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Palliative Care in HIV/AIDS hivmanagement/palliative.html

Explore palliative care issues and pain control methods in HIV/AIDS patients. Learn about symptom management, hospice care, and case presentations. Understand the WHO Analgesic Ladder and strategies for controlling acute and chronic pain. Discover approaches for addressing neuropathic pain and managing pain in addicted patients.

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Palliative Care in HIV/AIDS hivmanagement/palliative.html

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  1. Palliative Care in HIV/AIDShttp://hivmanagement.org/palliative.html James A Zachary MDLSU Health Sciences CenterDelta AETC December 13, 2004

  2. Identify palliative care issues involved with HIV/AID • Discuss tools of palliation • Hospice: purpose, goals, methods, identifcation of barriers & overcoming them • Case presentations • The Hospice Rx

  3. HIV/AIDS Palliative Care Issues • Dermatomal herpes zoster • 15x higher incidence than uninfected • Post herpetic neuralgia • Approx 20% incidence without HIV • Increased incidence with HIV • Distal sensory polyneuropathy 10-40% • HIV, drugs, infection (e.g. CMV)

  4. HIV/AIDS Palliative Care Issues • Miscellaneous pain • Chronic musculoskeletal pain especially spinal pain • Chronic headaches • Trauma-related injuries • Chronic post-operative pain

  5. Pain Control Basics • Believe the patient! • Thoroughly evaluate pain • History and physical • Blood testing • Imaging • Consultants • Always treat the cause if possible • Pain control during work-up and until resolved • Close follow-up!!!!

  6. WHO Analgesic Ladder

  7. Acute Pain • Apply analgesic ladder principle • Short acting analgesics • Adjuvant therapy with gabapentin • Avoid constipation • Examples: acute herpes zoster, acute headache

  8. Acute Pain • NSAIDs • Buprenorphene IM • Tramodol • Merperidine • Codeine/acetaminophen • Hydrocodone/acetaminophen or ibuprofen • Oxycodone/acetaminophen or aspirin • Oxycodone • Hydromorphone • Immediate release morphine sulfate

  9. Chronic PainPain >48 hours • Begin with adequate supply of short acting analgesic: avoid acetaminophen combination drugs • Oxycodone tablets or suspension • Morphine sulfate immediate release liquid or tablets • Allow patient to re-administer (and slowly escalate) every 2-4 hours • At the end of 24-48 hours, begin a long-acting opiate based on the previous 24 hour dosage of short-acting analgesic and continue short-acting

  10. Chronic PainPain >48 hours • Extended release morphine • MS Contin, Oramorph, generics: q8-12 hours • Avinza, Kadian: q24 hour • Extended release oxycodone: OxyContin • Transdermal fentanyl • Methadone • Buprenorphene sublingual*

  11. Neuropathic Pain • Description: lancinating, numbness, burning, itching • Palliative options • Nerve blocks – not too practical • Topical lidocaine (Lidoderm) • Gabapentin (or levacetram) up to 5600 mg per day or more • Opiates

  12. Opiates • Use a consistent approach to your pain assessment such as asking the patient to use the 1-10 scale • Document clearly that you are doing your best to diagnose and treat the pain • Don’t prescribe on the first visit with a new patient unless source of pain is very clear • Addiction seldom occurs when used for pain control.

  13. Pain In Addicts • Higher incidence of pain in addiction • Same principles apply as in nonaddicted patients • Consider a pain contract • Consider urine toxicology testing if suboptimal results are achieved • Look for prescribed substances primarily • Evaluate and treat for nonprescribed substances as you would normally

  14. Pain In Addicts

  15. Pain In Addicts • Higher incidence of pain in addiction • Same principles apply as in nonaddicted patients • Consider a pain contract • Consider urine toxicology testing if suboptimal results are achieved • Look for prescribed substances primarily • Evaluate and treat for nonprescribed substances as you would normally

  16. Pain In Addicts • Boundary issues are extremely important! • Consider a Pain Management referral • Consider a Mental Health referral

  17. Opiates • Avoid constipation! • Senna + stool softener = Senokot • Lactulose • Go-lytely or Miralax • Sorbitol • To control possible nausea provide an antiemetic such as promethazine or metoclopropamide and administer it on a schedule

  18. HIV/AIDS Palliative Care Issues • Nausea • Drugs • CNS processes: meningitis, abscess, tumor, increased intracranial pressure, motion sickness • Metabolic processes: hepatitis, adrenal insufficiency • GI: pancreatitis, gastritis, PUD, KS, microsporidiosis, cryptococcosis, CMV, DMAC

  19. Nausea Control • Be aggressive in approach! • Diagnose and treat underlying cause if possible • Prevent nausea: much easier than suppressing it once started!

  20. Nausea Control • Phenothiazines: promethazine (Phenergan), prochlorperazine (Compazine), etc. • Metoclopropamide (Reglan) • Ondansetron (Zofran), granisetron (Kytril) • Dranabinol (Marinol) • Lorazepam • Haloperidol (Haldol) • Dexamethasone (Decadron)

  21. Conclusions • Palliate aggressively even during active care • Close follow-up is probably helpful to patient and provider • The approach and treatment of the addicted patient is fundamentally no different from that of any other patient. • The use of opiates can be simple and safe. • Adjuvant drugs such as gabapentin should be frequently considered.

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