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Palliative Care in HIV/AIDShttp://hivmanagement.org/palliative.html
James A Zachary MDLSU Health Sciences Center
Delta AETC
December 13, 2004
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• Identify palliative care issues involved with HIV/AID
• Discuss tools of palliation• Hospice: purpose, goals, methods,
identifcation of barriers & overcoming them
• Case presentations• The Hospice Rx
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HIV/AIDS Palliative Care Issues
• Dermatomal herpes zoster– 15x higher incidence than uninfected
• Post herpetic neuralgia– Approx 20% incidence without HIV– Increased incidence with HIV
• Distal sensory polyneuropathy 10-40%– HIV, drugs, infection (e.g. CMV)
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HIV/AIDS Palliative Care Issues
• Miscellaneous pain– Chronic musculoskeletal
pain especially spinal pain– Chronic headaches– Trauma-related injuries– Chronic post-operative
pain
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Pain Control Basics
• Believe the patient!• Thoroughly evaluate pain
– History and physical– Blood testing– Imaging– Consultants
• Always treat the cause if possible• Pain control during work-up and until resolved• Close follow-up!!!!
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WHO Analgesic Ladder
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Acute Pain• Apply analgesic ladder principle• Short acting analgesics• Adjuvant therapy with gabapentin• Avoid constipation• Examples: acute herpes zoster,
acute headache
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Acute Pain• NSAIDs• Buprenorphene IM• Tramodol• Merperidine• Codeine/acetaminophen• Hydrocodone/acetaminophen or
ibuprofen• Oxycodone/acetaminophen or aspirin• Oxycodone• Hydromorphone• Immediate release morphine sulfate
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Chronic PainPain >48 hours
• Begin with adequate supply of short acting analgesic: avoid acetaminophen combination drugs– Oxycodone tablets or suspension– Morphine sulfate immediate release
liquid or tablets• Allow patient to re-administer (and
slowly escalate) every 2-4 hours• At the end of 24-48 hours, begin a long-
acting opiate based on the previous 24 hour dosage of short-acting analgesic and continue short-acting
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Chronic PainPain >48 hours
• Extended release morphine– MS Contin, Oramorph, generics: q8-12 hours– Avinza, Kadian: q24 hour
• Extended release oxycodone: OxyContin• Transdermal fentanyl• Methadone• Buprenorphene sublingual*
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Neuropathic Pain
• Description: lancinating, numbness, burning, itching
• Palliative options– Nerve blocks – not too practical– Topical lidocaine (Lidoderm)– Gabapentin (or levacetram) up to
5600 mg per day or more– Opiates
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Opiates• Use a consistent approach to your pain
assessment such as asking the patient to use the 1-10 scale
• Document clearly that you are doing your best to diagnose and treat the pain
• Don’t prescribe on the first visit with a new patient unless source of pain is very clear
• Addiction seldom occurs when used for pain control.
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Pain In Addicts• Higher incidence of pain in addiction• Same principles apply as in nonaddicted
patients• Consider a pain contract• Consider urine toxicology testing if
suboptimal results are achieved– Look for prescribed substances
primarily– Evaluate and treat for nonprescribed
substances as you would normally
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Pain In Addicts
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Pain In Addicts• Higher incidence of pain in addiction• Same principles apply as in nonaddicted
patients• Consider a pain contract• Consider urine toxicology testing if
suboptimal results are achieved– Look for prescribed substances
primarily– Evaluate and treat for nonprescribed
substances as you would normally
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Pain In Addicts• Boundary issues are extremely
important!• Consider a Pain Management
referral• Consider a Mental Health
referral
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Opiates• Avoid constipation!
– Senna + stool softener = Senokot– Lactulose– Go-lytely or Miralax– Sorbitol
• To control possible nausea provide an antiemetic such as promethazine or metoclopropamide and administer it on a schedule
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HIV/AIDS Palliative Care Issues
• Nausea– Drugs– CNS processes: meningitis, abscess,
tumor, increased intracranial pressure, motion sickness
– Metabolic processes: hepatitis, adrenal insufficiency
– GI: pancreatitis, gastritis, PUD, KS, microsporidiosis, cryptococcosis, CMV, DMAC
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Nausea Control
• Be aggressive in approach!• Diagnose and treat underlying cause if
possible• Prevent nausea: much easier than
suppressing it once started!
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Nausea Control
• Phenothiazines: promethazine (Phenergan), prochlorperazine (Compazine), etc.
• Metoclopropamide (Reglan)• Ondansetron (Zofran), granisetron (Kytril)• Dranabinol (Marinol)• Lorazepam• Haloperidol (Haldol)• Dexamethasone (Decadron)
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Conclusions• Palliate aggressively even during active care• Close follow-up is probably helpful to patient and
provider• The approach and treatment of the addicted patient
is fundamentally no different from that of any other patient.
• The use of opiates can be simple and safe.• Adjuvant drugs such as gabapentin should be
frequently considered.