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