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

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.