Trust and the ethics of chronic pain management in HIV.
Trust and the ethics of chronic pain management in HIV.
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艾滋病毒慢性疼痛管理的信任和伦理。
DOI：
10.1016/j.jana.2015.05.007
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发表时间：
2015
期刊：
影响因子：
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通讯作者：
George,MaryCatherine
中科院分区：
文献类型：
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作者：
Robinson-Papp,Jessica;George,MaryCatherine
美国护士协会将2015年定为道德年，并相应发布了修订后的护理道德规范（Willard，2015）。该准则明确将促进社会正义和减少医疗保健差异视为道德要求。鉴于艾滋病毒对主要是少数族裔、社会经济弱势群体的影响尤为严重，这些主题将引起致力于艾滋病毒护理的医疗保健提供者的强烈共鸣。艾滋病毒护理人员必须特别警惕潜在的医疗保健差异和不公正的一个领域是慢性疼痛。人们越来越认识到，慢性疼痛是慢性 HIV 感染者面临的多种疾病中常见且难以治疗的部分（Lee 等，2009；Merlin 等，2012；Miaskowski 等，2011；Parker、Stein 和 Jelsma，2014）。在艾滋病毒领域之外，疼痛管理方面的差异已经很明显（Campbell 等，2012），特别是对于非裔美国人来说，这一人口群体也受到艾滋病毒的影响尤为严重。例如，事实证明，医疗保健提供者低估了非洲裔美国患者的痛苦（Staton 等人，2007 年），并且对他们缺乏同情心（Drwecki、Moore、Ward 和 Prkachin，2011 年）。不同环境下镇痛药使用情况存在差异，包括急诊科的急性疼痛（Todd, Samaroo, & Hoffman, 1993；Todd, Deaton, D’Adamo, & Goe, 2000），初级保健和专科诊所的慢性非癌症疼痛（Chen 等，2005；Ringwalt, Roberts, Gugelmann, & Skinner, 2015），甚至癌症治疗指南更加牢固且争议较少（Cleeland 等人，1994 年；Cleeland、Gonin、Baez、Loehrer 和 Pandya，1997 年）。 HIV 感染者在慢性疼痛管理中经历不公正和差异的程度仍然未知，而阻碍获得这一知识的事实是，难以定义公正和公平的 HIV 慢性疼痛管理。一个特别有争议的问题是，考虑到滥用（包括成瘾和转移）的风险，长期阿片类镇痛药是否合适。临床指南表明，通过仔细选择和监测患者可能会减轻这种风险，但这对于护理患有慢性疼痛的艾滋病毒感染患者的日常实践意味着什么？ HIV 领域之外的研究已经确定了处方阿片类药物滥用的危险因素，包括过去吸毒或酗酒（Ives 等人，2006 年；Michna 等人，2004 年；Schieffer 等人，2005 年）、年龄较小（Edlund 等人，2010 年；Ives 等人，2006 年）、男性（Edlund、Steffick、Hudson、Harris 等）。 Sullivan，2007；Ives 等人，2006；Liebschutz 等人，2010）、精神共病（Ives 等人，2006）、教育水平较低（Wasan 等人，2007）、药物滥用家族史（Liebschutz 等人，2010；Michna 等人，2004），以及成为虐待受害者的历史（Wasan 等人，2007 年）。提供商在将这些风险因素付诸实际使用时所面临的道德困难是显而易见的。选择也许是最明显的例子，将患者排除在外显然是不公正的。
The American Nurses Association has designated2015 as the Year of Ethics, and accordingly has published a revised code of nursing ethics (Willard, 2015). This code explicitly identifies promoting social justice and reducing health care disparities as ethical imperatives. These themes will resonate strongly with health care providers devoted to HIV care, given the disproportionate effects of HIV on predominantly minority, socioeconomically disadvantaged communities. One area in which HIV care providers must be particularly alert to the potential for health care disparities and injustice is chronic pain. It is increasingly recognized that chronic pain is a common and treatment-resistant part of the multi-morbidity faced by patients living with chronic HIV (Lee et al., 2009; Merlin et al., 2012; Miaskowski et al., 2011; Parker, Stein, & Jelsma, 2014). Outside the realm of HIV, disparities in pain management have been well established (Campbell et al., 2012), particularly for African Americans, a demographic group that is also disproportionately affected by HIV. For example, health care providers have been shown to underestimate the pain of African American patients (Staton et al., 2007), and to feel less empathy toward them (Drwecki, Moore, Ward, & Prkachin, 2011). Disparities in the receipt of analgesics have been documented across various settings, including acute pain in the emergency department (Todd, Samaroo, & Hoffman, 1993; Todd, Deaton, D’Adamo, & Goe, 2000), chronic noncancer pain in primary care and specialty practice (Chen et al., 2005; Ringwalt, Roberts, Gugelmann, & Skinner, 2015), and even in cancer pain where treatment guidelines are far more firmly established and less controversial (Cleeland et al., 1994; Cleeland, Gonin, Baez, Loehrer, & Pandya, 1997).The extent to which HIV-infected patients experience injustice and disparities in chronic pain management is still unknown, and hindering the acquisition of this knowledge is the fact that just and equitable chronic pain management for HIV is difficult to define. A particularly controversial issue is whether chronic opioid analgesics are appropriate given the risks of misuse, including addiction and diversion. Clinical guidelines suggest that this risk might be mitigated by careful patient selection and monitoring, but what does this mean in the day-to-day practice of caring for HIV-infected patients with chronic pain? Studies outside the realm of HIV have identified risk factors for prescription opioid misuse, including past drug or alcohol abuse (Ives et al., 2006; Michna et al., 2004; Schieffer et al., 2005), younger age (Edlund et al., 2010; Ives et al., 2006), male sex (Edlund, Steffick, Hudson, Harris, & Sullivan, 2007; Ives et al., 2006; Liebschutz et al., 2010), psychiatric comorbidity (Ives et al., 2006), lower education level (Wasan et al., 2007), family history of substance use (Liebschutz et al., 2010; Michna et al., 2004), and history of having been the victim of abuse (Wasan et al., 2007). The ethical difficulty a provider would face in putting these risk factors to practical use is immediately apparent. Choosing perhaps the most obvious example, it would clearly be unjust to exclude a patient from