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

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pain management in hiv aids

Pain Management in HIV/AIDS

Gayle Newshan, PhD, ANP

pain management in hiv aids objectives
Pain Management in HIV/AIDSObjectives
  • 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.)

pain management in hiv aids objectives cont
Pain Management in HIV/AIDSObjectives (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
pain in hiv aids
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
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 management6
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
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 of pain management
Principles and Goals ofPain Management
  • Pain is subjective
  • Self-report is the most reliable indicator
principles and goals of pain management9
Principles and Goals ofPain 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.)

principles and goals of pain management10
Principles and Goals ofPain 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
principles and goals of pain management11
Principles and Goals ofPain 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
liability issues
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 in pain management
JCAHO: New Standards inPain 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.)

jcaho new standards in pain management cont
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 analgesics world health organization step ladder
Optimal Use of AnalgesicsWorld 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
step 1 non opiates
Step 1: Non Opiates

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
step 1 non opiates cont
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 cont18
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
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
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

step 2 non opiate weak opiate with or without adjuvants cont21
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

step 2 non opiate weak opiate with or without adjuvants cont22
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
step 3 opiates with without adjuvants
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
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
step 3 opiates with without adjuvants cont25
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)
step 3 opiates with without adjuvants cont26
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
step 3 opiates with without adjuvants cont27
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
step 3 opiates with without adjuvants cont28
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
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)

Step 4: Complementary and Non-Pharmacological Therapies

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

step 5 interventional strategies
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
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
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
inter individual analgesic variability drug polymorphism cont33
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
inter individual analgesic variability drug polymorphism cont34
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
pain and chemical dependence
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
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 cont37
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
Neuropathy: Etiology
  • HIV
  • CMV
  • Drugs, ie, didanosine, zalcitabine, isoniazid
  • Mitochondrial toxicity
neuropathy treatment strategies
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
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