New Guidelines for Managing Chronic Pain in Patients With HIV

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The new guidelines cover the screening and initial assessment process, approaches to chronic pain management, and more.
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)

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)

Table 1
Screening and Initial Assessment

Recommendation Commentary/Details
Standardized screening
  • How much bodily pain have you had during the last week (none, very mild, mild, moderate, severe, very severe)
  • Do you have bodily pain that has lasted for >3 months?
  • A response of moderate pain or more during last week plus bodily pain for >3 months can be considered a positive screen result
If patient screens positive on initial assessment
  • Use biopsychosocial approach that includes:
    • An evaluation of the pain's —
      • Onset and duration
      • Intensity and character
      • Exacerbating and alleviating factors
      • Past and current treatments
      • Underlying or co-occurring disorders and conditions
      • The effect of pain on psychological function
    • Physical examination
    • Psychosocial evaluation
    • Diagnostic workup
    • Pain assessment tools can include
      • Brief Pain Inventory (BPI)
      • 3-item pain health questionnaire (PEG)
Monitoring patients
  • Periodically assess progress on achieving functional goals
  • Documentation of pain intensity, quality of life, adverse events, and adherent vs aberrant behaviors
  • Conduct assessments at regular intervals and after each change/initiation of therapy after an adequate amount of time 

Table 2
Nonpharmacologic Approaches for PLWH

Modality Features, Rationale
CBT
  • Acceptance of responsibility for change
  • Development of adaptive behaviors (eg. exercise)
  • Addressing maladaptive behaviors (eg, avoidance of exercise due to fear of pain)
Yoga
  • Treatment of chronic neck/back pain, headache, rheumatoid arthritis, general musculoskeletal pain
Physical/occupational therapy
  • For chronic pain
Hypnosis
  • Neuropathic pain
Acupuncture
  • A trial might be considered for chronic pain

CBT=cognitive behavioral therapy



Table 3
Pharmacologic Treatments for Chronic Neuropathic Pain in PLWH

Treatment Recommendations
Antiretroviral therapy
  • Early initiation recommend for preventing/treating HIV-associated distal symmetric polyneuropathy
Gabapentin
  • First-line oral pharmacologic treatment
  • Typical adult regimen titrates to 2400mg/day in 2 divided doses
  • Improves sleep scores, somnolence
  • Patients with inadequate response might receive
    • Trial of SNRIs
    • Trial of TCAs
    • Trial of pregabalin for patients with post-herpetic neuralgia
Medical cannabis
  • May be effective in appropriate patients
  • Relatively high value placed on symptoms reduction, relatively low value placed on legal implication of medical cannabis possession
  • May be more effective for patients with prior cannabis use
  • Balance potential benefits against potential risks of neuropsychiatric adverse effects
  • Balance potential benefit against harmful effects of smoked forms in patients with preexisting severe lung disease
  • Balance risks of addiction in patients with cannabis use disorder
Alpha lipoic acid
  • For peripheral difficult-to-treat neuropathic pain
  • May be helpful for patients with diabetic neuropathy
Lamotrigine
  • Not recommended
  • May cause lamotrigine-related rash
Opioid analgesics
  • Do not use as first-line agents
  • Potential risk of pronociception, cognitive impairment, respiratory depression, endocrine/immunological changes, misuse/addiction
  • Consider time-limited trial for patients who do not respond to first-line therapies and report moderate-to-severe pain
  • Use smallest effective dose
  • Combine short- and long-acting opioids

HIV=human immunodeficiency virus; SNRI-serotonin-norepinephrine reuptake inhibitors; TCS=tricyclic antidepressant


Table 4
Opioid Analgesics for PLWH

Agent Comments/Rationale
Opioids as a class
  • Balance potential benefits with potential risks of adverse events, misuse, diversion, and addiction
  • As second- or third-line treatment, typical adult regimen should start with lowest effective dose and combine short- and long-acting opioids
Tramadol
  • Up to 3 months of use
  • May decrease pain and improve stiffness, function, overall well-being in patients with osteoarthritis
  • Use 37.5mg combined with 325mg of acetaminophen once/day to 400mg in divided doses

