Assessing and managing pain in AIDS care: The patient perspective

Assessing and Managing Pain in AIDS Care: The Patient Perspective William L. Hoizemer, RN, Phl), FAAN, Suzanne B. Henry, RN, DNSc, FAAN, and Cheryl A. Reilly, RN, MS Although the prevalence and complexity of pain management in HIV/AIDS has been described in the literature, little is known about the management of pain from the patient perspective. This study used a set of standardized instruments, a medication chart audit, and a semistructured interview to elicit patients' selfreports of pain and patients" perceptions of nursing and self-care pain management strategies and examined potential physiological and psychosocial correlates of pain. The sample of 249 AIDS patients from three types of care settings (hospital, home care, skilled nursing facility) reported a modest overall current pain intensity (M = .14, range = 0-1). "They reported experiencing pain in all body parts as measured by a body outline and characterized their pain with an average of 8.96 wordsfrom a list of 67 words. A lowerpain rating was correlated with higher ratings on quality of life and perceived psychological support. An audit of the medication record revealed that the study sample received thefollowing medications: narcotic analgesics (49%), nonnarcotic analgesics (4 7%), and antidepressants (22 %). In a semistructured interview, medications were rated as effective by 80% of patients experiencing pain who stated that their health care providers included pain medications as part of the patient's pain management plan. Patients reported few nonpharmacologic self-care or health care provider interventions to manage their pain, and the effectiveness ratings of the interventions demonstrated wide variability. The study findings suggest that because pain was related to quality of life ratings and the pain management strategies reported by patients were not completely effective, further work is needed to examine pain management strategies that incorporate both pharmacologic and nonpharma-

cologic interventions with particular attention to selfcare interventions. In addition, the data suggest that nursing assessments shouM include questions aimed at eliciting potentially harmful (e.g., street drugs, selfprescribed medications) strategies that patients may be using to manage their pain.

Key words: Pain, HIV/AIDS, nursing care T h e nursing management of pain in people with AIDS is complex and challenging. The purpose of this study was to describe AIDS patients' serf-reports of pain intensity, quality, and location and to explore potential correlates of pain. Brief interviews with patients elicited their perceptions of nursing pain management strategies. Two recent studies reported in the nursing literature confirm the prevalence of pain for HIV/AIDS clients and the complexity of managing HIV-related pain. Hurley and Ungvarski (1994) reviewed charts of 244 HIVIAIDS clients receiving honie-care services, and pain was reported on admission in 42.2% of the sample. In addition, they noted other painful conditions such as skin lesions, oral lesions, and dyspnea, suggesting that it is unclear ff their 42.2% rate underestimated the prevalence of pain. In their study of four domains of nursing practice, Baigis-Smith, Gordon, McGuire, and Nanda (1995) sampled 386 HIV/AIDS patients in four settings, includinghospital, outpatient, William L Holzemer is a professor in and the chair of the

School of Nursing at the Universityof California, San Francisco; Suzanne B. Henry is an associate professor in the School of Nursing at the Universityof California, San Francisco; CherylA. Reilly is a doctoral candidate in the School of Nursing at the Universityof California, San Francisco.

JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 9, No. 1, January/FebruatT 1998, 22-30 Copyright 9 1998 Association of Nurses in AIDS Care

Holzemeret al. / The PatientPerspective 23 long-term care, and home, and 15% (n = 58) of the sample reported pain. Several studies have documented the relationship between pain and service utilization for HIV/AIDS patients. Lewis and Warfield (1990) reported that "pain is the second most common reason for hospitalization of AIDS patients" (p. 51). Fleishman, Hsia, and Hellinger (.1994) reported that experienced pain was associated with increased service use over and above the patient's particular disease stage in a sample of 1,449 participants from ambulatory visits, inpatient admissions, and emergency room visits. In cancer patients, Grant, Ferrell, Rivera, and Lee (1995) linked readmission to the hospital with uncontrolled pain. Pain is a problem for hospitalized patients and for those in ambulatory care and terminal care. McCormick, Li, Zarowny, and Singer (1993) reported that of a sample of 148 HIV positive ambulatory patients, 55% (n = 82) experienced pain due to their disease in the month prior to the survey. Approximately 65% reported that pain interfered with their activities of daily living, and 40% reported they were not receiving any treatment for their pain. Anand, Carmosino, and Glatt (1994) reported that chronic refractory severe pain "is a common and often neglected problem" in HIV/AIDS terminal care. Of the 24 patients they followed, 50% were injection drug users. They reported that effective pain control can be achieved using around-the-clock opioid analgesia in terminal HIVinfected patients with severe, chronic, and refractory pain, even if the patients are injection drug users.

