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JessicaS.Merlin,MD,MBAAssistantProfessorofMedicine
UniversityofAlabamaatBirminghamBirmingham,Alabama
ChronicPaininHIVPrimaryCare:APractical,Evidence-BasedApproach
LearningObjectives
Uponcompletionofthispresentation,learnersshouldbebetterableto:
• Developanevidence-basedapproachtotheoverallevaluationandmanagementofchronicpaininpeoplelivingwithHIV
• Assesstherisksandbenefitsoflong-termopioidtherapyinHIV-infectedindividualswithchronicpain(includingrisksinthosewhoarenotyetonopioidsandthoseinwhomopioidcontinuationisbeingassessed)
Agenda
• ChronicpaininHIV:stateofthescience• Evaluation• Management
Agenda
• ChronicpaininHIV:stateofthescience• Evaluation• Management
Opioids
Agenda
• ChronicpaininHIV:stateofthescience• Evaluation• Management
Whatischronicpain?
• >3months,beyondnormaltissuehealing• Examples:– chroniclowbackpain,otherregionalmskpain,chronicwidespreadpain,headaches,neuropathy
• Commoninthegeneralpopulation• Uniqueneurobiologicbasis• Heavilyinfluencedbybiological,psychological,andsocialfactors
IOM,RelievingPaininAmerica,2011;InteragencyPainResearchCoordinatingCommittee,NationalPainStrategy,2016.
Whatischronicpain?
• Associatedwithsubstantialdisability• Difficulttotreat• IOM/NationalPainStrategy:keyareaofresearchfocus,especiallyinpopulationsmostaffected
IOM,RelievingPaininAmerica,2011;InteragencyPainResearchCoordinatingCommittee,NationalPainStrategy,2016.
EpidemiologyofChronicPaininHIV
• Neuropathicpainisclassicallydescribed• Recentstudies:predominanceofmskpain• Multisitepaincommon
EllisRJ,ArchNeurol,2010;JiaoJM,Pain,2015;JohnsonA,JOpioidManag,2012;PerryB,JPallliatMed,2012;MiaskowskiC,JPain,2011.
EpidemiologyofChronicPaininHIV
• ChronicpainisanimportantcomorbidityinHIVfortwokeyreasons:– Prevalence(30-85%)– Impactonoutcomes:Retention,function,healthcareutilization,suboptimalARTadherence,useofheroinandrx opioids
JiaoJM,Pain,2015;MiaskowskiC,JPain,2011;EdelmanEJ,JGIM,2013;MerlinJS,JAIDS,2012;MerlinJS,PainMed,2013;Surratt,AIDSPtCareSTDs2015;KnowltonAR,JPalliatCare,2015.
Agenda
• ChronicpaininHIV:stateofthescience• Evaluation• Management
Question1:Iknowmypatient’spainisrealbecause:
a) Thepatientsayssob) Thepatient’spartnersayssoc) TheMRIsayssod) Ihavenoidea,howshouldIknow!?!
Historyandscreening• Allthatstuffyoulearnedinschool,plus:• Impactofpainonfunction:PEG,howtheyspendtheirtime• Painmanagementhistory(getrecords!)• Screenfor:–moodsymptoms:PHQ-2,GAD-7–etohandsubstanceuse:NIDAquickscreenhttps://www.drugabuse.gov/nmassist/–sleepproblems(andaskabouthistoryoftheseinthepast)
Notecopingandself-management
DiagnosticTesting
• Evidence-basedjudicioususeisbest• Youcan’talwaysseepainonanimageorabloodtest• Thisisachallengeforboththepatientandtheprovider
Expertopinion.
Agenda
• ChronicpaininHIV:stateofthescience• Evaluation• Management
Treatingchronicpainischallengingbecause:
• Communicationaboutchronicpaincanbedifficult–Patientsandproviderscomewithbaggage,opioidsratherthanfunctionalrestorationbecomethefocus
• Providersaren’ttrainedtodothis• Financialincentivestotakeabiomedicalapproach• Commonlyusedmedicationshavealimitedevidencebaseandcarryrisk• Patientsmayhavemooddisorders/addiction• Besttreatmentsareofteninaccessibletopatients
But…don’tdespair.ThereareLOTSofthingsyoucando.
