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Chronic Pain in Patients With HIV: What Clinicians Need to Know

Chronic Pain in Patients With HIV: What Clinicians Need to Know. Jessica S. Merlin, MD, MBA Assistant Professor of Medicine University of Alabama at Birmingham Birmingham, Alabama. FORMATTED: 11/03/2015. New Orleans, Louisiana: December 15-17, 2015.

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Chronic Pain in Patients With HIV: What Clinicians Need to Know

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  1. Chronic Pain in Patients With HIV: What Clinicians Need to Know Jessica S. Merlin, MD, MBAAssistant Professor of MedicineUniversity of Alabama at Birmingham Birmingham, Alabama FORMATTED: 11/03/2015 New Orleans, Louisiana: December 15-17, 2015

  2. HIV and Chronic Pain in the Current Treatment Era • Prevalence as high as 39-85% • Often coexists with mood disorders and addiction • Often musculoskeletal • Associated with key outcomes (functional impairment, retention) • Can be challenging for HIV providers Merlin JS, JAIDS, 2012; Merlin JS, J Pain Symptom Manage, 2011; Cervia LD, Pain Med, 2010; Lee KA, J Pain Symptom Manage, 2008; Tsao JC, Pain 2011, Lum P, JAIDS 2011.

  3. Communicating About Chronic Pain • Not easy, because: • Patients come with “baggage” • Providers come with “baggage” • Pain is the 5th vital sign, pain is an emergency • Medications come with risk • Patients may have active psychiatric illness/addiction • Patients’ behaviors may evoke severe negative countertransference

  4. Initial Discussion What is chronic pain Patience Partnership and collaboration Pharmacologic and non-pharmacologic management Mind-body connection Functional goals Motivational interviewing can be very useful

  5. Evidence-Based Non-OpioidPharmacologic Therapy • Acetaminophen - OA, < 3g, consider relative contraindications • NSAIDs - back pain, consider CV (naproxen), GI (cox-2/celecoxib), renal risk • Muscle relaxants • Benzodiazepines • Other: anticonvulsants, antidepressants, topicals • Specific indications: e.g., lidocaine post-herpetic neuralgia, capsaicin post-herpetic/DSP, diclofenac-OA

  6. My take on opioids • They ARE NOT first-line therapy for chronic pain • They work for some people • However, evidence of benefit is limited • What we know about their risk is growing

  7. Evidence-Based Non-Pharmacologic Strategies Hayden JA, Cochrane Database Syst Rev, 2005; Trafton JA, J Behav Health Serv Res, 2012; Cucciare CA, J Behav Med, 2009; Vickers AJ, Arch Int Med, 2012. ICSI Guideline for Management of Chronic Pain; Turk DC, Lancet, 2011, Mirza SK, Spine, 2007. Behavioral approaches Physical therapy Exercise Interventional treatments Complementary and alternative therapies Surgery

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