Description of Pain Several classification systems have been proposed for HIV/AiDS-related pain. Breitbart and Patt (1994) proposed three categories of pain syndromes: (a) pain related to HIV/AIDS, including HIV neuropathy, HIV myelopathy, Kaposi sarcoma (KS), secondary infections (intestines, skin), organomegaly, arthritis/vasculitis, and myopathy myositis; (b) pain related to HIWAIDS therapy, including antiretrovirals and antivirals, antimycobacterials, PCP prophylaxis, chemotherapy, radiation, surgery, and procedures such as hronchoscopy and biopsies; and (c) pain unrelated to AIDS, including conditions such as disc disease or diabetic neuropathy. Schofferman (1988) proposed two classifications of pain: pain due to a potentially reversible cause (e.g.,

infection) that will potentially resolve and pain whose cause is not directly treatable, either because maximum treatment has already been provided or because no direct treatment is currently available. He reported that 53% of home-care AIDS patients (n = 100) in San Francisco had pain that was not directly treatable. The etiology and location of pain in people with HIV disease has been reported by numerous authors. Lewis and Warfield (1990) reported on four etiologies of pain including neurologic, rheumatologic, pulmonary, and gastrointestinal pathology. Singer et al. (1993) reported pain symptoms related to the nervous system, and the most common were headaches, herpes simplex, painful peripheral neuropathy, back pain, herpes zoster, AZT-induced headaches, throat pain, and arthralgia. Although pain was present at all disease stages, pain was reportedly related to severity of illness, increased disability, and depression. Newshan and Wainapel (1993) reported on types of pain for 100 AIDS patients, which included some drug users. The types of pain reported included abdominal (26%), neuropathic (24%), esophagitis (17%), headache (17%), cutaneous KS (12%), back (5%), and bone and joint (5%). Keithley and Kohn (1990) reported on oral and esophageal pain, which is often due to candidiasis (thrush), herpetic lesions, KS lesions, or hairy leukoplakia, and the impact of pain on managing nutritional problems in people with AIDS. Reilly, Holzemer, Henry, Slaughter, and Portillo (in press) reported on pain-related symptoms in a sample of 207 hospitalized AIDS patients. Pain-related symptoms included headaches (51%), thrush (42%), painful joints (38%), muscle aches (37%), numbness/tingling (37%), abdominal pain (33%), chest pain (20%), and KS lesions (19%). Studies have focused on different body locations of pain. For example, Thuluvath, Cormolly, Forbes, and Gazzard (1991) reported on abdominal pain. Lebovits et al. (1989) reviewed the prevalence of pain and reported that chest pain was the most prevalent, which was related to PCP. Eldridge, Severance-Lossin, Nicholas, and Leuner (1994) conducted a retrospective chart review for 50 AIDS patients and reported on the prevalence and characteristics of pain. Forty-eight percent reported no pain, 22% reported lower extremity pain, 16% back pain, 8% abdominal pain, 8% head pain, and 6% coccyx/rectum pain.

