Management of Chronic Pain in Patients Living With Human Immunodeficiency Virus
Diagnosis
Screening and Initial Assessment
“Do you have bodily pain that has lasted for more than 3 months?”
Remark: A response of moderate pain or more during the last week combined with bodily pain for >3 months can be considered a positive screen result.
a https://www.painedu.org/Downloads/NIPC/Brief_Pain_Inventory.pdf
b http://health.gov/hcq/trainings/pathways/assets/pdfs/PEG_scale.pdf
Treatment
Management
Non-Pharmacological Treatments
Pharmacological Treatments For Neuropathic Pain
Non-Opioids
Capsaicin is recommended as a topical treatment for the management of chronic HIV-associated peripheral neuropathic pain.
( S , H)Values and preferences: This recommendation places a relatively high value on the reduction of symptoms and a relatively low value on the legal implication of medical cannabis possession.
Remark: Current evidence suggests medical cannabis may be more effective for patients with a history of prior cannabis use, and the potential benefits of a trial of cannabis need to be balanced against the potential risks of neuropsychiatric adverse effects at higher doses, the harmful effects of smoked forms of cannabis in patients with pre-existing severe lung disease, and addiction risk to patients with cannabis use disorder.
Values and preferences: This recommendation places a high value on providing tolerable medications which may be of some benefit in patients with difficult-to-treat neuropathic pain.
Remark: Studies in patients with HIV are lacking. However, there is a growing body of literature of the benefits of ALA in patients with diabetic neuropathy.
Values and preferences: This recommendation places a relatively high value on the discontinuation of neurotoxic agents and minimizing the incidence of lamotrigine-associated rash and places a relatively low value on the reduction in pain symptoms found in an earlier RCT by the same authors.
Opioids
Pharmacological Treatments For Non-Neuropathic Pain
Non-Opioids
Opioids
Values and preferences: This recommendation places a relatively high value on safer opioid prescribing. The potential benefits of opioid analgesics need to be balanced with the potential risks of adverse events, misuse, diversion, and addiction.
Remark: As a second or third line treatment for chronic non-neuropathic pain, a typical adult regimen should start with the smallest effective dose, combining short- and long-acting opioids.
Consequences of Opioid Treatment
(e.g., misuse, substance use disorder, possible diversion)
Values and preferences: This recommendation places a high value on clinical strategies that neutralize bias and reduce stigma in the care of all PLWH and the possibility of behavior change over time.
Remark: A patient’s history of addiction or substance use disorder is not an absolute contraindication to receiving controlled substances for the management of chronic pain. A risk-benefit framework that views controlled substances as medications with unique risks to every patient (“a universal precautions approach”) should be applied uniformly to help providers make fair and informed clinical decisions about controlled substance prescribing.
Methadone
Buprenorphine
Mental Health Disorders
Remark: Potentially modifiable factors include: self-esteem and coping skills, recent major loss or grief, unhealthy substance use, history of violence or lack of safety in the home, mood disorders, history of serious mental illness or suicidal ideation.
- During the past two weeks have you often been bothered by feeling down, depressed, or hopeless?
- During the past two weeks have you been bothered by little interest or pleasure in doing things?
a http://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf
b http://ccoe.rbhs.rutgers.edu/online/ARCHIVE/12HC03/article4.htm
Recommendation Grading
Overview
Title
Management of Chronic Pain in Patients Living With Human Immunodeficiency Virus
Authoring Organizations
HIV Medicine Association
Infectious Diseases Society of America
Publication Month/Year
October 30, 2017
Last Updated Month/Year
March 18, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Correctional facility
Intended Users
Addiction treatment specialist, counselor, nurse, nurse practitioner, physician, physician assistant, psychologist
Scope
Counseling, Assessment and screening, Treatment, Management
Diseases/Conditions (MeSH)
D059350 - Chronic Pain, D006678 - HIV
Keywords
pain, chronic pain, HIV/AIDS, HIV, HIV Pain
Source Citation
R Douglas Bruce, Jessica Merlin, Paula J Lum, Ebtesam Ahmed, Carla Alexander, Amanda H Corbett, Kathleen Foley, Kate Leonard, Glenn Jordan Treisman, Peter Selwyn, 2017 HIV Medicine Association of Infectious Diseases Society of America Clinical Practice Guideline for the Management of Chronic Pain in Patients Living With Human Immunodeficiency Virus, Clinical Infectious Diseases, Volume 65, Issue 10, 15 November 2017, Pages 1601–1606, https://doi.org/10.1093/cid/cix848