Pain Management in HIV/AIDS

1. Pain Management in HIV/AIDS Gayle Newshan, PhD, ANP

2. Pain Management in HIV/AIDSObjectives • Identify two essential steps in pain management • Identify common pain syndromes in persons with HIV/AIDS • Describe nursing assessment of pain in the person with HIV/AIDS • Describe implications of genetic factors and health habits on amount of pain relief obtained • Identify pharmacologic strategies for treatment of pain in persons with HIV/AIDS (cont.)

3. Pain Management in HIV/AIDSObjectives (cont.) • Describe two strategies for managing neuropathic pain in persons with HIV/AIDS • Identify two examples of aberrant behavior in chemically dependent patients with HIV/AIDS • Discuss two strategies for dealing with aberrant behavior in persons with HIV/AIDS • Identify three barriers to effective pain management in persons with HIV/AIDS • Describe pain management issues for persons on methadone maintenance

4. Pain in HIV/AIDS • Prevalence Pre-HAART (Highly Active Antiretroviral Therapy) • Estimates vary between 53%-97% (Schofferman, 1998; Singh, Fermie & Peters, 1992; Breitbart et al, 1996) • Prevalence Post-HAART • Estimate of 30% (Newshan, Bennett, Holman, 2000) • Undermanagement of pain: Women and injection drug users (Breitbart, et al, 1996)

5. Barriers to Pain Management • Health Care Providers • Lack of knowledge • Myths and misconceptions • Cultural barriers • Fear of addiction • Fear of legal sanctions

6. Barriers to Pain Management • Patients/Family/Caregivers • Fear of addiction • Wanting to be “good” patients • Stoicism • Cultural barriers • Social and Governmental Barriers • Stigma • Regulatory issues

7. Etiology of Chronic Pain HIV • Neuropathy • Postherpetic Neuralgia • Avascular Necrosis • Osteopenia • Arthropathy, Adhesive Capsulitis • Myopathy • Back Pain • Renal Calculi/Loin Pain • Herpes Simplex • Candida Esophagitis • Pancreatitis Related to Didanosine, Dicalcitabine, CMV

8. Principles and Goals ofPain Management • Pain is subjective • Self-report is the most reliable indicator

9. Principles and Goals ofPain Management • Assessment • Onset and duration • Location • Character (sharp, dull, burning, etc…) • Intensity – using the 0-10 numerical rating scale, the verbal scale (none, mild, moderate, severe) or the FACES scale for children (cont.)

10. Principles and Goals ofPain Management • Assessment (cont.) • Exacerbating and relieving factors • Response to current and past treatments • Meaning of pain to patient • Cultural responses to pain • Emotional state • History of chemical dependence

11. Principles and Goals ofPain Management • Listen to the patient • Pain is subjective – there is no pain-o-meter or pain blood test, only what the patient tells us • Reassessment • After treatment is initiated, pain should be regularly reassessed to determine the efficacy of the intervention • Optimal functioning with least side effects • The right dose of pain medication is whatever dose it talks to relieve the pain with the fewest side effects • Functioning is usually more of a priority in patients who are not end-stage

12. Liability Issues • Pain management is not just “nice to do”. Nurses and physicians have been held legally accountable for inadequate pain management

13. JCAHO: New Standards inPain Management As of 2001, JCAHO is requiring that all members meet new standards in pain management. In particular they are stressing: • Importance of pain assessment and management • Every patient should be assessed for pain • Healthcare facility commitment • The organization plans, supports and coordinates activities and resources to assure that pain is addressed including education of providers, patients and their families (cont.)

14. JCAHO: New Standards inPain Management (cont.) • Accountability • The organization collects data to monitor performance • Outcome assessment • The organization assesses the adequacy and effectiveness of pain management • Continuous improvement • The organization is responsible for continuously monitoring and improving outcomes related to pain management

15. Optimal Use of AnalgesicsWorld Health Organization Step Ladder • Begin with non-opiate, nonsteroidal antiinflammatory agents (NSAIDS) • Add a “weak” opiate, such as codeine or hydrocodone (with or without an adjuvant) • Move to a stronger opiate, such as oxycodone, morphine (with or without an adjuvant) • Complementary, non-pharmacologic strategies • Interventional strategies

