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Pain Management and Palliative Care in HIVAIDS Patients

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Title: Pain Management and Palliative Care in HIVAIDS Patients


1
Pain Management and Palliative Care inHIV/AIDS
Patients
  • Timothy L. Sternberg, DMD, MD
  • Director, Center for Pain Management
  • University of Florida/Shands Jacksonville

2
Disclosure of Financial Relationships
  • This speaker has no significant financial
    relationships with commercial entities to
    disclose.

This slide set has been peer-reviewed to ensure
that there are no conflicts of interest
represented in the presentation.
3
Pain Palliative Care in HIV/AIDSObjectives
  • 1. Pain incidence and prevalence
  • 2. Barriers to effective pain symptom
    management
  • 3. Assessing pain in HIV AIDS
  • 4. HIV/AIDS specific painful syndromes
  • 5. General pain management guidelines
  • 6. Specific treatment strategies

4
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5
HIV/AIDS Pain Etiologies
  • HIV tissue damage
  • Opportunistic Infections
  • Malignancies
  • Side effect of treatment
  • Incidental to HIV disease

6
Is pain in HIV/AIDS patients common?
  • Not a concern to most patients who just want
    their disease cured.
  • Only common in terminal AIDS.
  • Only common with high viral loads.
  • Common in all stages of the disease.
  • No Adequately treated with current available
    care.

7
Prevalence of Pain in HIV/AIDS
  • 28 asymptomatic HIV seropositive men
  • 56 AIDS-related complex
  • 80 AIDS
  • (Singer, 1993)
  • 97 terminal
  • (Singh 1992)
  • 57-61 hospitalized AIDS patients
  • 2nd most common admitting problem
  • (Lebovits 1989, 1994)

8
Prevalence of Pain in HIV/AIDS
  • Average 2.5 different pains
  • Severity 5.4 (average) 7.4 (worse) / 10 NRS
  • Prevalence correlated
  • CDC category
  • Number of current HIV related symptoms
  • Treatment for HIV related infections
  • Absence of antiretroviral therapy
  • Intensity correlated
  • Females
  • Non-Caucasions (Breitbart
    1996)

9
Prevalence of Pain in HIV/AIDS
  • Pre-HAART 56-80
  • Prevalence Post-HAART
  • Estimate of 30
  • (Newshan, Bennett, Holman, 2000)

10
Prevalence of Pain in HIV/AIDS
  • Prevalence and Intensity associated with
  • Greater impairment functional ability
  • Physical symptom distress
  • Psychological morbidity

11
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12
Barriers to Pain Management
  • Pain generally under-treated in HIV/AIDS pts
  • Particularly patients with IV drug abuse hx
  • Only 15 ambulatory AIDS pts received adequate
    analgesia
  • Only 6 with severe pain Rxd opioids
  • Under-treatment 85 (cancer 42)
  • Women minorities more likely under-treated
  • (Brietbart 1994)

13
Barriers to Pain Management
  • Patient related barriers
  • Clinician related barriers
  • System related barriers
  • HIV specific barriers

14
What is the most common barrier to adequate pain
management in HIV/AIDS?
  • Fear of addiction
  • Poor compliance
  • Governmental restrictions
  • Poor patient assessment
  • Inadequate application of knowledge and
    therapeutic modalities currently available

15
Barriers to Pain Management
  • Patient related barriers
  • Fear of addiction
  • Misconceptions about tolerance
  • Concern about side effects
  • Fear of correlation with disease progression
  • Poor compliance with antiviral medications

16
Barriers to Pain Management
  • Clinician related barriers
  • Misconceptions of addiction, dependence, and
    tolerance
  • Inadequate training
  • Inadequate patient assessment
  • Poor pharmacologic knowledge
  • Inadequate application of knowledge and
    therapeutic modalities currently available

17
Barriers to Pain Management
  • System related barriers
  • Regulatory issues
  • Pharmacy restrictions
  • Governmental restrictions
  • Economic issues

18
HIV/AIDS Specific Barriers
  • Many African Americans consider Hospice second
    class care
  • Unfamiliarity with medical system
  • Inner city prevalence of illicit drug use
  • Continued illicit drug use
  • Poverty
  • Poor access to phones, refrigerators, housing
  • Poor compliance with antiviral therapy

19
(No Transcript)
20
Assessing Pain in HIV AIDS
  • Pain history
  • Intensity
  • Location
  • Qualities
  • Radiation
  • Work-up possible etiologies
  • Rule out infections and malignancies
  • Consider multiple concurrent etiologies
  • Thorough HP
  • Eval psychological/emotional/social factors

