New Guidelines Issued for Managing Chronic Pain in HIV Patients

All PLWH should receive brief standardized screening for chronic pain
All PLWH should receive brief standardized screening for chronic pain

The HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA) has released new guidelines for the management of chronic pain in patients living with human immunodeficiency virus (PLWH).1 This article provides a brief summary of the guidelines.

Recommended Approach to Screening and Initial Assessment of PLWH and Chronic Pain

  • All PLWH should receive brief standardized screening for chronic pain. A biopsychosocial approach should be used; and appropriate monitoring should take place. (Table 1)

Recommended General Approach to Management of PLWH and Chronic Pain

  • Healthcare providers should develop and participate in interdisciplinary teams
  • For patients with controlled pain, any new report of pain should be carefully investigated. While the issue is being evaluated, these patients may require added treatments or adjustment in the dose of pain medications
  • Clearly document new symptoms
  • Consult with a provider experienced in pain management of PLWH or with a pain specialist

Recommended Therapeutic Approach to Chronic Pain for PLWH at the End of Life

  • Age-related and HIV-related changes and comorbidities may cause changes in pain experiences in patients with HIV. Clinicians should address these changes in the context of disease progression.
  • A multidisciplinary team approach is necessary for maintaining pain control and communicating with the patient and his/her support system.
  • Clinicians should use language that patients and families can understand and may need to schedule longer appointments to work out the goals of care
  • Consult with a palliative care specialist
  • For patients with advance illness, a support system beyond the clinician might be necessary and the primary care clinician should remain in communication with the patient and family through the end of life for accurate continuity of care and to avoid a sense of abandonment on the patient's part.

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Recommended Nonpharmacologic Treatment for Chronic Pain in PLWH  (Table 2)

  • The authors recommend cognitive behavioral therapy, yoga, physical/occupational therapy, hypnosis, and a trial of acupuncture.

Recommended Pharmacologic Treatments for Chronic Neuropathic Pain in PLWH (Table 3)

  • The authors recommend early initiation of antiretroviral therapy, gabapentin, capsaicin, medical cannabis, and alpha lipoid acid (ALA).
  • The authors recommend against using lamotrigine.

Recommended Nonopioid Pharmacologic Treatments for Chronic Nonneuropathic Pain in PLWH

  • The authors recommend acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line agents for musculoskeletal pain, noting that acetaminophen has fewer side effects than NSAIDs.
  • Lower dosing is recommended for those with liver disease.