24 JANAC Vol. 9, No. 1, January/February 1998

Two studies have also reported that health care providers and HIV patients do not report their painrelated symptoms in a congruent fashion. Butters, Higginson, George, and McCarthy (1993) studied 19 patients receiving palliative care; patients reported significantly more pain than did health care providers or caregivers. Reilly et al. (in press) reported similar findings in 207 pairs of hospitalized AIDS patients and their nurses. Several studies have explored pain in HIV/AIDS patients who are injection drug users. Selwin and O'Connor (1992) discussed pain management for substance users and their potential difficulty with drugseeking behavior and potential interactions with methadone. Hoyt, Nokes, Newshan, Staats, and Thorn (1994) explored pain perceptions in a sample of substance users and nonsubstance users (n = 71) with AIDS. They reported no difference in pain perception between the two groups. Pain has been associated with stage of disease (Wu et al., 1991), changes in health status (Revicki, Wu, & Murray, 1995), and as part of women's experience of living with HIV (Stevens, 1996). These studies have documented the location, intensity, and distressfulness of pain associated with H/V disease.

Management of Pain Studies consistently document the tmdertreatment of pain in general, and HIV disease is no exception. Lebovits and Lefkowitz (1990) wrote that "perhaps the most overlooked, yet central pain management principle is to review treatment options with patients" (p. 3). They suggested that pain management was most effective when patients are put on a fixed dose and at a fixed time schedule to control pain. Cleary et al. (1992) used patient reports to evaluate quality of care for AIDS patients (n = 50) and reported that 25% of patients on scatter units reported they received too little pain medication versus 8% on the AIDS-dedicated unit. Lebovits, Smith, Maignan, and Lefkowitz (1994) audited 139 charts; 61% had at least one note of nonprocedural pain. They concluded, although pain is a prevalent problem in hospitalized AIDS patients, narcotics, as well as antide-

pressants, appear to be underutilized. It is suggested that medical education regarding pain management in AIDS patients is an important first step in a more aggressive approach. (p. 156) Abrams et al. (1994) demonstrated that pain is a significant side effect of HIV medications and noted that "in contrast to pain in cancer, pain in HIV disease will more commonly have an underlying treatable cause" (p. 4). They reported that "a major factor determining the undertreatment of pain is inadequate assessment" (p. 80). From an oncology nursing perspective, Ferrell, Eberts, McCaffery, and Grant (1991) observed that pain management is linked to decision making and that nurses play an important role in effective pain management. Ferrell (1995) reviewed 10 years of research and linked pain assessment and management in the oncology population to quality of life. In summary, the body of literature reviewed indicates similarities between pain assessment and management in HIV/AIDS and other diseases (e.g., cancer) in three areas: (a) pain is a prevalent problem, (b) health care providers consistently underestimate the intensity of patients' pain, and (c) pain is frequently undertreated. However, differences in the study findings also exist. There is some evidence that HIVrelated pain is more likely to be due to an underlying treatable cause than cancer pain, thus different pain management strategies may be indicated. Also, little is known about the self-care strategies used by those with HIV to manage their pain. Given the complexity of the nature of pain in HIV/AIDS, research on pain assessment and management as a nursing care strategy has the potential to enhance quality of life for people living with HIV disease. Subsequently, in addition to describing pain, the current study examines the correlations between pain and symptom status, functional status, and quality of life and describes pain management strategies (health care provider and self-care) from the perspective of the patient's self-report.

Method Study Questions The three study questions were the following:

Holzemeret al. / The Patient Perspective 25 1. What is the location, intensity, and quality of pain for people living with AIDS? 2. Is pain correlated with symptoms, functional status, and quality of life? 3. w h a t pain-related nursing and self-care activities are reported by patients?