Generalchronicpaintreatmentpearls
• Remember….first,donoharm!!• Focusonevidence-basedtherapies,avoidunnecessaryprocedures,surgeries,medications• Setconcretegoalsandtimelines• Bereadytodiscontinuetherapiesthatdon’twork• Ifpossible,treatpsychiatricillnessfirst
Expertopinion.
LearnsomeMIandCBTtricks
PainEducation
• Whatischronicpain• Patience• Partnershipandcollaboration• Pharmacologicandnon-pharmacologicmanagement• Roleofmultipleteammembers• Mind-bodyconnection• Functionalgoals
Non-opioidpharmacologictherapies
• Acetaminophen- OA,<3g,considerrelativecontraindications• NSAIDs- backpain,considerCV(naproxen),GI(cox-2/celecoxib),renalrisk• Musclerelaxants• Benzodiazepines• Anticonvulsants• Antidepressants• Topicals– Specificindications:e.g.,lidocainepost-herpeticneuralgia,capsaicinpost-herpetic/DSP,diclofenac-OA
Evidence-BasedNon-PharmacologicStrategies
• Behavioralapproaches• Physicaltherapy• Exercise• Interventionaltreatments• Complementaryandalternativetherapies• Surgery
HaydenJA,CochraneDatabaseSystRev, 2005;TraftonJA,JBehavHealthServRes,2012;CucciareCA,JBehavMed,2009;VickersAJ,ArchIntMed,2012.ICSIGuidelineforManagementofChronicPain;TurkDC,Lancet,2011,MirzaSK,Spine,2007.
Mybestadvicetoyou• Developateaminyouroffice:– Physician,nurse,socialworker,pharmacist
• Developateaminyourcommunity:– Physicaltherapist/PM&Rphysician– Anesthesiologist/interventionist– Psychologist– Psychiatrist– Addictionphysicianthatprescribesbup,naltrexone– Methadoneprogram– Addictiontreatmentprogram(Don’tforgetschools/trainingprograms)
Opioids
SlidecourtesyofErinKrebs.
Opioids
SlidecourtesyofErinKrebs.
Question2:Case
• 55y/omalewithHIV,onTDF/FTC/ral CD4500VL<25seeingyouforroutinefollow-up
• Alsohasahistoryofdepressiononescitalopram10mgdaily,hypertension,diabetes,hyperlipidemia
• Historyofheroinandcocaineaddictioninhis20s• Attheendofyour15minuteencounter…mentionshehashadlowbackpainforpast6monthsandasksforhydrocodone-acetominophen
• Noredflags;unremarkableneuroexam;nopersonalhistoryofmalignancy
Question2:Casecont’dWhatdoyoudonext?
a. Prescribehydrocodone-acetominophen,#90permonthwithrefills,andarrangefollow-upinayear
b. Informhimthatyoudonotprescribeopioidstopatientswithahistoryofaddiction,andreferhimtothelocalpainclinic
c. TellhimyouwillneedanMRItodetermineifhehaspain,anddependingontheresults,youwillconsideranopioid
d. Performahistoryandphysicalexam,considerwhetheradditionalworkupisneeded,anddiscusspharmacologicandnon-pharmacologicmanagementoptions
Why?Theperfectstorm.
• Painisthe5th vitalsign=painisalwaysanemergency• Palliativecare’searlysuccesses• Misinterpretationofearlystudies• Marketingoflong-actingoxycodone• Professionalorganizations,keyindividuals
Mytakeonopioids• TheyARENOTfirst-linetherapyforchronicpain• Theyworkforsomepeople• However,evidenceofbenefitislimited• Whatweknowabouttheirriskisgrowing• Ifstarted:– Theyshouldalwaysbeconsidereda“time-limitedtrial”– Findlowesteffectivedose
• TherecentCDCGuidelineforPrescribingOpioidsforChronicPainisagoodstartingplace:
https://www.cdc.gov/drugoverdose/prescribing/guideline.html
Lackofevidenceofbenefit
• “Nostudyofopioidtherapyversusplacebo,noopioidtherapy,ornonopioidtherapyevaluatedlong-term(>1year)outcomesrelatedtopain,function,orqualityoflife…..Evidenceisinsufficienttodeterminetheeffectivenessoflong-term opioid therapyforimprovingchronicpainandfunction.”
