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The Center for Palliative Care Education
Assessing and Managing Pain in HIV/AIDS
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Learning objectives
• Understand the common etiologies and the diagnostic evaluation for pain in HIV/AIDS
• Know characteristics of and treatment approaches for nociceptive vs. neuropathic pain
• Describe pitfalls in treating pain in patients with substance abuse
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Overview
• Case I: 35 M with HIV
–Neuropathic pain
• Case 2: 60 F with HIV and avascular necrosis
–Nociceptive pain
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Case 1
• 35-year-old HIV+ man on antiretroviral therapy: –Burning, shooting, lower extremity pain–Intermittent–Not responsive to oxycodone/acetminophen (Percocet)
–Neuro exam unremarkable
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Neuropathic pain
•Disordered peripheral or central nerves
•Compression, metabolic injury, ischemia, infiltration
•Peripheral, deafferentation, regional syndromes
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Neuropathic pain syndromes with HIV/AIDS
• HIV neuropathy, myelopathy
• Antiretroviral medication (dideoxynucleosides)
• Chemotherapy
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Additional causes of neuropathic pain
• Herpes zoster
• Diabetes
• Multiple sclerosis
• Alcoholism
• Amputation (phantom limb)
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Neuropathic pain
• Pain may exceed observable injury
• Described as: burning, tingling, shooting, stabbing, electrical
• Management:
–Adjuvant medications
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Pain assessment
• History: Quality, timing of pain
• Exam: Neuropathy, color, skin temperature, sensation
• Watch for: Allodynia (pain from mild stimulation, such as touching or rubbing)
• Use 0 – 10 scale
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Pain management
• Switch antiretroviral medication if suspicion is high
• Don’t delay for investigations or disease treatment
• Unrelieved pain causes nervous system changes:
–Permanent damage
–Amplification of pain• Address underlying cause where possible
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Evidence-based treatment of neuropathic pain
• Amitriptyline 10-75 mg po qhs:
–No placebo-controlled trials for HIV neuropathy
–+ controlled trials for diabetic neuropathy• Gabapentin (Neurontin) 100-800 tid:
–Widely used, renally cleared• Lamotrigine (Lamictal):
–200-400 mg qd
–Rare Stevens-Johnsons La Spina; Eur J Neurol 2001; 8:71-5
Simpson; Neurology 2000; 54:2115-9
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Evidence-based treatment of neuropathic pain
• Topical Capsaicin (Zostrix): Often not well tolerated
• Topical Lidocaine gel
• Acupuncture: A negative trial in HIV
• Phenytoin: Occasional responders, no + controlled trials
• Mexiletine: No better than placebo (ACTG 242)
Paice; J Pain Symptom Manage 2000; 19:45-52Shlay; JAMA 1998; 280:1590-5Kieburtz; Neurology 1998; 51:1682-8
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Case 1: Management
• HIV meds switched to non-ddI regimen
• Trial amitriptyline 10 mg qhs escalated to 100 mg qhs over 2 weeks
• Mild relief but still very bothersome
• Gabapentin 100 mg tid escalated to 300 mg tid over 2 weeks
• Substantial relief
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Summary points: Case 1
• Neuropathic pain:
–Characteristic history
–Physical findings incl Allodynia
–Need adjuvant meds (Gabapentin)
–May also need opioids
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Case 2
• 60 F HIV+ x 7 years
• Presented with aching hip pain, worse at night
• Diagnosed with avascular necrosis related to HIV
• Treated with calcium
• Started on oxycodone/acetaminophen 5mg 6x/d
• PMH alcohol abuse
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Nociceptive pain
• Direct stimulation of intact nociceptors (pain receptors)
• Transmission along undamaged nerves
• Quality of pain: aching, throbbing
–Somatic: easy to localize
–Visceral: difficult to localize
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Nociceptive pain
• Tissue injury apparent
• Management:
–Opioids
–Co-analgesics (NSAIDS) when possible
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WHO 3-step ladder
Morphine
Hydromorphone
Methadone
Levorphanol
Fentanyl
Oxycodone
± Adjuvants
3 severe
2 moderate
A/Codeine
A/Hydrocodone
A/Oxycodone
A/Dihydrocodeine
± Adjuvants
1 mild
ASA
Acetaminophen
NSAIDs
± Adjuvants
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Acetaminophen
• WHO Step 1 drug
• Site, mechanism of action unknown
• Minimal anti-inflammatory effect
• Hepatic toxicity if > 4 g / 24 hours:
–increased risk