21
Characterizing Pain in HIV/AIDS
  • Nociceptive
  • Somatic
  • w, w/o inflammation
  • Visceral
  • Neuropathic
  • Central
  • Peripheral
  • Sympathetic

22
Assessing Pain in HIV AIDSEtiologies
  • HIV related
  • tissue damage
  • infection
  • tumors
  • HIV treatment
  • Medications
  • Chemotherapy, radiation
  • Unrelated to HIV

23
Which locations are relatively unaffected by HIV
related pain?
  • Head and face
  • Chest
  • Abdomen
  • Pelvis
  • Musculoskeletal system

24
Common Painful HIV/AIDS Syndromes
  • Headaches 46
  • Oral cavity 53
  • Throat pain 20
  • Chest pain 41
  • Abdominal pain 12-26
  • Anorectal pain 34
  • Peripheral neuropathy 25 (10-50)
  • Musculoskeletal system 72
  • Herpes zoster/PHN 5
  • Social pain
  • Psychological pain

25
HIV/AIDS Headache Syndromes
  • HIV specific
  • Aseptic meningitis with acute infection
  • CNS lymphoma
  • Metastatic Kaposis sarcoma
  • Infections HSV, CMV, Toxoplasmosis, TB, Syphilis
  • HIV encephalitis
  • HIV treatment
  • Zidovudine
  • Efavirenz
  • Emtricitabine
  • Stavudine
  • Tenofovir
  • Concurrent illness
  • Tension-type, Migraines
  • Sinus infections

26
HIV/AIDS Oral-pharyngeal Syndromes
  • Candidiasis 28-75
  • Necrotizing gingivitis
  • HSV, CMV, HIV, EBV ulcers
  • Recurrent aphthous ulcers
  • Zalcitabine ulcers
  • Kaposis sarcoma
  • Dental abscesses

27
Oral-pharyngeal Candidiasis
28
HIV/AIDS Oral-pharyngeal Syndromes
  • Interferes with oral hygiene
  • More oral pharyngeal pathology
  • Interferes with nutritional intake
  • Wasting syndrome

29
AIDS/HIV Related Oral Pathology
30
HIV/AIDS Chest Pain Syndromes
  • Incidence 41
  • Pneumocystis carinii pneumonia
  • Retrosternal, burning
  • Esophagitis (/- dysmotility)
  • Candidiasis
  • HSV, CMV, HIV ulcerations
  • GERD
  • Herpes Zoster- Post Herpetic Neuralgia

31
Herpes Zoster- Post Herpetic Neuralgia
32
HIV/AIDS Abdominal Pain Syndromes
  • Nausea
  • NRTIs zidovudine, didanosine, emtricitabine,
    lamivudine, tenofovir
  • Diarrhea
  • Infectious
  • NRTIs tenofovir, emtricitabine,
  • CMV ileitis, colitis
  • Visceromegaly (didanosine)
  • Pancreatitis (pentamidine, ddI, ddC, )
  • Acalculous cholecystitis
  • Schlerosing cholangitis (AIDS cholangitis)
  • CMV bowel perforation
  • Tumor Kaposis, Lymphoma

33
HIV/AIDS Anorectal Pain Syndromes
  • Affect 34 AIDS/ARC males
  • Infections/STDs
  • Trauma
  • Fistulae/fissures/abscesses
  • Rectal cancers
  • KS, NHL, SSC

34
HIV/AIDS Anorectal Pain Syndromes
35
HIV/AIDS Gynecologic Pain Syndromes
  • STDs
  • Herpes simplex ulceration
  • Human papilloma virus
  • Cervical cancer
  • Pelvic inflammatory disease

36
HIV/AIDS Gynecologic Pain Syndromes
37
HIV/AIDS Pain SyndromesPeripheral Neuropathies
  • Acute inflammatory demyelinating polyneuropathy
  • Chronic inflammatory demyelinating polyneuropathy
  • Mononeuritis multiplex
  • Radiculitis
  • VZV Herpes Zoster post-herpetic neuralgia
  • CMV
  • HIV
  • Distal symmetrical peripheral neuropathy
  • HIV (AIDS associated distal sensory neuropathy)
  • Toxic (Antiretroviral toxic neuropathy)
  • Vitamin deficiencies