Setting/Sample Participants (N = 249) in this study were a subsampie of those subjects in the study, Quality of Nursing Care for People with AIDS (NR02215). They were recruited from three area hospitals (58.2%; n = 146), one home-care agency (25.9%; n = 65), and one skilled nursing care facility (15.1%; n = 38). All patients and nurses consented to participate in this study, and permission to recruit subjects was received from each participating site as well as from the University of California, San Francisco. The average age of the sample was 39.3 years (SD = 8.7; range = 23-68); 88% (n = 219) were male and 12% (n = 30) were female. The ethnicity of the participants was as follows: White, 52.6% (n = 132); African American, 21.5% (n -- 54); Latino, 17.9% (n = 45); Asian/Pacific Islander, 5.6% (n = 14); and Native American, 2% (n = 5). The participants reported that 76.9% (n = 193) were on disability, and their insurance status was as follows: Medical (California's Medicaid), 54.2% (n = 136); private, 22.3% (n = 56); Medical and Medicare, 8% (n = 20); and none, 2.8% (n = 7). Only 30.3% (n = 76) of the participants lived alone. Approximately one third of the sample (30.3%; n = 76) reported current or past injection drug use. The participants reported they had been known HIV positive for an average of 35.6 months (SD = 23.4; range = 2-127 months) with an average CD4 count of 75mm 3 (SD = 100; range = 1-526). For the parent study, participants were followed for 6 months after their episode of care; however, 13.5% (n = 34) died after 3 months, and 21.9% (n = 55) died by 6 months. The AIDS-defining condition for this sample included (only those with greater than n = 5 are reported) the following: PeP, 24.3% (n = 61); KS, 8.4% (n = 21); thrush, 4% (n = 10); Cryptococcal meningitis, 3.2% (n = 8); Toxoplasmosis, 2.8% (n = 7); Cytomegalovirus (CMV), 2.0% (n = 5); other (less than n = 5), 33.9% (n = 85); and missing data, 19.1% (n = 48).

Several descriptive physiological variables important in HIV care were collected based on chart audit. The participants had an average temperature of 37.1 degrees Celsius. Sodium (M = 135) and potassium (M = 4.1) values were within normal limits. Their hematocrit (M = 31.0) and hemoglobin (M = 10.3) were below normal, suggesting that the participants were anemic.

Instruments All chart audit data were collected by a registered nurse research assistant. Nine instruments were used for data collection, including the following:

Demographic questionnaire. Demographic information was collected through a self-report questionnaire and chart audit. Patient status self-report. Patients rated their level of physical condition and psychological support on a 10-point, visual analogue scale, where 1 = very poor and 10 = excellent. Physiological markers. Achart audit was conducted to capture potentially relevant physiological variables, including vital signs, laboratory values, and x-ray findings. Medications. Achart audit was conducted to capture current medications. Pain management interview. A subset of participants was asked to respond to questions regarding their self-management of pain and their nurses' activities related to pain. These responses were content analyzed and counted. Adolescent and Pediatric Pain Tool (APPT). The APPT was used to measure perceptions of pain location (marking sections on a body outline), quality (selecting pain-related words), and intensity (marking a 10 cm scale). Four dimensions of the quality of pain were evaluated by having subjects select words that are commonly used to describe pain, including sensory (e.g., hurting, pounding, sharp, hot), affective (e.g., awful, killing, terrifying, sickening), evaluative (e.g., bad, terrible uncomfortable, never goes away), and temporal (e.g., steady, off and on, constant, always). Excellent validity and reliability estimates have been demonstrated on participants as old as 18 years of age (Savedra, Holzemer, Tesler, & Wilkie, 1993;

