1. Jessica S. Merlin, MD, MBA Assistant Professor of Medicine University of Alabama at Birmingham Birmingham, Alabama Chronic Pain in Patients With HIV: What Clinicians Need to Know FORMATTED: 11/03/2015 New Orleans, Louisiana: December 15-17, 2015

2. Slide 2 of 38 HIV and Chronic Pain in the Current Treatment Era Prevalence as high as 39-85% Often coexists with mood disorders and addiction Often musculoskeletal Associated with key outcomes (functional impairment, retention) Can be challenging for HIV providers Merlin 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.

3. Slide 3 of 38 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

4. Slide 4 of 38 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

5. Slide 5 of 38 Evidence-Based Non-Opioid Pharmacologic 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

6. Slide 6 of 38 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

7. Slide 7 of 38 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.