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Palliation and Pain Control in HIV/AIDS


 

Direct Links to Palliative Care Info
Palliation & Pain Control in HIV/AIDS
Painful Conditions
Palliative Care Medication Use
Non-Opiate Pain Management
Opiates for Acute Pain
Opiates for Chronic Pain
Equianalgesic Dosing of Opiates
Pain Management Guidelines
Algorithm for Initiation of Chronic Pain Therapy
Guidelines for Chronic Pain Therapy in Chemically Dependent Patients
Non-Pain Symptom Management Guidelines
Constipation
Nausea
Fatigue & Sedation due to medical therapy

 

The Medications Used for Pain Management

 

Non-Opiate Pain Management Medications, Adjuvants, and Other Treatments
Medication Indications Dosing Considerations
nonsteroidal anti-inflammatory drugs (NSAIDs)
including ibuprofen, naproxen, etc.		 Musculoskeletal pain
Other types of mild inflammatory pain		 ibuprofen: up to 800 mg every 8 hours
naproxen: up to 500 mg every 8 hours		 Avoid in persons with gastritis, PUD, renal failure, congestive heart failure or on aspirin for antiplatelet effect
Always take NSAIDs with food
Cox-2 inhibitors are no more effective or better tolerated and may have adverse cardiovascular effects.
Antipyretic effect which may cause sweats.
For best results, these medications should be taken on a fixed schedule and NOT as needed.
acetaminophen


 (Tylenol or generics)

 Mild pain of any type Up to 2400-3000 mg per day in 3-4 divided doses Avoid using in anything but mild pain.
Antipyretic effect may cause sweats.
Avoid use in hepatic disease.
gabapentin


 (Neurontin or generic)

 Adjuvant therapy for most types of pain
Primary therapy for neuropathic pain
May be used as a hypnotic		 Available in 100, 300, 400, 600, 800 mg formulations
Start with 300-400 mg at bedtime and slowly increase to 800-1200 BID or TID.

5600 mg per day or more may be used if beneficial and tolerated

 May cause sedation, memory loss, dry mouth, vivid dreams, dyspraxia, expressive aphasia
levetiracetam


(Keppra)

 Adjuvant therapy for most types of pain
Primary therapy for neuropathic pain		 1000-3000 mg per day in two doses Adjust dose for renal failure and severe hepatic failure
Sedation, depression, and behavioral side effects fairly common
amitriptyline


(Elavil or generics)

 May intensify the sedative effects of other drugs 25-200 mg, increase slowly and take at bedtime to avoid excessive daytime sedation Seldom used.
No more effective than placebo for neuropathic pain
May produce dry mouth, orthostatic hypotension
Avoid in setting of urinary retention, BPH or hypotension / elderly patient
lidocaine patches

 (Lidoderm)		 Adjuvant or primary therapy for neuropathic pain Apply one patch to the painful area or proximal to it for 12 hours each day and remove for 12 hours. 

Patches may be cut up for optimal adhesion and to apply to different areas simultaneously.

 Adhesive reactions and lack of adhesion are possible.
 
duloxetine

 (Cymbalta)		 Neuropathic pain 60-120 mg per day Improvements may be noted within 1 week of initiation of therapy
Not recommended for Ccr<30 cc/min or any hepatic insufficiency
Use with caution with tricyclic antidepressants, phenothiazines, propafenone, flecainide
Taper off at discontinuation if possible
Contraindicated with thioridazine, MAO inhibitors
Pregnancy category C
Nausea, dizziness, somnolence, fatigue are the most common AE
Sexual dysfunction is also possible.
pregabalin

 

(Lyrica)

 Neuropathic pain ? FDA-approved 12/31/2004 for diabetic neuropathy and post-herpetic neuralgia
I believe pregabalin is a prodrug for gabapentin.
Not yet available as of 1/24/2005.