38
Distal Symmetrical Peripheral Neuropathy
  • Most common HIV/AIDS neuropathy
  • Usually late complication
  • Sensory predominantly small fiber
  • Pain, paresthesias soles of feet
  • Signs large fiber
  • Reduced Achilles DTR/vibration sense
  • Etiology HIV infection or treatment
  • AIDS Associated Distal Sensory Neuropathy
  • Antiretroviral toxic neuropathy (NRTIs)
  • Risk Factors
  • age, high viral load, low CD4 count, cumulative
    NRTI dose

39
Common Painful HIV/AIDS Syndromes
Musculoskeletal system
  • Arthropathies
  • Reactive arthritis
  • Reiters syndrome
  • Non-specific arthralgias
  • Psoriatic arthritis
  • HIV arthritis
  • Septic arthritis

40
Common Painful HIV/AIDS Syndromes
Musculoskeletal system
  • Myopathies
  • Inflammatory polymyositis
  • Subacute proximal weakness and myalgia
  • HIV and other virus, infection vs. inflammation
  • Zidovudine
  • Necrotizing non-inflammatory myopathy
  • Zidovudine
  • Infectious Myositis
  • Toxoplasmosis
  • Microsporidiosis mysositis

41
HIV/AIDS Social Pain
  • Young
  • Family estrangement
  • Social stigma
  • STD's
  • Drug use
  • HIV
  • Homosexual
  • Poor coping mechanisms
  • Limited support

42
Unos Cuantos Piquetitos(A Few More
Sticks)Frida Kahlo
43
Pain Palliative Care in HIV/AIDS Management
Options
  • Cognitive-behavioral interventions
  • Systemic pharmacotherapy
  • General pain management medications
  • HIV/AIDS specific pain medications
  • Interventional techniques
  • Surgical techniques
  • Physical Modalities
  • Electro-stimulation therapy

44
General Pain Management Principles
  • Thorough assessment
  • Somatic nociceptive vs. neuropathic pain
  • Intensity, quality, timing
  • Exacerbating and relieving factors
  • Treatment history
  • Pharmacologic history
  • Psychosocial modifiers

45
Systemic Pharmacotherapy General Management
Principles
  • By the patient
  • By the syndrome
  • By the clock
  • By the analgesic ladder
  • Consider drug interactions

46
General Pharmacotherapeutic Principles WHO
Analgesic Ladder in HIV/AIDS
47
Nociceptive Neuropathic Analgesic Ladder
48
Optimal Use of AnalgesicsWorld Health
Organization Step Ladder
  • Begin with non-opiate, nonsteroidal
    anti-inflammatory 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

49
WHO Analgesic Ladder in HIV/AIDS
  • Non-opioid analgesic
  • Acetaminophen
  • Tramadol
  • NSAID
  • Weak opioids
  • Propoxyphene
  • Hydrocodone
  • Strong opioids
  • Oxycodone
  • Morphine
  • Hydromorphone (Dilaudid)
  • Fentanyl (Duragesic)

50
Non-Opioid Analgesics
51
NSAIDs Side Effects
  • Gastric irritation/ulceration
  • Prolong bleeding time, esp. ASA
  • CNS stimulation
  • Hepatic dysfunction
  • Renal dysfunction
  • Elevated BP
  • Edema
  • Allergic Rxn's

52
Opioid Analgesics
53
Opioid Analgesics
54

Opioid Side Effects
  • Respiratory System
  • -depresses ventilation
  • GI System
  • - N/V
  • - Constipation
  • Biliary muscle spasm
  • GU System
  • -urinary retention
  • -urinary urgency
  • Cutaneous System
  • -vasodilation
  • -flushing
  • -pruritis

CNS -euphoria -dysphoria -confusion -sedation -mi
osis
CV System -Orthostatic hypotension
-Venodilation -Bradycardia
(tachycardia with meperidine)
55
Analgesic Ladder for Neuropathic Pain
Opioid analgesic Topical capsaicin,
lidocaine TCA/SRRI, anticonvulsant, topical
agent
Anti-arrhythmic Topical capsaicin,
lidocaine TCA/SRRI, anticonvulsant analgesic
I certainly
Anti-epileptics TCA/SNRI /- analgesic
Tricyclic Antidepressant Serotonin/NE Reuptake
Inhibitor /- analgesic
56
Anti-neuropathic Pain MedicationsFirst Line
57
Anti-neuropathic Pain MedicationsSecond Line
58
Antineuropathic Medications Efficacy

