First Comprehensive Guidelines for Chronic Pain in HIV

Veronica Hackethal, MD

September 14, 2017

The HIV Medicine Association (HIVMA) of the Infectious Disease Society of America (IDSA) has issued the first comprehensive guidelines for managing chronic pain in people living with HIV.

The guidelines, published online September 14 in Clinical Infectious Diseases, recommend that everyone living with HIV be screened for chronic pain. People who screen positive should be offered multidisciplinary treatment focused on nondrug therapies.

"It has been long known that patients with HIV/AIDS are at high risk for pain, and for having their pain inadequately diagnosed and treated," Peter Selwyn, MD, MPH, said in a news release. Dr Selwyn was cochair of the guidelines committee and is affiliated with Albert Einstein College of Medicine, Bronx, New York.

Between 39% and 85% of people living with HIV experience chronic pain, the authors note. And pain represents the second most common symptom for which patients with HIV seek care in outpatient settings. Because chronic pain has been linked to poor adherence to antiretroviral therapy (ART), treating chronic pain may be important for disease management, as well as quality of life.

However, pain often goes undertreated among people living with HIV. In particular, women, people with low socioeconomic status, and injection drug users often do not receive adequate pain management. Moreover, many patients do not have access to pain specialists.

To counter these issues, the IDSA stresses that all providers who care for patients with HIV should be familiar with chronic pain management.

"These comprehensive guidelines provide the tools and resources HIV specialists need to treat these often-complex patients, many of whom struggle with depression, substance use disorders, and have other health conditions such as diabetes," first author Douglas Bruce, MD, from Yale University in New Haven, Connecticut, said in the news release.

Musculoskeletal and Neuropathic Pain

The guidelines were drawn up by 10 experts in HIV, pain, pharmacology, psychiatry, palliative care, and addiction medicine and were based on a review of literature published between 1966 and 2016.

Recommendations cover musculoskeletal pain, such as lower back pain or joint pain caused by arthritis, and neuropathic pain, which accounts for almost half of chronic pain in HIV and may be caused by inflammation, the effects of ART, or direct injury to the central or peripheral nervous system caused by HIV infection. They guidelines do not cover cancer pain, which should be managed according to current cancer pain guidelines, the authors say.

According to the guidelines, all patients with HIV should be screened for chronic pain using two simple questions: "How much bodily pain have you had during the last week?" and "Do you have bodily pain that has lasted for more than 3 months?"

People with moderate or higher pain in the last week, along with bodily pain for more than 3 months should receive a comprehensive evaluation, with a physical exam, psychosocial evaluation, and diagnostic testing. Treatment should focus on a multidisciplinary approach.

"Because HIV clinicians typically are not experts in pain management, they should work closely with others, such as pain specialists, psychiatrists and physical therapists to help alleviate their patients' pain," Dr Bruce said in the news release.

Patients should also have periodic monitoring, medication adjustment as needed, and referral to a pain specialist when possible. The guidelines also emphasize early initiation of ART, which may prevent and treat some forms of HIV-associated nerve pain.

The treatment approach stresses nondrug therapy, with recommendations for cognitive behavioral therapy, yoga, physical and occupational therapy, and hypnosis. Providers may also consider acupuncture.

If nondrug therapy proves inadequate, nonopioid drugs can be tried, with the antiseizure medication gabapentin considered first-line. In cases of inadequate response, serotonin norepinephrine reuptake inhibitors, tricyclic antidepressants, or pregabalin can be tried. Other recommended agents include capsaicin (a topical pain relieve derived from chili peppers), medical cannabis in appropriate patients, and alpha lipoic acid (an antioxidant that has been found to reduce diabetic nerve pain).

The guidelines recommend against using lamotrigine, as benefit has only been seen in patients receiving neurotoxic ART. The IDSA recommends discontinuing all neurotoxic ART.

The IDSA also makes a strong recommendation against using opioids as first-line management for chronic pain in people living with HIV because of the risk for misuse, addiction, cognitive impairment, respiratory depression, and endocrine or immune changes.

"Opioids are never first-line," Dr Bruce said in the news release. "The guidelines always recommend the most effective treatment with the lowest risk."

However, opioids may be considered as a second- or third-line therapy in patients with inadequate response to first-line therapies and with moderate to severe pain, and when the benefits outweigh the potential harms.

The guidelines also cover several other issues, including approaches for treating chronic pain near the end of life, managing chronic pain in people with substance abuse and mental health conditions, and assessing and safeguarding against harms when using opioids. They also provide a table listing drug interactions between ART agents and opioids.

The authors have disclosed no relevant financial relationships.

Clin Infect Dis. Published online September 14, 2017. Full text

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