hepatic disease, heavy alcohol use
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Non-steroidal anti-inflammatory medications (NSAIDS)
• WHO Step 1: Analgesic, coanalgesic
• Inhibit cyclo-oxygenase (COX):
– Vary in COX-2 selectivity
• All have analgesic ceiling effects:
–Effective for bone, inflammatory pain
–Individual variation, serial trials
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NSAIDs
• Highest incidence of adverse events
• Gastropathy:
–gastric cytoprotection
–COX-2 selective inhibitors
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Short-acting opioids
• WHO Step 2:
• Short-acting opioids combined with acetaminophen
• Useful for moderate pain
• Short half-life (3-4 hours at most)
• Use limited by limitations of acetaminophen
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Opioids: Routine oral dosing
• WHO Step 3:
• Use extended-release preps (morphine SR) to improve compliance, adherence
• Dose q 8, 12, or 24 h (product specific):
–Don’t crush or chew tablets
• Adjust dose q 2–4 days (i.e., once steady state reached)
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Morphine dosing
• Escalate until pain is relieved
• Refrain from combining opiates
• Consider documenting a pain plan in the chart
• Low opioid dosing for chronic, non-malignant pain is an option
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Opioids: Breakthrough dosing
• Use immediate-release opioids (morphine IR or elixir):
–5%–15% of 24-h dose
• Do NOT use extended-release opioids for breakthrough pain
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Opioids: Essential pharmacology
• Conjugated by liver
• 90%–95% excreted in urine
• If dehydration, renal failure, severe hepatic failur:
dosing interval, dosage size
for oliguria or anuriaSTOP routine dosing of morphineuse ONLY prn
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Not recommended
• Meperidine (demerol)
• Mixed agonists-antagonists (Talwin)
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Opioid Side Effects
• Constipation
• Drowsiness
• Neuropsychiatric symptoms, including vivid or bad dreams
• Myoclonic jerks
• Delirium
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Switching Opioids
• Consider switching if dose-limiting toxicity develops
• Use an equianalgesic chart
• Adjust the new dose for incomplete cross tolerance
–Start with about 2/3 the new calculated dose
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Switching Opioids Example
• 60 mg morphine SR q12h (120 mg/24 hours)
• To convert to SR oxycodone:
–Equianalgesic dose: 120 mg/1.5=80 mg
–New dose: 2/3 x 80 = 55 mg
• Start with SR oxycodone 30 mg q 12h
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Approach to managing substance abuse
• Respect patient’s report of pain
• Distinguish between tolerance and addiction (psychological dependence)
• Distinguish between active users and those in recovery
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Approach to managing substance abuse
• Set clear goals for opioid therapy
-identify and discuss abuse behaviors
-use written contracts
-establish single provider
• Use a multidimensional approach:
-attention to psychosocial issues
-team approach
• Reflect on your own attitudes towards substance abuse
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Is use of opioids appropriate?
• Literature for cancer pain and substance abuse suggests:
–Relapse of substance abuse occurs but is not common
–Under treatment of pain contributes to substance abuse
–Clear limits are needed
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Pitfalls in treating patients with substance abuse
• Not believing pain reports
• Not prescribing adequate pain meds
• Not setting clear limits regarding prescriptions
• Clinician attitudes
• Having multiple clinicians prescribe
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Case 2: Management
• Taking percocet 5mg 6x/d• Changed to long-acting oxycodone 30 mg
q12• Morphine IR 10 mg q1 hour prn
breakthrough pain• Bowel regimen: 4 glasses water, senekot
2 tabs qhs• Improved mood, activity
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Summary points: Case 2
• Severe nociceptive pain often requires opioids
• Use long- and short-acting opioids together
• Treating patients with substance abuse with opioids can be successful
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Contributors
Anthony Back, MD DirectorJ. Randall Curtis, MD, MPH Co-DirectorFrances Petracca, PhD EvaluatorLiz Stevens, MSW Project Manager
Visit our Website at uwpallcare.org
Copyright 2003, Center for Palliative Care Education, University of Washington
This project is funded by the Health Resources and Services Administration (HRSA) and the Robert Wood Johnson Foundation (RWJF).