16. Step 1: Non Opiates If one non-opiate is ineffective, switch to a different one. If one NSAID is ineffective, switch to a different class • Acetaminophen • No effect of platelet function • Avoid in cases of hepatic insufficiency • Maximum of 4g/day

17. Step 1: Non Opiates (cont.) • NSAIDS • Avoid if low albumin level • Avoid if low platelets • Avoid if renal insufficiency • Useful with throbbing, aching pain • Administer with food to reduce gastric irritation • Salsalate and tolmetin produce less inhibition of platelet aggregation than other NSAIDS • Maximum dose of aspirin is 10g/day • Use with caution in persons with asthma • Indomethacin is available in suppository form

18. Step 1: Non Opiates (cont.) • Cox-2 Inhibitors • Rofecoxib (Vioxx) • Celebrex (Celebrex) • Have no effect on platelet aggregation or bleeding time • Less chance of gastric irritation • Monitor hepatic functioning

19. Step 2: Non opiate + Weak Opiate With or Without Adjuvants • Acetaminophen with codeine or hydrocodone • Maximum dose related to acetaminophen • Adjuvants are those medicines that enhance the efficacy of the opiate and may have independent analgesic activity

20. Step 2: Non opiate + Weak Opiate With or Without Adjuvants (cont.) • Types of adjuvants • NSAIDS: provide additive analgesia when given to supplement the opiate, often lengthen the duration of opiates • Corticosteroids: treats both the cause and resulting pain of aphthous ulcers; also relieves cerebral edema Corticosterioids caution: can cause gastric bleeding, caution with low platelet counts

21. Step 2: Non opiate + Weak Opiate With or Without Adjuvants (cont.) • Types of Adjuvants • Antidepressants (amitriptyline, desipramine, etc): used for neuropathic pain and post-herpetic neuralgia and additive analgesia with opiates Antidepressants caution: can cause dry mouth, urinary retention and “hangover effect • Antihistamines (hydroxyzine): provides additive analgesia as well as antiemetic and anxiolytic effect Antihistamine Caution: Can cause dry mouth and drowsiness

22. Step 2: Non opiate + Weak Opiate With or Without Adjuvants (cont.) • Types of adjuvants • Anticonvulsants: gabapentin is the most useful with the fewest side effects and is used to treat neuropathic pain Anticonvulsant Caution: carbamazepine can cause neutropenia • Caffeine: drinking a cup of strong coffee along with opiate will increase its effect

23. Step 3: Opiates With/Without Adjuvants • Dosing schedule and titration • Prevent pain with ATC dosing • Titrate to pain relief – doses are individualized: the right dose is whatever it takes to relieve the pain with the least amount of side effects/toxicity • Long-acting opiates should be used for long-term pain

24. Step 3: Opiates With/Without Adjuvants (cont.) • Conversion/equianalgesic dosing • Morphine 10 mg sc/im = 20 mg oral solution • Hydromorphone 4 mg sc/im = 8 mg oral • When switching from one opiate to another, reduce the dose by 1/3 due to incomplete crossover tolerance and titrate from that dose

25. Step 3: Opiates With/Without Adjuvants (cont.) • Delivery Formulations • Morphine: available in concentrated oral immediate release solutions, suppository, short and long-acting oral pills, iv and im/sc • Oxycodone: available with or without aspirin and acetaminophen, long and short-acting formulations (Q12h and Q4h)

26. Step 3: Opiates With/Without Adjuvants (cont.) • Delivery formulations • Hydromorphone: available in suppository, short-acting pill, iv, im/sc • Fentanyl: available in short-acting lollipop and long-acting patch (q48-72h) • Meperidine: not recommended when doses of >300 mg/day are needed as can lead to tremors, restlessness and seizures; oral form is equivalent to acetaminophen and should be avoided • Propoxphene HVL: limited efficacy, can lead to accumulation of neurotoxic metabilites

27. Step 3: Opiates With/Without Adjuvants (cont.) • Tips with long-acting oral opiates • Do not crush or break • Hydration is important • Supplement with short-acting opiates for break-through pain • Dolophine (methadone) should be given q6h and titrated very slowly to avoid accumulation due to long half-life