26 JANAC Vol. 9, No. 1, January/February 1998

Savedra, Tesler, Holzemer, & Brokaw, 1995). The scale was selected because of its extensive validation across ethnic groups and the reading level of the scale. The scale was found to be appropriate for and acceptable to the study sample in a small pilot study. HIV Symptom Check List. The HIV Symptom Check List is a 41-item checHist of HIV-related signs and symptoms. It is scaled on a 3-point severity scale (mild, moderate, and severe) and was developed based on a review of the literature and discussion with HIV clinicians (Reilly et al., in press). Reliability (Cronbach's alpha) of the total scale was 0.90. In this analysis, total number of symptoms selected was used as the variable. Quality Audit Marker (QAM). The QAM is a 10item scale completed by the nurse data collectors based on observations, interviews, and chart audit of the participant. It meaSures self, care (6 items), ambulation (2 items), and psychological distress (2 items). Adequate validity and reliability have been reported in a sample of 201 persons with AIDS (Holzemer, Henry, Stewart, & Janson-Bjerklie, 1993). Higher scores indicate better self-care, greater ambulation, and less psychological distress. Reliability alphas in this sampie were the following: self-care, ct = 0.89; ambulation, ot = 0.88; and psychological distress, 0t = 0.89. Health Status Questionnaire (HSQ). Wu et al. (1991) tailored the Medical Outcomes Study Short Form 36 (SF36) for people living with HIV disease and created a 30-item version. It measures 11 constructs scored on a scale from 1 to 100; the higher the score, the more positive the health status. Alpha reliability estimates in this sample were the following: cognitive function, o~ = 0.84; energy/fatigue, a = 0.78; health distress, o~ = 0.91; mental health, a = 0.86; physical function, 0c = 0.86; and role functioning, a -- 0.50. Single-item factors include quality of life, body pain, health transition, overall health, and social function; no alpha can be calculated for these singie-item scales. Wu et ai. (1991) reported extensively on the validity and reliability of the scale. The HSQ was collected only on hospitalized patients (n = 144) for two reasons. First, a pilot study in the nonhospital samples revealed a floor effect in subject responses. Second, the length of time to complete the instrument was determined to be too great for the respondents.

Data Analysis

Instruments were scored and descriptive statistics calculated. Appropriate tests of significance (e.g., Chisquare, t tests, and ANOVAs) were calculated to explore differences between gender, ethnic groups, injection drug use, site, and several dependent variables including pain location, quality, intensity, and quality of life. Alpha was set at 0.05. A stepwise multiple regression was conducted to explore predictors of body pain. Results

Participants reported a modest, current overall pain intensity mean score on a 10-cm scale of 0.14 (range = 0-1). However, they reported pain located in all parts of their body and evaluated their pain to have a higher quality of evaluative than sensory nature. Patients selected an average of 8.96 words from a list of 67 words to describe their pain and an average of 6.65 affected body parts from a total possible of 39 body parts (see Table 1 and Figure 1). Participants reported strong perceived psychological support and average physiological status. Patients were rated by nurse data collectors aS high oil their ability for self-care and ambulation and low on psychological distress as measured by the QAM. They reported an average of 17.94 (S/) = 9.86; range = 1-41 ) symptoms out of a potential 41. HSQ scores of 144 hospitalized patients were highest on cognition and lowest on role-functioning scales (see Table 2). Participants were taking an average of 6.08 medications, with a range from 0 to 14. The most frequently taken medications were narcotic analgesic (48.6%), nonnarcotic analgesic (46.6%), and bactrim/septra (45A%) (see Table 3). There were no significant differences related to gender, ethnic groups, injection drug users and nonusers, or clinical setting on any of the pain measures, including location, quality, and intensity. There were also no differences on quality of life scores or total symptoms reported. A stepwise multiple regression was performed to attempt to determine the predictors of overall body pain. For the 144 subjects with HSQ data, 16 variables were entered into the analysis, and five were signifi-

Holzemer et al. / The Patient Perspective 27 Table 1. Pain Location, Quality, and lntenMty as Measured by the Adolescent and Pediatric Pain Tool (APPT) (N = 249) n

Pain location (based on those areas of the body outline that were identified by 20% or more) Abdomen 86 Head 85 Upper legs 82 Chest 78 Back 75 Feet 72 Lower legs 67 Pain quality (based on selected words) Evaluative

%

M

SD

Range

34.3 33.5 32.7 31.1 29.9 28.7 26.7

U 0.34 0.24 0.24 0.16

0.24 0.19 0.17 0.14

0.13-1.00 0.09-0.91 0.09-0.91 0.03-0.92

Words

8.96

9.55

Body parts

6.65

7.30

0-58 (total words; N = 67 possible) 0-39 (total body parts selected; N = 39 possible) 0-1 (mean pain intensity, 10 cm scale)