Oral agents TCAs (2.64) opioids (2.67)
gabapentin (4.29) tramadol (4.76) pregabalin
(4.93) Topical agents aspirin/diethyl ether
(1.83) lidocaine patch (2) capsaicin
(3.26) (Numbers needed to treat) e.g., PHN
59
Systemic Pharmacotherapy Antiretroviral-Analgesic
Interactions
  • Fentanyl Clearance decreased by ritonavir
  • Methadone Withdrawal reported with nevirapine,
    efavirenz
  • Phenytoin, Carbamazepine reduced levels/efficacy
    of NNRTIs/protease inhibitors
  • TCAs/trazadone inhibited metabolism by
    ritonavir
  • Benzodiazepines Enhanced sedation with
    ritonavir, protease inhibitors

60
Are treatment with opioids in a patient with a
past history of addiction contra-indicated?
  • Yes
  • No

61
Opioid Treatment with Chemical Addiction
  • Diagnose pain syndrome and pathway
  • Differentiate dependence, tolerance, addiction,
    and pseudo-addiction
  • Maximize non-opioid medications
  • One clinic - one doctor - one pharmacy - one
    month
  • Written agreements
  • Long-acting or controlled release formulations

62
My Nurse and I Frida Kahlo
63
Specific TreatmentHeadache Syndromes
  • Primary headaches
  • - Abortive acetaminophen, NSAID's
  • Migraines triptans (5HTS antagonists)
  • - Prophylactic TCA's, b-blockers, Ca
    channel blockers
  • Zizovudine/NRTI associated HA
  • - Resolves with discontinuance
  • Cerebral toxoplasmosis
  • - sulfadiazine 1-4 gm/d
  • with pyrimethamine (Daraprim) 50-75 mg/d
  • Cryptococcal meningitis
  • - fluconozole (Diflucan) 12 mg/kg/d, then 6
    mg/kg/d
  • Cerebral lymphoma
  • - steroids/radiation

64
Specific Treatment Oral-pharyngeal Syndromes
Candidiasis
  • Nystatin
  • (Mycostatin) 100,000 u/ml, 5 ml qid swish and
    swallow
  • Vaginal suppositories, Dissolve in mouth qid
  • Clotrimazole
  • (Mycelex) troches 10 mg, Dissolve in mouth 5x/d
  • Ketoconazole
  • (Nizoral) 200 mg, 1 qd, Maintenance
  • Hepatoxicity
  • Fluconozole
  • (Diflucan) 100 mg, 2 stat, then 1 qd
  • Less toxic, expensive
  • Itraconazole (Sporanox)
  • Soln 10mg/ml, 10 ml bid swish and swallow
  • 100 mg tabs bid
  • Hepatoxicity

65
Specific Treatment Oral-pharyngeal Syndromes
  • Aphthous ulcer stomatitis
  • Nonsteroidal aphthasol (Amlexanox) 5 qid
  • Non steroidal Orabase qid
  • Triamcinolone (Kenalog in Orabase) 0.1 qid
  • Dexamethasone (Decadron) elixir 0.5mg/5ml rinse
    and expectorate qid
  • Diphenhydramine/AlOH,MgOH (Benadryl/Maalox) 30/60
    ml 5 mg swish and swallow tid before meals
  • Diphenhydramine/sucrulfate (Benadryl/Carafate)
    30/60 ml 5 mg swish and swallow tid before meals
  • Periodontal/periapical abscesses
  • Dental treatment
  • Pen VK 250-500 mg qid
  • Erythromycin 250 mg qid
  • Cephalexin (Keflex) 250-500 mg qid

66
Specific Treatment Oral-pharyngeal Syndromes
  • Primary (acute) herpetic (HSV) gingivostomatitis
  • acyclovir (Zorivax) 200 mg tabs, 2 tid x 7days
  • Recurrent herpes simplex
  • penciclovir (Denavir) cream 1 q2h x 4d
  • docosanol (Abreva) cream (OTC) 5x/d x 4d
  • Shingles (HVV) acute herpes zoster
  • acyclovir (Zorivax) 800 mg caps, 1 5x/d x 7days
  • valacyclovir (Valtrex) caps 500 mg 2 tid x 7 d
  • Sympathetic plexus (stellate ganglion) blocks

