pain management in hiv/aids gayle newshan, phd, anp

Pain Management in HIV/AIDS

Gayle Newshan, PhD, ANP

Pain Management in HIV/AIDSObjectives

1. Identify two essential steps in pain management2. Identify common pain syndromes in persons with

HIV/AIDS3. Describe nursing assessment of pain in the person

with HIV/AIDS4. Describe implications of genetic factors and health

habits on amount of pain relief obtained5. Identify pharmacologic strategies for treatment of

pain in persons with HIV/AIDS(cont.)

Pain Management in HIV/AIDSObjectives (cont.)

6. Describe two strategies for managing neuropathic pain in persons with HIV/AIDS

7. Identify two examples of aberrant behavior in chemically dependent patients with HIV/AIDS

8. Discuss two strategies for dealing with aberrant behavior in persons with HIV/AIDS

9. Identify three barriers to effective pain management in persons with HIV/AIDS

10. Describe pain management issues for persons on methadone maintenance

Pain in HIV/AIDS

• Prevalence Pre-HAART (Highly Active Antiretroviral Therapy)– Estimates vary between 53%-97% (Schofferman,

1998; Singh, Fermie & Peters, 1992; Breitbart et al, 1996)

• Prevalence Post-HAART– Estimate of 30% (Newshan, Bennett, Holman,

2000)• Undermanagement of pain: Women and injection drug

users (Breitbart, et al, 1996)

Barriers to Pain Management

• Health Care Providers– Lack of knowledge– Myths and misconceptions– Cultural barriers– Fear of addiction– Fear of legal sanctions

Barriers to Pain Management

• Patients/Family/Caregivers– Fear of addiction– Wanting to be “good” patients– Stoicism– Cultural barriers

• Social and Governmental Barriers– Stigma– Regulatory issues

Etiology of Chronic Pain HIV

• Neuropathy• Postherpetic Neuralgia• Avascular Necrosis• Osteopenia• Arthropathy, Adhesive Capsulitis• Myopathy• Back Pain• Renal Calculi/Loin Pain• Herpes Simplex• Candida Esophagitis• Pancreatitis Related to Didanosine, Dicalcitabine, CMV

Principles and Goals ofPain Management

• Pain is subjective

• Self-report is the most reliable indicator


• Assessment– Onset and duration– Location– Character (sharp, dull, burning, etc…)– Intensity – using the 0-10 numerical rating

scale, the verbal scale (none, mild, moderate, severe) or the FACES scale for children

(cont.)


• Assessment (cont.)– Exacerbating and relieving factors– Response to current and past treatments– Meaning of pain to patient– Cultural responses to pain– Emotional state– History of chemical dependence


• Listen to the patient

– Pain is subjective – there is no pain-o-meter or pain blood test, only what the patient tells us

• Reassessment

– After treatment is initiated, pain should be regularly reassessed to determine the efficacy of the intervention

• Optimal functioning with least side effects

– The right dose of pain medication is whatever dose it talks to relieve the pain with the fewest side effects

– Functioning is usually more of a priority in patients who are not end-stage

Liability Issues

• Pain management is not just “nice to do”. Nurses and physicians have been held legally accountable for inadequate pain management

JCAHO: New Standards inPain Management

• Importance of pain assessment and management– Every patient should be assessed for pain

• Healthcare facility commitment– The organization plans, supports and coordinates

activities and resources to assure that pain is addressed including education of providers, patients and their families

(cont.)

As of 2001, JCAHO is requiring that all members meet new standards in pain management. In particular they are stressing:

JCAHO: New Standards inPain Management (cont.)

• Accountability– The organization collects data to monitor

performance• Outcome assessment

– The organization assesses the adequacy and effectiveness of pain management

• Continuous improvement– The organization is responsible for continuously

monitoring and improving outcomes related to pain management

Optimal Use of AnalgesicsWorld Health Organization Step Ladder

1) Begin with non-opiate, nonsteroidal antiinflammatory agents (NSAIDS)

2) Add a “weak” opiate, such as codeine or hydrocodone (with or without an adjuvant)

3) Move to a stronger opiate, such as oxycodone, morphine (with or without an adjuvant)

4) Complementary, non-pharmacologic strategies

5) Interventional strategies

Step 1: Non Opiates

• Acetaminophen– No effect of platelet function– Avoid in cases of hepatic insufficiency– Maximum of 4g/day

If one non-opiate is ineffective, switch to a different one.If one NSAID is ineffective, switch to a different class

Step 1: Non Opiates (cont.)