Affective Temporal Sensory

lain intensity

Scale

0.14

0.35

T o t a l P a r t s SeZected (n-43 parts) ~ean: SD:

6.65 7.30

Range:

0-39

Figure 1. Percentage of Partielpants Marking Sections of Body Outline (N ffi 246)

cantly related to body pain (see Table 4). A lower level of body pain was associated with higher quality of life, taking fluconazole, less pain in the chest area, high psychological support, and taking dermatological/ opthamologic medications. This solution accounted for 25% of the variance in body pain. Variables that did not explain any additional variance in body pain included CD4 count, months known HIV positive, total categories of medication taken, narcotic analgesic, nonnarcotic analgesic, total symptoms reported, total body parts marked, total pain words selected, patient's rating of their physiological condition, perceived health distress, and perceived health transition. The subset of patients (n = 83) who participated in an extra interview were asked to report interventions that health care providers were doing to manage their pain and what activities they were doing to self-manage

their pain. Participants reported that pain medications were used 78% of the time, and when used, they reported an 80% effectiveness (see Table 5). Although some interventions, like massage, were infrequently used (5%), when used, they were extremely effective (75%). When patients were asked to report self-care activities to manage pain, they reported relatively few activities. Rest and relaxation were reported by 14% of the respondents as the most frequently occurring activity, followed ironically by activity and exercise by 13% of the respondents. The most frequently reported category was none (18%). Discussion The findings of this study add to the knowledge of pain management in HIV/AIDS in several ways. The

28 JANAC Vol. 9, No. 1, January/February 1998

Table 2. Symptoms and Quality of Life (N = 249) M

Patient status self report Physiological status 5.15 Psychological status 7.48 Quality Audit Marker Self-care (5 items) 18.83 Ambulation (2 items) 7.05 Psychological distress (2 items) 5.89 Symptom score Number of symptoms 17.94 Health Status Questionnaire (n = 144) Cognitivefunction 65.94 Mental health 55.97 Health distress 51.08 Quality of fife

Health transition Social functioning Pain Energy/fatigue Physical function General health perception Role functioning

45.49 42.53 40.00 39.86 35.83 30.79 28.30 17.71

SD

Range

2.09 2.60

0-10 0-10

4.33 1.33 1.32

5-24 2-8 2-8

9.86

1-41

28.41 22.58 28.96 26.55 31.99 33.11 25.64 20.74 33.24 24.78 34.21

0-100 0-96 0-100 0-100 0-100 0-100 0-100 0-85 0-100 0-I00 0-100

Table 3. Participants' Medication Identified From Chart Audit (N-- 249) Medication

n

%

Narcotic analgesi~ Nonnarcotic analgesic Bactrim/septra (oral) Other anfimicrobial Fluconazole (oral/IV) Antiulcer Antiemetics Antihistamine/allergy Acyclovir (oral) Vitamins Antianxiety, psychotic, manic Clotrimazole Clarithromycin/biaxin (oral) Antidepressants Dapsone Steroids (oral) Skin/mucocutaneous/opthalmic Antituberculosis Bronchodilator Gancylovir (IV) Antidiarrhea Sodatives/hypnoties

122 117 114 110 I00 100 76 73 69 68 61 58 58 55 55 54 50 48 44 44 40 32 27 25

48.6 46.6 45.4 41.8 39,8 39.8 30.3 29.1 27.5 27.1 24.3 23.1 23.1 21.9 21.9 21.5 19.9 19.1 17.5 17.5 15.9 12.7 10.8 10.0

AZT

results confirm the prevalence of pain and the variety and complexity of its presentation in H1V disease. In contrast to other studies, pain medications were reported as effective by 80% of a subsample of subjects who reported the use of the medications in a semistructured interview. However, the data suggest that few patients are aware of or use nonpharmacologic interventions (nurse or self-initiated) that may be useful pain management. Of note, as well, are the findings that pain ratings did not differ according to patient demographics (e.g., ethnicity, gender), CIM counts, clinical setting, or use of injection drugs. Implications for nursing practice are in several areas. First, the data support the inclusion of questions aimed at elieiting potentially harmful (e.g., street drugs) strategies that patients may be using to manage their pain as part of a nursing pain assessment. Second, although the majority of patients reported that pain medications were effective, nonpharmacologic pain management strategies that have been reported in the nursing literature and that may be useful in treating HIV/AIDS patients were underused. Third, the study supports the utility of the APPT body outline in this population, not only to locate the site of the pain but

