Diagnosis and treatment of opiate-resistant pain in advanced AIDS.

A 35-year-old man with AIDS [acquired immunodeficiency syndrome] was admitted for end-of-life care. He had tested positive for the human immunodeficiency virus (HIV) in 1986, when he was diagnosed with Pneumocystis carinii pneumonia. He subsequently developed non-Hodgkin’s lymphoma with involvement of abdominal and periaortic lymph nodes. He had responded initially to antiretroviral therapy and chemotherapy, although his CD4 cell count never rose above 100 10/L (100/μL), indicating ongoing severe immune deficiency. He had stopped HIV therapy because of side effects 1 year before admission, and lymphoma had progressed. At the time of admission, he had severe neuropathic leg and abdominal pain with partial bowel obstruction from the lymphoma. Symptoms had made care at home (rendered by his mother and partner) very difficult, even though both were intensive care unit nurses. On admission, the patient was receiving patient-controlled-analgesia (PCA) morphine sulfate through a subclavian central line at an already high rate of 90 mg per hour with the ability to selfor partner-deliver 30 mg every 6 minutes. This was completely ineffective in managing his pain. The patient was remarkably responsive and coherent, even though narcotic hallucinosis (visual and auditory hallucinations) was intermittently present. The baseline dose of morphine was dramatically increased during the first 48 hours to 620 mg per hour; this brought no change in pain relief but worsening of his hallucinosis.