67
Stellate Ganglion Block
68
Specific TreatmentChest Pain Syndromes
  • Pneumocytis carinii pneumonia
  • - TMP/SMX
  • Candidiasis
  • Ketoconazole (Nizoral) 200 mg qd maintenance
  • Fluconozole (Diflucan) 100 mg, 2 stat, then 1 qd
  • less toxic, expensive
  • Herpes simplex esophagitis
  • - Acyclovir (Zorivax) 200 mg tabs, 2 tid x 7days
  • Herpes zoster/PHN - Acyclovir, TCA's,
    Gabapentin
  • Epidural steroid injections
  • Sympthetic (stellate ganglion) blocks

69
Specific Treatment Esophagitis
  • Underlying cause
  • CMV esophagitis- Ganciclovir (Cytovene) 1000 mg
    tid
  • Topical lidocaine
  • Proton pump inhibitors
  • Pro-kinetic agents
  • metoclopramide (Reglan) 10 mg tid
  • Coating agents
  • sucralfate (Carafate) 1 gm b.i.d.

70
Specific Treatment H. Zoster/PHNEpidural
Steroid Injection
71
Specific Treatment Abdominal Pain Syndromes
  • Infectious diarrhea
  • Ciprofaxin 500 mg bid x 5d, TMP/SMX DS bid x 5d,
    or Metronidazole 500 mg tid x 10 d
  • Fluids
  • Loperamide (Imodium) 2 mg p each stool
  • Antispasmotics
  • Cholangitis/cholecystis
  • Cefuroxime /or piperacillin /or mexolcillin
  • Endoscopic sphincterotomy? (sclerosing
    cholangitis)
  • CMV iliitis/colitis
  • Ganciclovir (Cytovene), 1000 mg tid
  • Antispasmotics
  • Drug induced pancreatitis and visceromegaly
  • pentamidine, didanosine, deoxycytidine
    associatedresolve with discontinuance
  • Celiac plexus block

72
Specific Treatment Anorectal Syndromes
  • Clindamycin aminoglycoside
  • Sitz baths
  • ID, surgery
  • Topical lidocaine (2-5 gel)
  • Glycerin/petrolatum/shark liver oil (Preparation
    H)
  • Hydrocortisone 1
  • Witch Hazel (50) (Tucks pads)

73
Specific TreatmentPeripheral Neuropathies
  • Acute or Chronic Inflammatory Demyelinating
    Polyneuropathy
  • Plasmapheresis
  • Steroids
  • Zidovudine
  • Distal Symmetrical Polyneuropathy
  • TCA's (amitriptyline, nortriptyline,
    desipramine), SNRI's
  • Anticonvulsants (gabapentin, carbamazepine)
  • Tramadol
  • Opioids
  • Vitamin B E supplementation
  • Topical capsaicin or lidocaine (Lidoderm)
  • Sympathetic neurolysis

74
What medications are not effective in treating
neuropathic pain?
  • TCAs (e.g., amitriptyline, nortriptyline, etc)
  • SSRI antidepressants (e.g. Prozac, Paxil, etc.)
  • SNRIs (e.g., Cymbalta, Effexor)
  • Opioids
  • Anti-epileptic medications (e.g. gabapentin)
  • 6. Topical lidocaine and capsaicin

75
Treatment Peripheral NeuropathiesEfficacy
Antineuropathic Medications

Oral agents TCAs (2.64) opioids (2.67)
gabapentin (4.29) tramadol (4.76) pregabalin
(4.93) Topical agents aspirin/diethyl ether
(1.83) lidocaine patch (2) capsaicin
(3.26) (Numbers needed to treat) e.g., PHN
76
Specific Treatment Musculoskeletal system
  • Non-specific arthralgias
  • NSAIDs
  • Non-opioid analgesic
  • Reactive arthritis
  • Methotrexate (Rheumatrex) 2.5-10 mg/wk
  • Intra-articular steroid injections
  • Myopathies
  • NSAIDs
  • Non-opioid analgesic
  • AZT
  • Steroids
  • Zidovudine myositis discontinue if possible

77
Specific Treatment ArthriditesHip and SIJ
Intra-articular Injections
78
SummaryPain Palliative Care in HIV/AIDS
  • Recognition
  • Prevalence
  • Barriers
  • Common HIV painful syndrome
  • Thorough assessment
  • Nociceptive vs. neuropathic
  • Dx specific process
  • Systemic pharmacotherapy
  • NSAIDs, opioids, anti-neuropathic medications
  • Syndrome specific therapy
  • Reassessment, adjustment, and empathy

79
The End
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