ChouR,AnnalsInternMed,2015.
Lotsofevidenceofrisks/harms
• “Evidencesupportsadose-dependentriskforseriousharms.”– Decreasedfunction/returntowork– Induceddepression(duration>dose)–Motorvehicleaccidents(OR1.2-1.4≥20mgequivalentsofmorphinecomparedto<20)
– Falls(especiallysoonafterinitiation)– Addiction(~10%)– Overdose(worsewithdose>100mgequivalentsofmorphine,co-rxbenzos)
Webster BS et al, Spine, 2007; White KT et a, Am J Phys Med Rehabil, 2009; Volinn E et al,Pain, 2009; Franklin GM et al, Spine, 2008; Brede E et al, Arch Phys Med Rehabil, 2012;Degenhardt L, Lancet Psychiatry, 2015; Chou R, Annals Intern Med, 2015; CDC,MMWR, 2016;Brennan MJ, Am J Med, 2013; Scherrer JF, JGIM, 2013; Soderberg KC, CNS Drugs, 2013;Gomes T, JAMA Int Med, 2013.
Whattodowhenyouhaveapatientsittinginfrontofyou
Imagecourtesyof:www.pilladvised.com
Whethertostart(lesscommoncase)
• “Nonpharmacologictherapyandnonopioidpharmacologictherapyarepreferredforchronicpain.Cliniciansshouldconsideropioidtherapyonlyifexpectedbenefitsforbothpainandfunctionareanticipatedtooutweighriskstothepatient.Ifopioidsareused,theyshouldbecombinedwithnonpharmacologictherapyandnonopioidpharmacologictherapy,asappropriate(recommendationcategory:A,evidencetype:3).”
CDC,MMWR,2016.
Whethertocontinue(morecommoncase– “inheriting”)• “Cliniciansshouldevaluatebenefitsandharmsofcontinuedtherapywithpatientsevery3monthsormorefrequently.Ifbenefitsdonotoutweighharmsofcontinuedopioidtherapy,cliniciansshouldoptimizeothertherapiesand workwithpatientstotaperopioidstolowerdosagesortotaperanddiscontinueopioids(recommendationcategory:A,evidencetype:4).”
CDC,MMWR,2016.
Howto“evaluateforharms”
• “Universalprecautions”approach–OpioidTreatmentAgreements–UrineDrugTesting–PractitionerDatabaseMonitoringProgramsLimitedevidence,butcanbeveryuseful,becomingstandardofcare.Knowyourstate’srequirements.
• BealerttoconcerningbehaviorsthatcanariseGourlayD,PainMed,2005;StarrelsJL,AnnIntMed,2010.
OpioidTreatmentAgreements
• NOTcontracts• Informedconsent;youandyourpatient’sresponsibilities–Oneprescriber,onepharmacy–Takeasprescribed,nochangesonone’sown–Urinedrugtesting–Howmedicinesarerefilled,replacementrxs–Conditionsforstoppingopioids
UrineDrugTesting• Usefulforcheckingforadherencetorx’ddrugsandforpresenceofsubstancesnotrx’d
• “Atoolnotanoracle”:lotsofpitfalls• Sendscreeningimmunoassay;discussunexpectedresults;ifstillunclear,sendconfirmatorytest(GCMS/LCMS);ifstillunclear,considerddx
• Knowyourtoxicologist• Bemindfulofcost• ConsiderPOC
• Decisionsupport:Mytopcare.orgStarrelsJL,AnnIntMed,2010.