• NSAIDS

– Avoid if low albumin level

– Avoid if low platelets

– Avoid if renal insufficiency

– Useful with throbbing, aching pain

– Administer with food to reduce gastric irritation

– Salsalate and tolmetin produce less inhibition of platelet aggregation than other NSAIDS

– Maximum dose of aspirin is 10g/day

– Use with caution in persons with asthma

– Indomethacin is available in suppository form

Step 1: Non Opiates (cont.)

• Cox-2 Inhibitors– Rofecoxib (Vioxx)– Celebrex (Celebrex)– Have no effect on platelet aggregation or

bleeding time– Less chance of gastric irritation– Monitor hepatic functioning

Step 2: Non opiate + Weak Opiate With or Without Adjuvants

• Acetaminophen with codeine or hydrocodone• Maximum dose related to acetaminophen• Adjuvants are those medicines that enhance the

efficacy of the opiate and may have independent analgesic activity

Step 2: Non opiate + Weak Opiate With or Without Adjuvants (cont.)

• Types of adjuvants– NSAIDS: provide additive analgesia when

given to supplement the opiate, often lengthen the duration of opiates

– Corticosteroids: treats both the cause and resulting pain of aphthous ulcers; also relieves cerebral edema

Corticosterioids caution: can cause gastric bleeding, caution with low platelet counts


• Types of Adjuvants– Antidepressants (amitriptyline, desipramine, etc):

used for neuropathic pain and post-herpetic neuralgia and additive analgesia with opiatesAntidepressants caution: can cause dry mouth, urinary retention and “hangover effect

– Antihistamines (hydroxyzine): provides additive analgesia as well as antiemetic and anxiolytic effectAntihistamine Caution: Can cause dry mouth and drowsiness


• Types of adjuvants– Anticonvulsants: gabapentin is the most useful

with the fewest side effects and is used to treat neuropathic pain

Anticonvulsant Caution: carbamazepine can cause neutropenia

– Caffeine: drinking a cup of strong coffee along with opiate will increase its effect

Step 3: Opiates With/Without Adjuvants

• Dosing schedule and titration– Prevent pain with ATC dosing– Titrate to pain relief – doses are individualized:

the right dose is whatever it takes to relieve the pain with the least amount of side effects/toxicity

– Long-acting opiates should be used for long-term pain

Step 3: Opiates With/Without Adjuvants (cont.)

• Conversion/equianalgesic dosing– Morphine 10 mg sc/im = 20 mg oral solution– Hydromorphone 4 mg sc/im = 8 mg oral– When switching from one opiate to another,

reduce the dose by 1/3 due to incomplete crossover tolerance and titrate from that dose


• Delivery Formulations– Morphine: available in concentrated oral

immediate release solutions, suppository, short and long-acting oral pills, iv and im/sc

– Oxycodone: available with or without aspirin and acetaminophen, long and short-acting formulations (Q12h and Q4h)


• Delivery formulations

– Hydromorphone: available in suppository, short-acting pill, iv, im/sc

– Fentanyl: available in short-acting lollipop and long-acting patch (q48-72h)

– Meperidine: not recommended when doses of >300 mg/day are needed as can lead to tremors, restlessness and seizures; oral form is equivalent to acetaminophen and should be avoided

– Propoxphene HVL: limited efficacy, can lead to accumulation of neurotoxic metabilites


• Tips with long-acting oral opiates– Do not crush or break– Hydration is important– Supplement with short-acting opiates for break-

through pain– Dolophine (methadone) should be given q6h

and titrated very slowly to avoid accumulation due to long half-life


• Topical fentanyl should be used cautiously if patient is febrile. Do not apply topical fentanyl to broken skin

