Because ongoing pain is a significant problem that affects 39% to 85% of people living with HIV, everyone with the infection should be assessed for chronic pain, recommend guidelines released by the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA). Those who screen positive should be offered a variety of options for managing pain, starting with non-drug treatment such as cognitive behavioral therapy, yoga and physical therapy, suggest the first comprehensive guidelines on HIV and chronic pain.
“Because HIV clinicians typically are not experts in pain management, they should work closely with others, such as pain specialists, psychiatrists and physical therapists to help alleviate their patients’ pain,” said Dr Douglas Bruce, lead author of the guidelines, chief of medicine at Cornell Scott-Hill Health Centre, and associate clinical professor of medicine at Yale University. “These comprehensive guidelines provide the tools and resources HIV specialists need to treat these often-complex patients, many of whom struggle with depression, substance use disorders, and have other health conditions such as diabetes.”
The guidelines recommend all people with HIV be screened for chronic pain using a few simple questions: How much bodily pain have you had during the week; and do you have bodily pain that has lasted more than three months.
Those that screen positive should undergo comprehensive evaluation, including a physical exam, psychosocial evaluation and diagnostic testing. Nearly half of chronic pain in people with HIV is neuropathic (nerve pain), likely due to inflammation or injury to the central or peripheral nervous system caused by the infection. Non-neuropathic pain typically is musculoskeletal, such as low-back pain and osteoarthritis in the joints.
“It has been long known that patients with HIV/Aids are at high risk for pain, and for having their pain inadequately diagnosed and treated,” said Dr Peter Selwyn, co-chair of the guidelines and professor and chair of the department of family and social medicine, and director of the palliative care programme for Montefiore Medical Centre, Albert Einstein College of Medicine. “This is an aging population and the changing clinical manifestations of HIV, complexity of the disease and additional challenges related to substance abuse make treatment complicated. These guidelines help provide clarity in treating these patients.”
HIV specialists should work with an interdisciplinary team to offer multi-modal treatment. The guidelines recommend offering alternative, non-pharmacological therapies first, including cognitive behavioural therapy, yoga, physical and occupational therapy, hypnosis and acupuncture. If medication is needed, the guidelines recommend beginning with non-opioids, such as gabapentin (anti-seizure medicine) and capsaicin (topical pain reliever made from chili peppers), both of which help with nerve pain.
“Opioids are never first-line,” said Bruce. “The guidelines always recommend the most effective treatment with the lowest risk.”
The online version of the guidelines includes an extensive list of resources for physicians to reference to help them treat the patients comprehensively.
Pain has always been an important part of human immunodeficiency virus (HIV) disease and its experience for patients. In this guideline, we review the types of chronic pain commonly seen among persons living with HIV (PLWH) and review the limited evidence base for treatment of chronic noncancer pain in this population. We also review the management of chronic pain in special populations of PLWH, including persons with substance use and mental health disorders. Finally, a general review of possible pharmacokinetic interactions is included to assist the HIV clinician in the treatment of chronic pain in this population.
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The Infectious Diseases Society of American considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient’s individual circumstances.
R Douglas Bruce, Jessica Merlin, Paula J Lum, Ebtesam Ahmed, Carla Alexander, Amanda H Corbett, Kathleen Foley, Kate Leonard, Glenn Jordan Treisman, Peter Selwyn