Palliation and Pain Control in HIV/AIDS

Pain Management Guidelines

The treatment of significant chronic painful conditions usually requires a long-acting pain reliever to serve as a baseline of analgesia accompanied by a immediate-release opiate for breakthrough pain which may accompany activity or other disease fluctuations.

2.  Provide the reliable opiate-naive patient patient with a large enough supply of short-acting, non-acetaminophen/non-aspirin-containing analgesic to cover their pain needs (e.g., oxycodone 5 mg #60-90 or immediate release morphine, etc.).  Allow the patient to administer it at 3-4 hour intervals if necessary and to slowly increase the dose if necessary.

3.  At the 24-48 hour mark, add up all the short-acting analgesic that has been used, and consider starting a long-acting opiate based on that amount (e.g., 30 tablets used at 48 hours = 75 mg oxycodone/day ---> begin extended releases oxycodone 40 mg bid).

4.  At the next 24-48 hour interval, add up all the short-acting oxycodone used.  If less than 33% of the long-acting dose, consider maintaining the current analgesic dosing.  If the short-acting opate use is > 33% of the long-acting dose, then increment the long-acting dose by that amount.

5.  Prevent constipation from the time of initiation of opiates (see constipation prevention and treatment options.)  Similarly consider providing a medication for nausea treatment (see below)

6.  Maintain close contact with the patient especially during the initiation phase.

7.  Strongly consider adjuvant analgesic therapy with gabapentin or pregabalin.

8.  Consider prescribing an antiemetic such as promethazine or metoclopropamide with the opiates, and advise the patient to take it on a fixed schedule if it is needed.  See nausea section.

9. Always provide the patient with a supply of opiates that is large enough to match the prescribed dose.  For example, provide 240 oxycodone 5 mg tablets for a prescription that is written take 1-2 tablets QID as needed for pain.  If the supply is smaller than the written instructions indicate permissible, the patient must return to the prescriber and/or to the pharmacy sooner than a one month interval; this type of behavior that is forced upon the patient may lead to concerns regarding addiction or some sort of abuse/diversion (also known as "pseudo-addiction.")

Treatment of acute or chronic pain in the patient with an addictive disorder is essentially no different from that in the patient without an addictive disorder

2.   Initiate therapy as detailed above in the algorithm for opiate initiation.  In some cases transdermal fentanyl may be a more appropriate long-acting analgesic in the chemically dependent patient especially those who have a tendency to self-medicate and inappropriately dose-adjust themselves.  In many cases, extended-release oxycodone should be avoided due to its high potential for diversion ($1 per milligram street price) and abuse.

3.   Strongly consider a formal pain "contract" which outlines the rights and responsibilities of the prescriber and the patient.  Give a copy to the patient and keep a signed copy in the patient's records.  A pain contract which can be downloaded and modified for your situation can be accessed HERE.  A pain contract is not "enforced"; it is merely a guide for handling patient behavior's that are harmful to the patient.

4.   Use random and non-random urine toxicology testing to confirm adherence to the prescribed opiates.  It is seldom possible to draw any firm conclusions regarding opiate use from one urine test.  "Abnormal" results should be confirmed and possibly re-confirmed.  Keeping track of the last dose of opiate used prior to the test will aid in the interpretation of urine toxicology testing.  The appearance of nonprescribed substances (e.g., cocaine, amphetamines, etc.) in the urine should not necessarily affect opiate prescribing in an otherwise stable patient with appropriate opiates found on urine toxicology.  Keep the addictive disorder and the painful condition(s) separated as much as possible as each requires a different strategy.

5.   Proper provider-patient boundaries are critical to a professional relationship with these patients.

6.   As in the general practice of medicine, all decisions should be based on achieving the optimal health of the patient.  Punishment or penalization is not within the purview of the medical profession.

7.   Consider enlisting the support and presence of a social worker or nurse if a patient must be informed of opiate discontinuation.

8.   Consult with a Pain Management expert in difficult cases.

9.   Insist on a mental health evaluation if possible.

10. If opiates must be stopped for any reason, strongly consider offering the patient a short tapering course of short-acting opiates to prevent withdrawal.

11. Close follow-up is very important.