PrescriptionDrugMonitoringPrograms(PDMP)
• State-by-state,lotsofvariability• TellsyouthreethingsthatpredictOD:–Dose–multiplerx’s–opioidandbenzoco-rx
ConcerningBehaviors• Examplesinclude:– Unexpectedurineresults– Runningoutearly/otherrxproblems–Multipleprescribers– Belligerentbehavior
• Allhaveadifferentialdiagnosis• Tipsforevaluatingthesebehaviors:– Detailedexplorationwithpatient– Re-education– Closermonitoring,smallprescriptions(isthisapattern?doesthepatienthaveanopioidusedisorder?)
– Involvementofpsychiatry/addictioncolleagues
Pearlsaboutharms
• Trytodecidewhetherthepatienthasanopioidusedisorder(soyoucanrefertotx)• ThiscanbeHARD• Regardless:youmaydeterminethattherisksofopioidrx>benefits
RecognizingOpioidUseDisorder(1/2)1. Opioidsareoftentakeninlongeramountsoroveralongerperiodthanwasintended.
2. Thereisapersistentdesireorunsuccessfuleffortstocutdownorcontrolopioiduse.
3. Agreatdealoftimeisspent inactivitiesnecessarytoobtaintheopioid,usetheopioid,orrecoverfromitseffects.
4. Craving,orastrongdesireorurgetouseopioids.5. Recurrentopioiduseresultinginafailuretofulfillmajorroleobligationsatwork,school,orhome.
DSM-5.
RecognizingOpioidUseDisorder(2/2)6.Continuedopioidusedespitehavingpersistentorrecurrentsocialorinterpersonalproblemscausedorexacerbatedbytheeffectsofopioids.7.Importantsocial,occupational,orrecreationalactivitiesaregivenuporreducedbecauseofopioiduse.8.Recurrentopioiduseinsituationsinwhichitisphysicallyhazardous.9.Continuedopioidusedespiteknowledgeofhavingapersistentorrecurrentphysicalorpsychologicalproblemthatislikelytohavebeencausedorexacerbatedbythesubstance.
DSM-5.
TreatingOpioidUseDisorder
• Threeevidence-based,FDA-approvedmedications:–Buprenorphine(onWHOlistofessentialmeds*)–Methadone(onWHOlistofessentialmeds*)–Naltrexone
*http://www.who.int/medicines/publications/essentialmedicines/en/
Naloxone
• $85foratwo-pack• Coveredbymanyinsurances• Considerinallpatients,especiallyhighdose• Knowlocallaws
Question3:Youshouldroutinelytellpatientswith
chronicpainthat:
a. Ifthey“break”theirpain“contract,”youwillgetangryandfirethemfromthepractice
b. Thegoalofpainmanagementisimprovementinphysicalfunction,ratherthanbeing“pain-free”
c. Theirpainis“mostlypsychological”d. Iftheygototheirinitialvisitwiththeirpaindoctor,theywill
getopioids
Thisiscomplicated!MaybeIcanjustavoidit…
• Thebadnews:therearen’tenoughpainspecialiststoseepatientswithchronicpain• So:–Whetheryou’reinprimarycare,psychiatry,neurology,palliativecare,oranothersubspecialty….–Whetheryou’readoctor,NP,PA,RN,socialworker,pharmacist….
• Patientswilllooktoyouforhelp.Youwillbetheirbestchanceofgettinghelp• Itissorewarding
Howtomakethisaseasyaspossible
• Developsystemsinyourpractice• Utilizeuniqueskillsofteammembers• Developpoliciesandagreed-uponapproaches• Utilizeresources–Thosementionedtoday–CDCmaterials–Conferences:AMERSA,ASAM,regionalAPS–Providers’ClinicalSupportSystem(PCSS)
Insum
• Chronicpainisamajorproblem• Wehavealotmoretoofferthanopioids• Ifyoudoprescribeopioids(andyouwill),useauniversalprecautionsapproach• Diagnoseandfacilitateaddictiontreatment• Utilizeavailableresources
Mycontactinformation:[email protected]