New Guidelines Issued for Managing Chronic Pain in HIV Patients

Table 1
Screening and Initial Assessment

Recommendation	Commentary/Details
Standardized screening	How much bodily pain have you had during the last week (none, very mild, mild, moderate, severe, very severe) Do you have bodily pain that has lasted for >3 months? A response of moderate pain or more during last week plus bodily pain for >3 months can be considered a positive screen result
If patient screens positive on initial assessment	Use biopsychosocial approach that includes: An evaluation of the pain’s — Onset and duration Intensity and character Exacerbating and alleviating factors Past and current treatments Underlying or co-occurring disorders and conditions The effect of pain on psychological function Physical examination Psychosocial evaluation Diagnostic workup Pain assessment tools can include Brief Pain Inventory (BPI) 3-item pain health questionnaire (PEG)
Monitoring patients	Periodically assess progress on achieving functional goals Documentation of pain intensity, quality of life, adverse events, and adherent vs aberrant behaviors Conduct assessments at regular intervals and after each change/initiation of therapy after an adequate amount of time

Table 2
Nonpharmacologic Approaches for PLWH

Modality	Features, Rationale
CBT	Acceptance of responsibility for change Development of adaptive behaviors (eg. exercise) Addressing maladaptive behaviors (eg, avoidance of exercise due to fear of pain)
Yoga	Treatment of chronic neck/back pain, headache, rheumatoid arthritis, general musculoskeletal pain
Physical/occupational therapy	For chronic pain
Hypnosis	Neuropathic pain
Acupuncture	A trial might be considered for chronic pain

CBT=cognitive behavioral therapy

Table 3
Pharmacologic Treatments for Chronic Neuropathic Pain in PLWH

Treatment	Recommendations
Antiretroviral therapy	Early initiation recommend for preventing/treating HIV-associated distal symmetric polyneuropathy
Gabapentin	First-line oral pharmacologic treatment Typical adult regimen titrates to 2400mg/day in 2 divided doses Improves sleep scores, somnolence Patients with inadequate response might receive Trial of SNRIs Trial of TCAs Trial of pregabalin for patients with post-herpetic neuralgia
Medical cannabis	May be effective in appropriate patients Relatively high value placed on symptoms reduction, relatively low value placed on legal implication of medical cannabis possession May be more effective for patients with prior cannabis use Balance potential benefits against potential risks of neuropsychiatric adverse effects Balance potential benefit against harmful effects of smoked forms in patients with preexisting severe lung disease Balance risks of addiction in patients with cannabis use disorder
Alpha lipoic acid	For peripheral difficult-to-treat neuropathic pain May be helpful for patients with diabetic neuropathy
Lamotrigine	Not recommended May cause lamotrigine-related rash
Opioid analgesics	Do not use as first-line agents Potential risk of pronociception, cognitive impairment, respiratory depression, endocrine/immunological changes, misuse/addiction Consider time-limited trial for patients who do not respond to first-line therapies and report moderate-to-severe pain Use smallest effective dose Combine short- and long-acting opioids

HIV=human immunodeficiency virus; SNRI-serotonin-norepinephrine reuptake inhibitors; TCS=tricyclic antidepressant

Table 4
Opioid Analgesics for PLWH

Agent	Comments/Rationale
Opioids as a class	Balance potential benefits with potential risks of adverse events, misuse, diversion, and addiction As second- or third-line treatment, typical adult regimen should start with lowest effective dose and combine short- and long-acting opioids
Tramadol	Up to 3 months of use May decrease pain and improve stiffness, function, overall well-being in patients with osteoarthritis Use 37.5mg combined with 325mg of acetaminophen once/day to 400mg in divided doses

Table 5
Safeguarding Against Opioid-Related Harm

Recommendation	Comments/Rationale
Routine monitoring	Consists of several components Urine drug testing Pill counts  Prescription drug monitoring programs
Opioid patient-provider agreement (PPA)	Tool for shared decision-making Consists of 2 components Informed consent Plan of care Consider broad differential diagnosis when patient’s behavior is inconsistent with PPA
Urine drug testing	Understand clinical uses/limitations Understand test characteristics Understand differential diagnosis of abnormal results

Table 6
Recommended Methods to Minimize Adverse Opioid-Related Events in PLWH

Recommendation	Comments/Details
Safe storage	Store safely away from individuals at risk of misuse/overdose
Patient/family education	Educate family members about overdose signs Have poison control number readily visible Teach patients/caregivers about use of naloxone to reverse overdose and have naloxone rescue kit available Educate patients/caregivers about adverse effects related to drug-drug interactions
Be knowledgeable about drug-drug interactions	Be prepared to identify/manage these interactions Follow patients closely when interactions are likely

Table 7
Pharmacologic Management of Chronic Pain in PLWH Who Are Taking Methadone

Recommendation	Comments/Details
Collaboration with opioid treatment program	Obtain signed release Maintain ongoing communication with program for assessment/periodic monitoring
Initial screening	Electrocardiogram to identify QTc interval prolongation Helpful if patient is taking other medications that may additively prolong QTc interval
Splitting methadone doses	Divide into 6- to 8-hour doses Some programs may offer split-dose regimen, alternatively medical provider may need to prescribe remaining doses
If additional methadone not possible	Additional medication alternatives Gabapentin for neuropathic pain NSAIDs for musculoskeletal pain Additional opioid
Acute exacerbations of pain (“breakthrough”)	Use small amount of short-acting opioids

Table 8
Treating PLWH and Chronic Pain Who Are Taking Buprenorphine

Recommendation	Comments/Details
Use adjuvant therapy for mild-to-moderate breakthrough pain	Includes nonpharmacologic treatments, steroids, nonopioid analgesics, and topical agents
Increase dosage of buprenorphine	Increase in divided doses as an initial step
If maximal dose of burprenorphine is reached	Add long-acting potent opiod (eg, fentanyl, morphine, hydromorphone)
If additional opioid is ineffective	Closely monitor trial of higher doses
If there is inadequate analgesia	Transition patient to methadone maintenance

Table 9
Recommended Instruments for Screening Common Mental Health Disorders in PLWH and Chronic Pain

Recommendation	Comments/Details
Review patient’s baseline mental status for modifiable risk factors	Self-esteem/coping skills Recent major loss/grief Unhealthy substance use History of violence/lack of safety in the home Mood disorders Serious mental illness/suicidal ideation
Screen patients for depression	2-question screen During past 2 weeks have you been bothered by feeling down, depressed, hopeless? During past 2 weeks have you had little interest/pleasure in doing things? If affirmative, ask if patient would like help
Use screening tool	Patient Health Questionnaire-9 (PHQ-9) recommended
Screen for comorbid neurocognitive disorders	Includes frequent memory loss, slower reasoning, planning activities, or solving problems, difficulties paying attention
Neuropsychiatric evaluation	Recommended for all patients with chronic pain to establish baseline capacity

Reference

1. Bruce RD, Merlin J, Lum PJ, Ahmed E, Alexander C, Corbett AH, Foley K, LeonardK, Treisman GJ, Selwyn P.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. Clin Infect Dis. 2017 Oct 30;65(10):1601-1606.