Side effects are similar to gabapentin: , somnolence, dry mouth, peripheral edema, blurred vision, weight gain and difficulty with concentration/attention.
Lyrica press releases states that it may be a "controlled substance"  (!!!)
Anodyne therapy Neuropathic pain? LED pads are applied and light is applied to the painful area for 30-45 minutes three times per week Unproven except in diabetic neuropathic pain (prevents ulcerations and infections)

 

 

Acute Pain - Opiate Analgesics: Combinations, Agonists, and Partial Agonists
Medication Indications Acute Pain Dosing Considerations
tramodol

 (Ultram and generics)		 Acute mild pain 5-10 mg every 6 hours as needed Weak agonist
More than 40 mg/day associated with seizures
codeine Acute mild pain 15, 30, 60 mg tablets

15-60 mg q4-6 hours as needed.

 Agonist

 

Generally it is hard to find this medication in pharmacies.
codeine / acetaminophen

 (Tylenol #3, Tylenol #4, and generics)		 Acute mild pain Tylenol #3: 15 mg codeine + 325 mg acetaminophen

Tylenol #4: 30 mg codeine + 325 mg acetaminophen
Generally given as 1-2 up to 4 times a day to limit acetaminophen toxicity.

 Agonist plus acetaminophen
 
hydrocodone / acetaminophen
or
hydrocodone / ibuprofen

 (Lortab, Vicodin, Vicoprofen, and generics)		 Acute mild to moderate pain Many formulations including 5/325, 5/500, 7.5/325, 7.5/500, 7.5/750

Generally given as 1-2 up to 4 times a day to limit acetaminophen toxicity.

 Agonist plus acetaminophen or ibuprofen
 
oxycodone

(Oxy-IR, Oxy-Fast and generics)		 Acute or chronic moderate to severe pain 5-25 mg every 4-6 hours as needed
Higher doses may be used if necessary		 Agonist
oxycodone / acetaminophen
or
oxycodone / aspirin

 (Percocet, Percodan and generics)		 Acute moderate pain 5/325 coformulations with aspirin or acetaminophen

Generally given as 1-2 up to 4 times a day to limit acetaminophen toxicity

Agonist plus acetaminophen or aspirin
meperidine

 (Demerol and generics)		 Acute mild to moderate pain 50-100 mg IM or IV Full agonist
Toxic metabolites
buprenorphene

 (Burprenex and generics)		 Acute or chronic* mild to moderate pain 0.3 - 0.6 mg IV/IM every 6-8 hours Partial agonist/antagonist
morphine

 (MS-IR and generics)		 Chronic moderate to severe pain 5-20 mg every 2-6 hours Full agonist
hydromorphone

 (Dilaudid and generics)		 Acute moderate to severe pain 2-4 mg every 4-6 hours as needed Full agonist
fentanyl

(Actiq)		 Acute or chronic moderate to severe pain Start at 200 mcg unit consumed over 15 minutes translingual and increase after 6 units consumed if necessary Full agonist


Chronic Pain: Baseline / Long-Acting and Breakthrough / Short-Acting Analgesics
Medication Category Formulation Dosing
Interval
(hours)		 Considerations
codeine Not recommended     Poor potency and tolerance
codeine / acetaminophen Not recommended     Poor potency, tolerance, and unnecessary, toxic acetaminophen decreases dosing flexibility
Excessive nausea, pruritus, constipation
hydrocodone / acetaminophen
or
oxycodone / ibuprofen		 Generally not recommended 5, 7.5, 10 mg / 325-750 mg 4-6 Unnecessary, toxic acetaminophen / ibuprofen decreases dosing flexibility
oxycodone immediate release

 

(Oxy-IR, Oxy-Fast and generics)

 Breakthrough 5, 10, 15 mg tablets
5 mg/5 cc solution

5 mg/1cc solution

 3-4 Very flexible, very potent, very inexpensive
oxycodone sustained release

 

(OxyContin)

 Baseline 10, 20, 40, 60, 80, 160 mg tablets 8-12 Do not start in analgesic naive patient.
Flexible, potent, but proprietary, expensive, and highly abused

Many patients require 8 hour dosing interval for extended-release oxycodone formulations.
oxycodone / acetaminophen
or
oxycodone / aspirin

 

(Percocet, , Percodan and generics)

 Generally not recommended   4-6 Unnecessary, toxic acetaminophen / aspirin decreases dosing flexibility
meperidine

 

(Demerol and generics)

