palliative care in hiv/aids hivmanagement/palliative.html

Palliative Care in HIV/AIDShttp://hivmanagement.org/palliative.html

James A Zachary MDLSU Health Sciences Center

Delta AETC

December 13, 2004

• 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

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)

HIV/AIDS Palliative Care Issues

• Miscellaneous pain– Chronic musculoskeletal

pain especially spinal pain– Chronic headaches– Trauma-related injuries– Chronic post-operative

pain

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!!!!

WHO Analgesic Ladder

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

acute headache

Acute Pain• NSAIDs• Buprenorphene IM• Tramodol• Merperidine• Codeine/acetaminophen• Hydrocodone/acetaminophen or

ibuprofen• Oxycodone/acetaminophen or aspirin• Oxycodone• Hydromorphone• Immediate release morphine sulfate

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

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*

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

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.

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

Pain In Addicts

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

Pain In Addicts• Boundary issues are extremely

important!• Consider a Pain Management

referral• Consider a Mental Health

referral

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

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

Nausea Control

• Be aggressive in approach!• Diagnose and treat underlying cause if

possible• Prevent nausea: much easier than

suppressing it once started!

Nausea Control

• Phenothiazines: promethazine (Phenergan), prochlorperazine (Compazine), etc.

• Metoclopropamide (Reglan)• Ondansetron (Zofran), granisetron (Kytril)• Dranabinol (Marinol)• Lorazepam• Haloperidol (Haldol)• Dexamethasone (Decadron)

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.