Treating pain in patients with AIDS and a history of substance use.

A 42-year-old man presents to your clinic complaining of severe pain related to Kaposi's sarcoma. He has a 26-year history of substance misuse and was diagnosed at a different clinic as having AIDS in 1990, when he said that he had stopped using illicit drugs. He developed Kaposi's sarcoma in 1991, when he originally sought treatment of pain, again denying, continued substance misuse. Because there was documented evidence that he was still misusing drugs, he was referred to a psychologist for behavioral modification techniques. These helped him to stay off illicit drugs but failed to relieve his pain. He reverted to using, substances in an attempt to relieve his pain and was subsequently arrested and jailed for 18 months. The patient emerged "clean," but the number of lesions of Kaposi's sarcoma had escalated, as had his pain. He returned to the clinic to seek analgesia. Nonopioid medications were prescribed but did nothing to relieve the pain. The patient persisted in seeking pain relief but was thought to be merely seeking opiate drugs to fuel his opiate addiction, and so he was denied opioid treatment. The patient felt rejected and despondent but did not want to revert to misusing opiates. He comes to your clinic in the hope of finding a physician who will believe that he is in severe pain.