On September 14, the HIV Medicine Association (HIVMA) of the Infectious Disease Society of America (IDSA) issued the very first comprehensive guidelines on HIV and chronic pain, recommending that all people living with HIV should be screened for chronic pain.
Ongoing pain is a significant problem that affects thirty-nine to eighty-five percent of people living with HIV. Thus, the new guidelines recommend that all HIV-positive patients be assessed for chronic pain. Those patients who screen positive should be offered a variety of options for managing that pain.
The guidelines, compiled by a panel of experts in HIV, substance abuse, pain, psychiatry, palliative care, and pharmacology, recommend that patients with HIV be screened using a few simple questions:
(1) How much bodily pain have you had during the week?
(2) Do you have bodily pain that has lasted more than three months?
Those that screen positive should undergo comprehensive evaluation, including a physical exam, psychosocial evaluation and diagnostic testing. Nearly half of chronic pain in people with HIV is due to neuropathy (nerve pain), likely from inflammation or injury to the central or peripheral nervous system caused by the infection. Non-neuropathic pain typically is musculoskeletal, such as low-back pain and osteoarthritis in the joints.
“Because HIV clinicians typically are not experts in pain management, they should work closely with others, such as pain specialists, psychiatrists and physical therapists to help alleviate their patients’ pain,” said Douglas Bruce, MD, MA, MS, lead author of the guidelines, Chief of Medicine at Cornell Scott-Hill Health Center and Associate Clinical Professor of Medicine at Yale. “These comprehensive guidelines provide the tools and resources HIV specialists need to treat these often-complex patients, many of whom struggle with depression, substance use disorders, and have other health conditions such as diabetes.”
HIVMA warns that those who have chronic pain should not receive opioids as a first-line treatment. They recommend offering alternative, non-pharmacological therapies first, including cognitive behavioral therapy, yoga, physical and occupational therapy, hypnosis and acupuncture. If medication is needed, the guidelines recommend beginning with non-opioids, such as gabapentin (anti-seizure medicine) and capsaicin (topical pain reliever made from chili peppers), both of which help with nerve pain.
“Opioids are never first-line,” said Dr. Bruce. “The guidelines always recommend the most effective treatment with the lowest risk.”
The online version of the HIVMA guidelines includes an extensive list of resources for physicians to reference to help them treat patients comprehensively.
The full guidelines are available free on the IDSA website at www.idsociety.org.
Reporting by Hank Trout