28. Step 3: Opiates With/Without Adjuvants (cont.) • Topical fentanyl should be used cautiously if patient is febrile. Do not apply topical fentanyl to broken skin • Opioid rotation for chronic pain and long-term therapy • When a patient is on opiates for several months, tolerance often develops and improved pain control can be achieved by rotating to an alternate opiate – for example, going from long-acting oxycodone to long-acting morphine and then to the fentanyl patch

29. Acupuncture Hypnotherapy Massage Magnet Therapy Nutriceuticals (dietary supplements such as glucosamine chondroitin) Music Therapeutic touch Aromatherapy Heat/ice Distraction (tv, reading) Step 4: Complementary and Non-Pharmacological Therapies These therapies have research to support that they reduce pain. Most research done in non-HIV patients

30. Step 5: Interventional Strategies • Plays a small role in pain management in HIV/AIDS • Usually done by anesthesiologist • Nerve blocks, using anesthetics, corticosteroids or neurolytic drugs • Implanted epidural pumps or intraspinal drug delivery – cautious use with persons with AIDS due to risk of infection

31. Inter-Individual Analgesic Variability/Drug Polymorphism:Same Drug, Different Response • Environmental Factors • Recreational drug-drug interactions • Cannabis increase effect of morphone • Ritonavir (Norvir) increases Ecstasy levels • Alcohol Increases abacavir (Ziagen levels) • Other drug-drug interactions • Ritonavir increases levels of meperidine, propoxyphene and fentanyl • Efavirenz and nevirapine lower methadone levels • NSAIDS increase lithium level • Phenytoin lowers methadone levels

32. Inter-Individual Analgesic Variability/Drug Polymorphism (cont.) • Environmental factors • Smoking • Smoking shortens half-life of NSAIDS and increases metabolism of meperidine, morphine and propoxyphene • Weight and body fat • Malnourishment can cause increase toxicities of NSAIDS • Diet • 7 oz grapefruit juice can effect certain drug metabolism for 24 hours • Increases plama levels of busprione, carbamazpeine, triazolam by 4-9 fold

33. Inter-Individual Analgesic Variability/Drug Polymorphism (cont.) • Genetic factors • Slow metabolizers – will find a drug less effective, build up drug levels and have greater toxicity • Rapid metabolizers – may find a drug more effective but shorter length of action

34. Inter-Individual Analgesic Variability/Drug Polymorphism (cont.) • Sexual dimorphism • Possibility that gender may influence both pain perception and efficacy of pain medications • Research is ongoing • Cultural factors • Beliefs, fears, values affect drug response • Expectations regarding pain and pain relief • Expectations regarding a drug’s effectiveness

35. Pain and Chemical Dependence • Identification of aberrant behavior • Examples include non-prescribed dose escalation and prescription forgery • Differential diagnoses of aberrant behavior • Somatiform disorder • Personality disorder • Obsessive compulsive personality

36. Pain and Chemical Dependence (cont.) • Strategies for managing aberrant behavior • Using a team approach • Directly address the concern with the patient • Oral or written agreements • Using long-acting formulations instead of short-acting • Encourage participation in recovery programs • Limit prescriptions to one provider, one pharmacy, one week supply

37. Pain and Chemical Dependence (cont.) • General guidelines for management • Be consistent • Address social, psychological and spiritual effects of pain • Methadone maintenance • Methadone maintenance does not provide analgesia • Phenytoin and rifampin may increase methadone metabolism and cause drug-seeking behavior • Patients on methadone need additional medicine for pain control

38. Neuropathy: Etiology • HIV • CMV • Drugs, ie, didanosine, zalcitabine, isoniazid • Mitochondrial toxicity

39. Neuropathy: Treatment Strategies • Gabapentin (Neurontin) – 2-3 g/day in divided doses • Amitryptiline (Elavil) – start at 25 mg/hs and increase every three days as tolerated to effect • Desipramine – start at 25 mg/hs and increase every three days as tolerated to effect • NSAIDs such as ibuprofen or naproxyn if associated throbbing pain

40. Neuropathy: Treatment Strategies (cont.) • Use anti-embolic stockings • Encourage exercise, such as cycling, walking • Massage • Use topical capsaicin P ointment if only small areas like toes or fingers are affected – takes several days to be effective, must be applied tid-qd • Discontinue the causative drug if possible • B6 and B 12 supplements • Acupuncture