• Opioid rotation for chronic pain and long-term therapy– When a patient is on opiates for several months,

tolerance often develops and improved pain control can be achieved by rotating to an alternate opiate – for example, going from long-acting oxycodone to long-acting morphine and then to the fentanyl patch

Step 4: Complementary and Non-Pharmacological Therapies

• Acupuncture

• Hypnotherapy

• Massage

• Magnet Therapy

• Nutriceuticals (dietary supplements such as glucosamine chondroitin)

• Music

• Therapeutic touch

• Aromatherapy

• Heat/ice

• Distraction (tv, reading)

These therapies have research to support that they reduce pain. Most research done in non-HIV patients

Step 5: Interventional Strategies

• Plays a small role in pain management in HIV/AIDS

• Usually done by anesthesiologist• Nerve blocks, using anesthetics, corticosteroids or

neurolytic drugs• Implanted epidural pumps or intraspinal drug

delivery – cautious use with persons with AIDS due to risk of infection

Inter-Individual Analgesic Variability/Drug Polymorphism:Same Drug, Different Response

• Environmental Factors– Recreational drug-drug interactions

• Cannabis increase effect of morphone• Ritonavir (Norvir) increases Ecstasy levels• Alcohol Increases abacavir (Ziagen levels)

– Other drug-drug interactions• Ritonavir increases levels of meperidine, propoxyphene

and fentanyl• Efavirenz and nevirapine lower methadone levels• NSAIDS increase lithium level• Phenytoin lowers methadone levels

Inter-Individual Analgesic Variability/Drug Polymorphism (cont.)

• Environmental factors– Smoking

• Smoking shortens half-life of NSAIDS and increases metabolism of meperidine, morphine and propoxyphene

– Weight and body fat• Malnourishment can cause increase toxicities of NSAIDS

– Diet• 7 oz grapefruit juice can effect certain drug metabolism

for 24 hours• Increases plama levels of busprione, carbamazpeine,

triazolam by 4-9 fold


• Genetic factors– Slow metabolizers – will find a drug less

effective, build up drug levels and have greater toxicity

– Rapid metabolizers – may find a drug more effective but shorter length of action


• Sexual dimorphism– Possibility that gender may influence both pain

perception and efficacy of pain medications– Research is ongoing

• Cultural factors– Beliefs, fears, values affect drug response– Expectations regarding pain and pain relief– Expectations regarding a drug’s effectiveness

Pain and Chemical Dependence

• Identification of aberrant behavior– Examples include non-prescribed dose

escalation and prescription forgery• Differential diagnoses of aberrant behavior

– Somatiform disorder– Personality disorder– Obsessive compulsive personality

Pain and Chemical Dependence (cont.)

• Strategies for managing aberrant behavior– Using a team approach– Directly address the concern with the patient– Oral or written agreements– Using long-acting formulations instead of

short-acting– Encourage participation in recovery programs– Limit prescriptions to one provider, one

pharmacy, one week supply

Pain and Chemical Dependence (cont.)

• General guidelines for management

– Be consistent

– Address social, psychological and spiritual effects of pain

• Methadone maintenance

– Methadone maintenance does not provide analgesia

– Phenytoin and rifampin may increase methadone metabolism and cause drug-seeking behavior

– Patients on methadone need additional medicine for pain control

Neuropathy: Etiology

• HIV• CMV• Drugs, ie, didanosine, zalcitabine, isoniazid• Mitochondrial toxicity

Neuropathy: Treatment Strategies

• Gabapentin (Neurontin) – 2-3 g/day in divided doses

• Amitryptiline (Elavil) – start at 25 mg/hs and increase every three days as tolerated to effect

• Desipramine – start at 25 mg/hs and increase every three days as tolerated to effect

• NSAIDs such as ibuprofen or naproxyn if associated throbbing pain

Neuropathy: Treatment Strategies (cont.)

• Use anti-embolic stockings• Encourage exercise, such as cycling, walking• Massage• Use topical capsaicin P ointment if only small

areas like toes or fingers are affected – takes several days to be effective, must be applied tid-qd

• Discontinue the causative drug if possible• B6 and B 12 supplements• Acupuncture

pain management in hiv/aids gayle newshan, phd, anp

Documents

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