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Slide 1 of 12
Chronic Pain in Patients with HIV:
What Clinicians Need to Know
Jessica S. Merlin, MD, MBA
Assistant Professor of Medicine
University of Alabama at Birmingham
From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.
IAS–USA
Slide 2 of 12
Acute vs. Chronic Pain
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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.
From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.
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
Antiretroviral
therapy
(e.g., nucleoside
neuropathy)
Opportunistic
Infections
(e.g., herpes
zoster)
HIV infection
(e.g., distal
sensory
polyneuropathy)
Chronic
Pain
Slide courtesy of Joanna Starrels.
From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.
Treatment of OI’s
(e.g., INH
polyneuropathy)
Non-HIV
(e.g., low back
pain, other MSK
pain)
Slide 5 of 12
Chronic pain history
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Impact of pain on:
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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.
From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.
Slide 6 of 12
Communicating about
Chronic Pain
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Not easy, because:
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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
From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.
Slide 7 of 12
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
From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.
Slide 8 of 12
Evidence-Based Management
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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
From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.
Slide 9 of 12
Evidence-Based Non-Opioid
Pharmacologic Therapy
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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
From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.
Slide 10 of 12
A Moment on Opioids….
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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.
From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.
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How to decide
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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.
From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.
Slide 12 of 12
Key Points
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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 symptoms
For more information: IAS-USA Cases on the Web
From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.