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:jmerlin@uabmc.edu