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Palliative Care in HIV/AIDS http://hivmanagement.org/palliative.html. James A Zachary MD LSU Health Sciences Center Delta AETC December 13, 2004. Identify palliative care issues involved with HIV/AID Discuss tools of palliation

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    1. Palliative Care in HIV/AIDShttp://hivmanagement.org/palliative.html James A Zachary MDLSU Health Sciences CenterDelta AETC December 13, 2004

    2. Identify palliative care issues involved with HIV/AID • Discuss tools of palliation • Hospice: purpose, goals, methods, identifcation of barriers & overcoming them • Case presentations • The Hospice Rx

    3. HIV/AIDS Palliative Care Issues • Dermatomal herpes zoster • 15x higher incidence than uninfected • Post herpetic neuralgia • Approx 20% incidence without HIV • Increased incidence with HIV • Distal sensory polyneuropathy 10-40% • HIV, drugs, infection (e.g. CMV)

    4. HIV/AIDS Palliative Care Issues • Miscellaneous pain • Chronic musculoskeletal pain especially spinal pain • Chronic headaches • Trauma-related injuries • Chronic post-operative pain

    5. Pain Control Basics • Believe the patient! • Thoroughly evaluate pain • History and physical • Blood testing • Imaging • Consultants • Always treat the cause if possible • Pain control during work-up and until resolved • Close follow-up!!!!

    6. WHO Analgesic Ladder

    7. Acute Pain • Apply analgesic ladder principle • Short acting analgesics • Adjuvant therapy with gabapentin • Avoid constipation • Examples: acute herpes zoster, acute headache

    8. Acute Pain • NSAIDs • Buprenorphene IM • Tramodol • Merperidine • Codeine/acetaminophen • Hydrocodone/acetaminophen or ibuprofen • Oxycodone/acetaminophen or aspirin • Oxycodone • Hydromorphone • Immediate release morphine sulfate

    9. Chronic PainPain >48 hours • Begin with adequate supply of short acting analgesic: avoid acetaminophen combination drugs • Oxycodone tablets or suspension • Morphine sulfate immediate release liquid or tablets • Allow patient to re-administer (and slowly escalate) every 2-4 hours • At the end of 24-48 hours, begin a long-acting opiate based on the previous 24 hour dosage of short-acting analgesic and continue short-acting

    10. Chronic PainPain >48 hours • Extended release morphine • MS Contin, Oramorph, generics: q8-12 hours • Avinza, Kadian: q24 hour • Extended release oxycodone: OxyContin • Transdermal fentanyl • Methadone • Buprenorphene sublingual*

    11. Neuropathic Pain • Description: lancinating, numbness, burning, itching • Palliative options • Nerve blocks – not too practical • Topical lidocaine (Lidoderm) • Gabapentin (or levacetram) up to 5600 mg per day or more • Opiates

    12. Opiates • Use a consistent approach to your pain assessment such as asking the patient to use the 1-10 scale • Document clearly that you are doing your best to diagnose and treat the pain • Don’t prescribe on the first visit with a new patient unless source of pain is very clear • Addiction seldom occurs when used for pain control.

    13. Pain In Addicts • Higher incidence of pain in addiction • Same principles apply as in nonaddicted patients • Consider a pain contract • Consider urine toxicology testing if suboptimal results are achieved • Look for prescribed substances primarily • Evaluate and treat for nonprescribed substances as you would normally

    14. Pain In Addicts

    15. Pain In Addicts • Higher incidence of pain in addiction • Same principles apply as in nonaddicted patients • Consider a pain contract • Consider urine toxicology testing if suboptimal results are achieved • Look for prescribed substances primarily • Evaluate and treat for nonprescribed substances as you would normally

    16. Pain In Addicts • Boundary issues are extremely important! • Consider a Pain Management referral • Consider a Mental Health referral

    17. Opiates • Avoid constipation! • Senna + stool softener = Senokot • Lactulose • Go-lytely or Miralax • Sorbitol • To control possible nausea provide an antiemetic such as promethazine or metoclopropamide and administer it on a schedule

    18. HIV/AIDS Palliative Care Issues • Nausea • Drugs • CNS processes: meningitis, abscess, tumor, increased intracranial pressure, motion sickness • Metabolic processes: hepatitis, adrenal insufficiency • GI: pancreatitis, gastritis, PUD, KS, microsporidiosis, cryptococcosis, CMV, DMAC

    19. Nausea Control • Be aggressive in approach! • Diagnose and treat underlying cause if possible • Prevent nausea: much easier than suppressing it once started!

    20. Nausea Control • Phenothiazines: promethazine (Phenergan), prochlorperazine (Compazine), etc. • Metoclopropamide (Reglan) • Ondansetron (Zofran), granisetron (Kytril) • Dranabinol (Marinol) • Lorazepam • Haloperidol (Haldol) • Dexamethasone (Decadron)

    21. Conclusions • Palliate aggressively even during active care • Close follow-up is probably helpful to patient and provider • The approach and treatment of the addicted patient is fundamentally no different from that of any other patient. • The use of opiates can be simple and safe. • Adjuvant drugs such as gabapentin should be frequently considered.