Slide 1 of 12

From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA. IAS–USA

Jessica S. Merlin, MD, MBAAssistant Professor of Medicine

University of Alabama at Birmingham

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

From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.

Slide 2 of 12

From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.

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.

Turk DC, Lancet, 2011; Institute of Medicine, 2012.

From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.

Chronic pain in persons with HIV

Slide courtesy of Joanna Starrels. From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.

Slide 5 of 12

From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.

Chronic pain history

Impact of pain on:– Function– Mood– Sleep

– Ask: “Some people report that pain impacts X; is that true for you?”

ICSI Guideline for Management of Chronic Pain; Kerns RD, Pain, 1985.

Slide 6 of 12

From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.

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

Slide 7 of 12

From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.

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

Slide 8 of 12

From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.

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

Slide 9 of 12

From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.

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

Slide 10 of 12

From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.

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.

Slide 11 of 12

From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.

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.

Slide 12 of 12

From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.

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 symptomsFor more information: IAS-USA Cases on the Web

For more information: IAS-USA Cases on the Web