Table 5
Safeguarding Against Opioid-Related Harm

Recommendation Comments/Rationale
Routine monitoring
  • Consists of several components
    • Urine drug testing
    • Pill counts 
    • Prescription drug monitoring programs
Opioid patient-provider agreement (PPA)
  • Tool for shared decision-making
  • Consists of 2 components
    • Informed consent
    • Plan of care
  • Consider broad differential diagnosis when patient's behavior is inconsistent with PPA
Urine drug testing
  • Understand clinical uses/limitations
  • Understand test characteristics
  • Understand differential diagnosis of abnormal results

Table 6
Recommended Methods to Minimize Adverse Opioid-Related Events in PLWH

Recommendation Comments/Details
Safe storage
  • Store safely away from individuals at risk of misuse/overdose
Patient/family education
  • Educate family members about overdose signs
  • Have poison control number readily visible
  • Teach patients/caregivers about use of naloxone to reverse overdose and have naloxone rescue kit available
  • Educate patients/caregivers about adverse effects related to drug-drug interactions
Be knowledgeable about drug-drug interactions
  • Be prepared to identify/manage these interactions
  • Follow patients closely when interactions are likely

Table 7
Pharmacologic Management of Chronic Pain in PLWH Who Are Taking Methadone

Recommendation Comments/Details
Collaboration with opioid treatment program
  • Obtain signed release
  • Maintain ongoing communication with program for assessment/periodic monitoring
Initial screening
  • Electrocardiogram to identify QTc interval prolongation
  • Helpful if patient is taking other medications that may additively prolong QTc interval
Splitting methadone doses
  • Divide into 6- to 8-hour doses
  • Some programs may offer split-dose regimen, alternatively medical provider may need to prescribe remaining doses
If additional methadone not possible
  • Additional medication alternatives
    • Gabapentin for neuropathic pain
    • NSAIDs for musculoskeletal pain
    • Additional opioid
Acute exacerbations of pain ("breakthrough")
  • Use small amount of short-acting opioids

Table 8
Treating PLWH and Chronic Pain Who Are Taking Buprenorphine

Recommendation Comments/Details
Use adjuvant therapy for mild-to-moderate breakthrough pain
  • Includes nonpharmacologic treatments, steroids, nonopioid analgesics, and topical agents
Increase dosage of buprenorphine
  • Increase in divided doses as an initial step
If maximal dose of burprenorphine is reached
  • Add long-acting potent opiod (eg, fentanyl, morphine, hydromorphone)
If additional opioid is ineffective
  • Closely monitor trial of higher doses
If there is inadequate analgesia
  • Transition patient to methadone maintenance

Table 9
Recommended Instruments for Screening Common Mental Health Disorders in PLWH and Chronic Pain

Recommendation Comments/Details
Review patient's baseline mental status for modifiable risk factors
  • Self-esteem/coping skills
  • Recent major loss/grief
  • Unhealthy substance use
  • History of violence/lack of safety in the home
  • Mood disorders
  • Serious mental illness/suicidal ideation
Screen patients for depression
  • 2-question screen
    • During past 2 weeks have you been bothered by feeling down, depressed, hopeless?
    • During past 2 weeks have you had little interest/pleasure in doing things?
    • If affirmative, ask if patient would like help
Use screening tool
  • Patient Health Questionnaire-9 (PHQ-9) recommended
Screen for comorbid neurocognitive disorders
  • Includes frequent memory loss, slower reasoning, planning activities, or solving problems, difficulties paying attention
Neuropsychiatric evaluation
  • Recommended for all patients with chronic pain to establish baseline capacity

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Reference

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.

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