 Not recommended Parenteral solution for IV/IM
Tablets		 2-4 Half-life excessively short
Toxic metabolites with prolonged use can cause seizures
Poor oral bioavailability
buprenorphene

 

(Buprenex, Suboxone, Subutex and generics)

 Generally not recommended
 		 Parenteral solution for injection
*Sublingual tablets 2, 4, 6, 8, 16 mg
*Also combined with naloxone in Suboxone formulation		 12-48 Partial opiate agonist / antagonist
WARNING: When used with other long-acting opiates, buprenorphene will produce acute opiate withdrawal, and therefore, buprenorphene is contraindicated in such a situation!

*May be used in highly select patients in sublingual form for opiate substitution therapy and mild baseline / long-acting pain control by a specially licensed physician
methadone

 

(Dolophine and generics)

 Baseline 5,10 mg tablets; 40 mg wafers; solution 8-12 Do not start in analgesic naive patient.
Potent, inherently long-acting and inexpensive opiate
Dose must be escalated slowly to avoid delirium/accumulation
Consider alternatives if doses higher than 240 mg/day must be used, and avoid use with other drugs that prolong the QT interval.
morphine immediate release

 

(MS-IR, Roxanol, and generics)

 Breakthrough 5, 10 mg tablets
5 mg/5cc and 20 mg/cc suspension
Parenteral solution for IM or IV or SQ		 2-4 Potent and inexpensive
Parenteral form not recommended when can be taken orally
morphine sustained release

 (MS Contin, Oramorph, Avinza, Kadian, and generics)		 Baseline 15, 30, 60, 100, 200 mg tablets 8-12 The Gold Standard of Pain Control
Do not start in analgesic naive patient.
Potent, flexible, and inexpensive
New formulations Avinza and Kadian may be administered on a once-a-day interval

Many patients require 8 hour dosing interval for MS Contin, Oramorph, and generic extended-release morphine formulations.
hydromorphone

 

(Dilaudid and generics)

 Breakthrough 2, 4 mg tablets
3 mg suppository
Parenteral solution		 2-4 Not used much
fentanyl translingual

 

(Actiq)

 Breakthrough 200-1600 mcg "suckers" or units for translingual administration over 15 mins 2-4 Potent but expensive
fentanyl transdermal

 

(Duragesic)

 Baseline 25, 50, 75, 100 mcg/hour patches 48-72 Do not start in analgesic naive patient.
Expensive
Not practical over 300 mcg/hour due to large number of patches
Not practical with diffuse dermatitis (e.g. psoriasis)
Not practical for diffuse body hair
Fairly frequent adhesive reactions
Possibly most useful in situation where patients have a tendency to adjust analgesia dosing inappropriately.

 

Equianalgesic Dosing of Opiates
[use only as an approximation]

 

Drug  Duration Half-life Route   Equianalgesic
 Dosage
Codeine 4–6 h 3 h IM/IV/SC 120 mg
      PO 200 mg
Fentanyl 1–2 h 1.5–6 h IM/IV 0.2 mg
Hydrocodone 4–8 h 3.3–4.5 h PO 20 mg
Hydromorphone 4–5 h 2–3 h IM/IV/SC 1.3–1.5 mg  (1.4)
      PO 7.5 mg
Levorphanol 6–8 h 12–16 h IM/IV/SC 2 mg
      PO 4 mg
Meperidineæ 2–4 h 3–4 h IM/IV/SC 75 mg
      PO 300 mg
Methadone 4–6 h 15–30 h IM/IV/SC 1-10 mg§   Medline
Short term: 5-10mg
Chronic use: 1-4 mg  
     (2 mg)
      PO 2 - 20 mg§   Medline
Short term use: 20 mg
Chronic dosing: 2-4 mg 
     (3mg)
Morphine 3–6 h 1.5–3 h IM/IV/SC 10 mg
      PO 30–60 mg#
Oxycodone 4–6 h NA PO 15-30 mg (20 mg)
Oxymorphone 3–6 h NA IM/IV/SC 1 mg
Propoxyphene 4–6 h 6–12 h PO 130-200 mg *

 

 


Updated 10.27.2005