Jessica S. Merlin, MD, MBAAssistant Professor of Medicine

University of Alabama at BirminghamBirmingham, Alabama

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

FORMATTED: 11/03/2015

New Orleans, Louisiana: December 15-17, 2015

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HIV and Chronic Pain in the Current Treatment Era

Prevalence as high as 39-85%Often coexists with mood disorders and addictionOften musculoskeletalAssociated with key outcomes (functional impairment,

retention)Can be challenging for HIV providersMerlin 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.

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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

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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

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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

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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

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Evidence-Based Non-Pharmacologic Strategies

Behavioral approaches Physical therapy Exercise Interventional treatments Complementary and alternative therapies Surgery

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.