Chronic Pain in Patients with HIV: What Clinicians Need to Know

1. Chronic Pain in Patients with HIV: What Clinicians Need to Know Jessica S. Merlin, MD, MBAAssistant Professor of MedicineUniversity of Alabama at Birmingham From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.

2. Acute vs. Chronic Pain • Acute pain: new pain, < 3 mo • Chronic pain: persists > 3-6 months, beyond the period of normal tissue healing • Examples: low back pain, other msk pain, fibromyalgia, neuropathy Turk DC, Pain, 1987; APA, DSM-IV, 1984.

3. Turk DC, Lancet, 2011; Institute of Medicine, 2012. From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.

4. Chronic pain in persons with HIV Slide courtesy of Joanna Starrels. From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.

5. Chronic pain history ICSI Guideline for Management of Chronic Pain; Kerns RD, Pain, 1985. • Impact of pain on: • Function • Mood • Sleep • Ask: “Some people report that pain impacts X; is that true for you?”

6. Communicating about Chronic Pain • Not easy, because: • Patients come with “baggage” • Providers come with “baggage” • Pain is the 5th vital sign, pain is an emergency • Medications come with risk • Patients may have active psychiatric illness/addiction • Patients’ behaviors may evoke severe negative countertransference

7. Initial Discussion (can be in the context of a treatment agreement) What is chronic pain Patience Partnership and collaboration Pharmacologic and non-pharmacologic management Mind-body connection Functional goals

8. Evidence-Based Management Remember….first, do no harm!! Focus on evidence-based therapies, avoid unnecessary procedures, surgeries, medications Set concrete goals and timelines Be ready to discontinue therapies that don’t work If possible, treat psychiatric illness first

9. Evidence-Based Non-OpioidPharmacologic Therapy • Acetominophen - OA, < 3g, consider relative contraindications • NSAIDs - back pain, consider CV (naproxen), GI (cox-2/celecoxib), renal risk • Muscle relaxants • Benzodiazepines • Other: anticonvulsants, antidepressants, topicals • Specific indications: e.g., lidocaine post-herpetic neuralgia, capsacin post-herpetic/DSP, doclofenac-OA

10. A Moment on Opioids…. • Evidence for long term use is lacking • Some evidence for increased mortality with doses > 100-200mg equivalents of morphine per day • Most overdose deaths due to methadone, often with benzos Noble M, Cochrane Database Syst Rev, 2010, Lum P, JAIDS, 2010, Manchikanti L, Pain Physician, 2011; Webster L, Pain Med, 2011; Gomes T, Arch Int Med, 2011; Bonhert AS, JAMA, 2011.

11. How to decide • Assess risk/benefit ratio of opioids • “Clinicians may consider a trial of COT if chronic non-malignant pain is severe, pain is having an adverse impact on function or quality of life, and benefits outweigh harms” (strong, low) Chou R, J Pain, 2009.

12. Key Points • Chronic pain is common in patients with HIV, and causes substantial functional impairment • You know a patient has pain if they say they have pain • We have a lot more to offer than opioids • Pay attention to psychiatric symptoms For more information: IAS-USA Cases on the Web For more information: IAS-USA Cases on the Web