"What a Pain" Gives Practical Pointers for Addressing HIV Chronic Pain in Clinical Settings

August 29, 2014

Sixty percent of HIV-infected patients have chronic pain, which remains under- or untreated in the vast majority of such patients (80%), according to R. Douglas Bruce, M.D., M.A., M.Sc. In the recent webinar "What a Pain: Addressing HIV Chronic Pain in Clinical Settings," Bruce discussed how physicians should address chronic non-cancer pain in HIV clinical settings.

Bruce recommended that a pain history be compiled for all HIV-infected patients, even those who are not currently complaining of chronic pain. He stressed the need to avoid bias -- or the appearance thereof -- in selecting the necessary evaluations, and the importance of considering all possible reasons for a patient's complaints or behavior. For example, chronic pelvic and rectal pain may indicate a history of sexual abuse rather than a purely physical problem. Similarly, all patients who are prescribed opioids should be subject to urine drug testing, while bearing in mind possible false positives (e.g., if the patient is taking ciprofloxacin) and the limitations to such testing.

In order for patients to feel that their concerns are taken seriously, questions (and thus messages) must be framed correctly. Instead of asking, "How many pain pills do you use?" ask "How many pills does it take to relieve your pain?" The answer to the first question is likely to be "as prescribed," whereas the second question is more likely to elicit a useful answer, Bruce said.

He emphasized proper documentation, as well as a contract for all patients who are on opioids that specifies only one provider in one clinic who prescribes any and all pain medications. This helps to prevent misuse of the medication by patients, as well as limit drug interactions.

Both opioid and non-opioid treatment options for chronic neuropathic and non-neuropathic pain were discussed, as were possible interactions with HIV medications. Bruce noted that the once-daily dose of methadone used for the treatment of addiction is insufficient when that drug is used to manage pain. Since the presumption is that chronic pain will not resolve and the goal of pain medication is to help patients perform the activities of daily living that they have trouble performing due to ongoing pain, long-acting opioids may be more helpful than shorter-acting ones, he said, although the latter show results much more quickly.

Bruce also noted that HIV itself may prevent some pain relief medications from working. A mouse model showed that HIV's gp120 receptor may block morphine and methadone analgesia, although it does not appear to inhibit response to buprenorphine.

He also recommended that providers establish a referral system to assist with the various evaluations needed before prescribing pain medication or while monitoring treatment.

Barbara Jungwirth is a freelance writer and translator based in New York.

Follow Barbara on Twitter: @reliabletran.

Copyright © 2014 Remedy Health Media, LLC. All rights reserved.


Reader Comments:

Comment by: Virginia Williams (Newburgh my ) Sat., Sep. 3, 2016 at 10:35 pm UTC
I see my infectious disease doctor few every other month am HIV positive take my meds every day to stay healthy for my self always in pain and discomfort with my muscles hurt try to not be in pain my doctor needs to help me with the pain been taking Motrin Tylenol just not working just getting started with the day is terrible what do I tell my doctor please let me know
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Comment by: david buccilla (columbus,ohio) Fri., Aug. 29, 2014 at 9:34 pm UTC
i am prescribed percocet 10/325 and i have noticed since i was diagnosed w/ hiv+ and the meds due not seem to work as well as bedore the hiv diagnosis?so i am wondering if i should share w/my pain clinic doctor that i have tested positive for hiv and i need somethiig stronger as my infectious disease doctor said he could address my pain issues as well as if not better than the pain doctor so who sghould i believe i am currently do not take a hiv medication but i have viral load 160,000 t4 count of 30 and should i be on an hiv meds but my hiv dr says no not right now but in the future?
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Comment by: Dave R (Amsterdam, Netherlands) Fri., Aug. 29, 2014 at 6:00 pm UTC
I do feel that this article panders a little to the current wave of hysteria regarding opioid abuse. Requiring a contract for all patients, plus so-called 'proper' documentation (meaning intense scrutiny)and even 'routine' urine testing' is a sledgehammer to a nut form of bureaucracy. It has been shown that patients who need to take opioids for chronic pain, especially cancer pain and neuropathic pain, are rarely likely to abuse. They are well aware of the nature of their pain and know what dosage will help and where the dangers lie. We don't ask HIV patients to sign a contract for their HIV medications do we (they can also be resold on the street!) and all strong medications can be abused. It is about time that recreational opioid abusers and criminal opioid dealers be separated from genuine patients suffering from chronic pain. It has become so ridiculous in parts of the the USA that pharmacists will not issue needed opioids to pain patients for fear of falling foul of the law. Surely, a normal monitoring of progress and keeping of records by doctors is sufficient for chronic pain patients - they shouldn't have to justify in triplicate, taking often the only remaining medication that helps their chronic condition. Opioids are a very effective analgesic for serious pain as long as they are treated with respect and doctors communicate with their patients to avoid addiction. If one opioid stops working,or the patient shows signs of needing more to achieve the same effect, switching to another one is a normal and effective step. The main thing is that patients are treated with respect and it is acknowledged that they are partners in their treatment, with an invested and intelligent awareness of what they are doing. The current drug-abuse hysteria runs the risk of neglecting the very people who need the medications most and harming their health. A little less media hype and a little more sensible doctor patient trust will work wonders.
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