and self-efficacy over the pain experience. This purpose of this paper is to describe, in detail, the structure of PMT utilizing patient examples to illustrate the approach.

The diagnosis of human immunodeficiency virus (HIV) infection and the impact it carries can be devastating. Living with HIV creates immensely difficult psychological challenges as the patient faces adapting to a severe life-threatening disease with its potential physical and neurological deterioration. Peripheral neuropathic pain is one of the many physical problems facing individuals with HIV infection. The syndrome is prevalent and associated with significant psychological and functional impairment (Breitbart, 1990; Breitbartet al., 1994; Lebovits et al,, 1989; McCormack et al., 1993; O'Neill & Sherrard, 1993; Rosenfeld et al., 1994; Singer et al., 1993). HIV-related peripheral neuropathy affects up to 30% of people with AIDS and is often characterized by sensations of burning, numbness, or pins and needles in the feet and hands (Cornblath & Me Arthur, 1988; Levy et al., 1985; Parry, 1988; Snider et al., 1983). Painful neuropathy can be caused by numerous other medical conditions (e.g., diabetes, post-herpetic neuralgia, alcohol, nutritional deficiencies, toxins) and by HIV-related therapies including antiviral drugs (e.g., ddl and ddC), chemotherapy agents for Kaposi's sarcoma (vincristine), phenytoin, and isoniazid, as well as by HIV itself (Lefkowitz & Breitbart, 1992; O'Neill & Sherrard, 1993).

Researchers have found that pain is a frequently cited negative influence on the quality of life in cancer patients, yet few studies have examined this relationship in HIV/AIDS. McCormick et al. (1993) found that more than half of 82 patients with HIV disease reported that pain interfered with their enjoyment of life, mood, relations with others, and abilities to work, sleep and walk. Similar findings have been reported in 71 persons with AIDS (Hoyt et al., 1994). Patients with HIV infection who had more physical symptoms were also more depressed, anxious, and had greater existential distress (Linn et al., 1993). Pain in cancer also compromises the quality of life of family caregivers, who sometimes wish for the patient's death to relieve the pain and suffering they are observing (Ferrell et al., 1991).

Depression, weakness and fatigue often accompany pain. In a pilot study of pain in ambulatory HIV- infected individuals, Breitbart et al. (1991) found depression and pain were highly correlated, and that patients with pain were twice as likely to report suicidal ideation (40%) as those without pain (20%). Patients with pain were also more functionally impaired. Such functional impairment was highly correlated to levels of pain intensity and depression. Those who felt that pain represented a threat to their health reported more intense pain than those who did not see pain as a threat. Patients with pain were more likely to be unemployed or disabled and reported less social support.

TREATMENT APPROACHES TO PAIN IN AIDS

Medical approaches to pain management in HIV/AIDS rely on analgesic medications with or without adjuvant antidepressant pharmacotherapy. …