1. Slide 1 of 12 From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA. IAS–USA Jessica S. Merlin, MD, MBA Assistant Professor of Medicine University of Alabama at Birmingham Chronic Pain in Patients with HIV: What Clinicians Need to Know From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.

2. Slide 2 of 12 From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA. Acute vs. Chronic Pain Acute pain: new pain, < 3 mo Chronic pain: persists > 3-6 months, beyond the period of normal tissue healing Examples: low back pain, other msk pain, fibromyalgia, neuropathy Turk DC, Pain, 1987; APA, DSM-IV, 1984.

3. Turk DC, Lancet, 2011; Institute of Medicine, 2012. From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.

4. Chronic pain in persons with HIV Chronic Pain HIV infection (e.g., distal sensory polyneuropathy) Antiretroviral therapy (e.g., nucleoside neuropathy) Opportunistic Infections (e.g., herpes zoster) Treatment of OI’s (e.g., INH polyneuropathy) Non-HIV (e.g., low back pain, other MSK pain) Slide courtesy of Joanna Starrels. From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA.

5. Slide 5 of 12 From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA. Chronic pain history Impact of pain on: – Function – Mood – Sleep – Ask: “Some people report that pain impacts X; is that true for you?” ICSI Guideline for Management of Chronic Pain; Kerns RD, Pain, 1985.

6. Slide 6 of 12 From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA. Communicating about Chronic Pain Not easy, because: – Patients come with “baggage” – Providers come with “baggage” – Pain is the 5 th vital sign, pain is an emergency – Medications come with risk – Patients may have active psychiatric illness/addiction – Patients’ behaviors may evoke severe negative countertransference

7. Slide 7 of 12 From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA. Initial Discussion (can be in the context of a treatment agreement) What is chronic pain Patience Partnership and collaboration Pharmacologic and non-pharmacologic management Mind-body connection Functional goals

8. Slide 8 of 12 From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA. Evidence-Based Management Remember….first, do no harm!! Focus on evidence-based therapies, avoid unnecessary procedures, surgeries, medications Set concrete goals and timelines Be ready to discontinue therapies that don’t work If possible, treat psychiatric illness first

9. Slide 9 of 12 From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA. Evidence-Based Non-Opioid Pharmacologic Therapy Acetominophen - 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, capsacin post-herpetic/DSP, doclofenac-OA

10. Slide 10 of 12 From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA. A Moment on Opioids…. Evidence for long term use is lacking Some evidence for increased mortality with doses > 100-200mg equivalents of morphine per day Most overdose deaths due to methadone, often with benzos Noble M, Cochrane Database Syst Rev, 2010, Lum P, JAIDS, 2010, Manchikanti L, Pain Physician, 2011; Webster L, Pain Med, 2011; Gomes T, Arch Int Med, 2011; Bonhert AS, JAMA, 2011.

11. Slide 11 of 12 From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA. How to decide Assess risk/benefit ratio of opioids “Clinicians may consider a trial of COT if chronic non-malignant pain is severe, pain is having an adverse impact on function or quality of life, and benefits outweigh harms” (strong, low) Chou R, J Pain, 2009.

12. Slide 12 of 12 From JS Merlin, MD, at Chicago, IL: May 20, 2013, IAS-USA. Key Points Chronic pain is common in patients with HIV, and causes substantial functional impairment You know a patient has pain if they say they have pain We have a lot more to offer than opioids Pay attention to psychiatric symptoms For more information: IAS-USA Cases on the Web