HIVMA releases chronic pain treatment guidelines for patients with HIV
All patients with HIV should be screened for chronic pain because research has shown that many suffer from it, according to guidelines published by the HIV Medicine Association.
For those who have chronic pain, HIV clinicians should take a multidisciplinary approach using nondrug treatment as the first-line option, the guidelines’ authors wrote in Clinical Infectious Diseases.
“Because HIV physicians are typically 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,” lead author R. Douglas Bruce, MD, MS, Cornell Scott-Hill Health Center chief of medicine and Yale University associate professor of medicine, said in a news release. “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.”
Previous research has shown that 39% to 85% of infected patients experience chronic pain, Bruce and colleagues said.
Almost half of chronic pain in those patients is neuropathic, or nerve pain, which is believed to be caused by HIV-induced inflammation of the central or peripheral nervous system. The other main type of pain is musculoskeletal.
The high prevalence of pain, the authors said, calls for screening in which patients are asked how much pain they have had in the past week and whether they have had pain for more than 3 months, as well as the level of severity.
Those who screen positive should undergo physical, psychosocial and diagnostic evaluations to seek potential causes of pain, the authors said. HIV clinicians should then assemble interdisciplinary teams of specialists to address any physical, psychological and other possible causes, they added.
Depending on patients’ needs, possible treatments include cognitive behavioral therapy, yoga, physical and occupational therapy, hypnosis and acupuncture.
For patients who need medication, opioids should never be a first-line treatment, the authors said. Nonopioid options include gabapentin, tricyclic antidepressants, capsaicin and medical marijuana, among others.
“Clinicians may consider a time-limited trial of opioid analgesics for patients who do not respond to first-line therapies and who report moderate or severe pain,” the authors wrote. “As a second or third-line treatment for chronic neuropathic pain, a typical adult regimen should start with the smallest effective dose and combine short- and long-acting opioids.”
They added that a combination of morphine and gabapentin is a possible option. They also recommended that, before prescribing opioids, clinicians evaluate all patients for the risk of consequences like misuse and addiction.
The authors cautioned that more research is needed to further assess what therapies work best.
“Findings from studies conducted in the general population are not always generalizable to people living with HIV, and interventions to reduce the negative, unintended consequences of opioid treatment have not been rigorously tested,” they wrote. “Additional studies are needed to ascertain the optimal nonpharmacological and pharmacologic treatment for HIV-associated neuropathic pain and nonneuropathic pain in people living with HIV.” – by Joe Green
Disclosure: Bruce reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.