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Pain Management in HIV/AIDS

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Presentation on theme: "Pain Management in HIV/AIDS"— Presentation transcript:

1 Pain Management in HIV/AIDS
Gayle Newshan, PhD, ANP

2 Pain Management in HIV/AIDS Objectives
Identify two essential steps in pain management Identify common pain syndromes in persons with HIV/AIDS Describe nursing assessment of pain in the person with HIV/AIDS Describe implications of genetic factors and health habits on amount of pain relief obtained Identify pharmacologic strategies for treatment of pain in persons with HIV/AIDS (cont.)

3 Pain Management in HIV/AIDS Objectives (cont.)
Describe two strategies for managing neuropathic pain in persons with HIV/AIDS Identify two examples of aberrant behavior in chemically dependent patients with HIV/AIDS Discuss two strategies for dealing with aberrant behavior in persons with HIV/AIDS Identify three barriers to effective pain management in persons with HIV/AIDS Describe pain management issues for persons on methadone maintenance

4 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)

5 Barriers to Pain Management
Health Care Providers Lack of knowledge Myths and misconceptions Cultural barriers Fear of addiction Fear of legal sanctions

6 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

7 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

8 Principles and Goals of Pain Management
Pain is subjective Self-report is the most reliable indicator

9 Principles and Goals of Pain Management
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.)

10 Principles and Goals of Pain Management
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

11 Principles and Goals of Pain Management
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

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

13 JCAHO: New Standards in Pain Management
As of 2001, JCAHO is requiring that all members meet new standards in pain management. In particular they are stressing: 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.)

14 JCAHO: New Standards in Pain 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

15 Optimal Use of Analgesics World Health Organization Step Ladder
Begin with non-opiate, nonsteroidal antiinflammatory agents (NSAIDS) Add a “weak” opiate, such as codeine or hydrocodone (with or without an adjuvant) Move to a stronger opiate, such as oxycodone, morphine (with or without an adjuvant) Complementary, non-pharmacologic strategies Interventional strategies

16 Step 1: Non Opiates Acetaminophen No effect of platelet function
If one non-opiate is ineffective, switch to a different one. If one NSAID is ineffective, switch to a different class Acetaminophen No effect of platelet function Avoid in cases of hepatic insufficiency Maximum of 4g/day

17 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

18 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

19 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

20 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

21 Step 2: Non opiate + Weak Opiate With or Without Adjuvants (cont.)
Types of Adjuvants Antidepressants (amitriptyline, desipramine, etc): used for neuropathic pain and post-herpetic neuralgia and additive analgesia with opiates Antidepressants caution: can cause dry mouth, urinary retention and “hangover effect Antihistamines (hydroxyzine): provides additive analgesia as well as antiemetic and anxiolytic effect Antihistamine Caution: Can cause dry mouth and drowsiness

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

23 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

24 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

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

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

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

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

29 Step 4: Complementary and Non-Pharmacological Therapies
These therapies have research to support that they reduce pain. Most research done in non-HIV patients Acupuncture Hypnotherapy Massage Magnet Therapy Nutriceuticals (dietary supplements such as glucosamine chondroitin) Music Therapeutic touch Aromatherapy Heat/ice Distraction (tv, reading)

30 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

31 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

32 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

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

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

35 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

36 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

37 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

38 Neuropathy: Etiology HIV CMV
Drugs, ie, didanosine, zalcitabine, isoniazid Mitochondrial toxicity

39 Neuropathy: Treatment Strategies
Gabapentin (Neurontin) – 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

40 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


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