New Guidelines for Managing Chronic Pain in Patients With HIV
The new guidelines cover the screening and initial assessment process, approaches to chronic pain management, and more.
The HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA) has released new guidelines for the management of chronic pain in patients living with human immunodeficiency virus (PLWH).1 This article provides a brief summary of the guidelines.
Recommended Approach to Screening and Initial Assessment of PLWH and Chronic Pain
- All PLWH should receive brief standardized screening for chronic pain. A biopsychosocial approach should be used; and appropriate monitoring should take place. (Table 1)
Recommended General Approach to Management of PLWH and Chronic Pain
- Healthcare providers should develop and participate in interdisciplinary teams
- For patients with controlled pain, any new report of pain should be carefully investigated. While the issue is being evaluated, these patients may require added treatments or adjustment in the dose of pain medications
- Clearly document new symptoms
- Consult with a provider experienced in pain management of PLWH or with a pain specialist
Recommended Therapeutic Approach to Chronic Pain for PLWH at the End of Life
- Age-related and HIV-related changes and comorbidities may cause changes in pain experiences in patients with HIV. Clinicians should address these changes in the context of disease progression.
- A multidisciplinary team approach is necessary for maintaining pain control and communicating with the patient and his/her support system.
- Clinicians should use language that patients and families can understand and may need to schedule longer appointments to work out the goals of care
- Consult with a palliative care specialist
- For patients with advance illness, a support system beyond the clinician might be necessary and the primary care clinician should remain in communication with the patient and family through the end of life for accurate continuity of care and to avoid a sense of abandonment on the patient's part.
Recommended Nonpharmacologic Treatment for Chronic Pain in PLWH (Table 2)
- The authors recommend cognitive behavioral therapy, yoga, physical/occupational therapy, hypnosis, and a trial of acupuncture.
Recommended Pharmacologic Treatments for Chronic Neuropathic Pain in PLWH (Table 3)
- The authors recommend early initiation of antiretroviral therapy, gabapentin, capsaicin, medical cannabis, and alpha lipoid acid (ALA).
- The authors recommend against using lamotrigine.
Recommended Nonopioid Pharmacologic Treatments for Chronic Nonneuropathic Pain in PLWH
- The authors recommend acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line agents for musculoskeletal pain, noting that acetaminophen has fewer side effects than NSAIDs.
- Lower dosing is recommended for those with liver disease.
Recommended Opioid Pharmacologic treatments for Chronic Nonneuropathic Pain in PLWH (Table 4)
- The authors recommend a time-limited trial of opioid analgesics for patients who do not respond to first-line therapies, report moderate-to-severe pain, and experience functional impairment.
Recommended Approach for Assessing Likelihood of Developing Negative, Unintended Consequences of Opioid Treatment in PLWH
- All patients should be assessed for potential risk of developing misuse, diversion, and addiction prior to prescribing opioids
Recommended Approach to Safeguarding PLWH Against Harm While Undergoing Treatment of Chronic Pain with Opioids
- The authors recommend routine monitoring and an “opioid patient-provider agreement (PPA).” (Table 5)
Recommended Methods to Minimize Adverse Effects from Chronic Opioid Therapy in PLWH
- The authors offer recommendations regarding storage of medication, patient education, and drug-drug interactions. (Table 6)
Recommended Approach to Prescribing Controlled Substances for Chronic Pain to PLWH and History of Substance Abuse Disorder
- The authors recommend careful evaluation and risk stratification. Those with a history of addiction for whom the risks outweigh benefits should have their pain “reasonably managed by other therapies” and also receive emotional support, close monitoring/reassessment, and linkage to addiction treatment and mental health services. They emphasize that a history of addiction or substance abuse disorder is not an absolute contraindication to receiving controlled substances and a universal precautions approach should be applied uniformly to patients.
Recommended Approaches to Pharmacologic Management of Chronic Pain in PLWH Who are Taking Methadone for Opioid Use Disorder
- The authors recommend a sign release, an initial screening protocol, dosing, and alternative strategies if prescribing additional methadone is contraindicated. (Table 7)
Recommended Approaches to Pharmacologic Management of Chronic Pain in PLWH Who Are Taking Buprenorphine for Treatment of Opioid Use Disorders
- Clinicians should use adjuvant therapy for mild-to-moderate pain, increase dose of buprenorphine, consider switching to transdermal formulation, and consider adding other opioid agent. (Table 8)
Recommended Screening Instruments for Common Mental Health Disorders in PLWH
- The authors recommend reviewing a patient's baseline mental health status for modifiable factors that affect successful pain management, use specific screening instruments, and recommend a full neuropsychiatric evaluation. (Table 9)
Screening and Initial Assessment
|If patient screens positive on initial assessment||
Nonpharmacologic Approaches for PLWH
CBT=cognitive behavioral therapy
Pharmacologic Treatments for Chronic Neuropathic Pain in PLWH
|Alpha lipoic acid||
HIV=human immunodeficiency virus; SNRI-serotonin-norepinephrine reuptake inhibitors; TCS=tricyclic antidepressant
Opioid Analgesics for PLWH
|Opioids as a class||
Safeguarding Against Opioid-Related Harm
|Opioid patient-provider agreement (PPA)||
|Urine drug testing||
Recommended Methods to Minimize Adverse Opioid-Related Events in PLWH
|Be knowledgeable about drug-drug interactions||
Pharmacologic Management of Chronic Pain in PLWH Who Are Taking Methadone
|Collaboration with opioid treatment program||
|Splitting methadone doses||
|If additional methadone not possible||
|Acute exacerbations of pain ("breakthrough")||
Treating PLWH and Chronic Pain Who Are Taking Buprenorphine
|Use adjuvant therapy for mild-to-moderate breakthrough pain||
|Increase dosage of buprenorphine||
|If maximal dose of burprenorphine is reached||
|If additional opioid is ineffective||
|If there is inadequate analgesia||
Recommended Instruments for Screening Common Mental Health Disorders in PLWH and Chronic Pain
|Review patient's baseline mental status for modifiable risk factors||
|Screen patients for depression||
|Use screening tool||
|Screen for comorbid neurocognitive disorders||
Bruce RD, Merlin J, Lum PJ, et al. 2017 HIV Medicine Association of Infectious Diseases Society of America clinical practice guideline for the management of chronic pain in patients living with human immunodeficiency virus. Clin Infect Dis. 2017 Oct 30;65(10):1601-1606.