Antimalarial m

Note: Total medication categories: median = 6, mode = 5; M = 6.08; SD = 2.37; range = 0-14.

also to quantify the extent of the pain by counting the number of affected body parts. This study has several limitations. Quality of life as measured by the HSQ scale was only administered to hospitalized patients because, as described in the method section, the items were judged to be inappropriate for patients in the skilled nursing facility or receiving home care. Subsequently, analyses related to quality of life did not include home care or skilled nursing facility patients who may have increased the variability in quality of life scores. To address this limitation in future studies, a new scale, Living with H/V(Holzemer, Spicer, Wilson, Kemppainen, & Coleman, in press; Wilson, Hutchinson, & Holzemer, 1997), has been tested and validated in another sample. A second limitation is that, with the exception of the audit of the medication record, patient self-report served as the only data source for describing pain management interventions. Chart audits of provider documentation or provider interviews may reveal that

Holzemer et al. / The Patient Perspective 29 Table 4. Stepwise Multiple Regression of Predictors of Body Pain (n ffi 144) Step

1. 2. 3. 4. 5.

Variable

Beta

Quality of life Taking fluconazole Pain at chest area Perceived psychological support Taking dermatological medications

Table 5.

.223 .191 -.216 -.228 .199

t Probability

t

2.599 2.268 -2.552 -2.669 2.355

Pain Management Strategies a

Strategy Patient's reports of professional management strategies and its effectiveness Pain medications Other medications (antibiotics) Attention/talking/comforting Massage Heat pads/hot baths Oxygen administration Mechanical aids (wheelchair) Activity/exercise Give fluids Dietary Positioning Other Nothing/no strategies reported Patients self-initiated pain management strategies Rest/relaxation Activity/exercise Positioning Pain medications Diversional activities Meditation Dietary Massage Other medications (antibiotics) Heat pads/hot baths Mechanical aids (wheelchair) Street drugs Lifestyle change Take fluids Other No strategies reported

Used n %

65 15 8 4 3 2 2 2 1 1 1 5 7

78 18 10 05 04 02 02 02 01 01 01 06 07

12 11 10 8 6 6 5 5 4 3 2 2 2 1 6 15

14 13 12 10 07 07 06 06 05 04 02 02 02 01 07 18

Effectiveness n %

52 8 3 3 2 0 1 0 0 1 1 4 n/a

80 53 38 75 67 00 50 00 00 100 100 80

a. n = 83 hospitalized AIDS patients reporting pain at time of interview.

patients were receiving pain management interventions that were not reported in the patient interview.

0.011 0.025 0.013 0.009 0.020

Multiple R .297 .214 .237 -.221 .218

R2

.088 .129 .167 .213 .252

R2 Change 0.088 0.042 0.037 0.046 0.039

F Value 10.639 8.131 7.208 7.228 7.137

Significant F .002 .001 .000 .000 .000

Zeller, Swanson, and Cohen (1993) suggested that pain, including its causes, should be one area of research in symptom management and indicated the need for the testing of nonpharmacological as well as pharmacological interventions. The findings of this study support the need for additional research on developing, testing, and implementing nonpharmacological interventions for use by both the health care provider and the patient. Additional work is needed to examine the impact of pain on functional status and quality of life in HIV/AIDS across clinical settings. The inverse relationship between perceived psychological support and pain intensity found in this study is also intriguing for future investigation. A c k n o w l e d g e m e n t s . This work has been supported by NIH NR02215 and a pilot grant from the A I D S Clinical Research Center, University o f California, San Francisco.

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