Chronic Pain and HIV: A Practical Approach

By Peter A. Selwyn, Glenn J. Treisman and Angela G. Giovanniello

Patients suffering from HIV/AIDS often experience chronic pain due to the many diseases and infections they pick up as a result of a weakened immune system. It interferes with their quality of life and physical functioning, impacts adherence to antiretroviral therapy and HIV primary care, and is associated with significant psychological/social distress and substance use disorders.

Chronic Pain and HIV addresses all these complex issues that can influence pain care that can influence pain care for the patient with HIV and acts both as a primer and a comprehensive review to define the field of chronic pain management. Using a clear, clinical approach, key topics include the following:

• Musculoskeletal pain in individuals in HIV
• Headache in individuals with HIV
• Psychiatric comorbidities among individuals with HIV and chronic pain
• Potential benefit and harm of prescription opioids in HIV
• Pain at the end of life in individuals with AIDS
• Treatment of chronic pain syndromes in the HIV-infected person.

Edited by an outstanding team with extensive experience in HIV/AIDS and pain/palliative care, every chapter is written by a world-famous expert in their field who provides a thorough review of the relevant literature, including the very latest in management guidelines from the leading international societies.

Perfect for all those in primary care, as well as infectious disease specialists managing patients with HIV/AIDS, Chronic Pain and HIV provides sensible, straightforward clinical advice to ensure the best possible patient management.

• Language: English
• Publisher: Wiley
• Release date: Jan 22, 2016
• ISBN: 9781118777398

Book preview

Foreword

Chronic pain is defined as pain lasting longer than 3–6 months, beyond the period of normal tissue healing.[1] Relieving Pain in America, a 2011 Report from the Institute of Medicine of the National Academy of Sciences, identified chronic pain as a serious public health concern and offered a blueprint for transforming prevalence, care, education, and research.[2] A follow-up National Pain Strategy (2015) is currently being developed. Internationally, the World Health Organization recognizes chronic pain as both a public health and human rights issue, and the 2014 World Health Assembly has passed Resolution 67 calling on member states to integrate pain treatment and palliative care services for patients with chronic diseases such as cancer and HIV/AIDS into their national health strategies.[3]

This increased national and international attention to prioritize chronic pain as a public health issue makes this book a timely and valuable reference text to guide policymakers and clinicians as they develop comprehensive strategies to address chronic pain among individuals with HIV.

In the early years of the AIDS epidemic, before disease-specific treatment was even available, clinicians learned to treat pain and suffering even as they could not alter the natural history of the disease. Few conditions in recent history have represented such an extreme example of the concept of total pain as AIDS in the preantiretroviral era.[4] Patients at that time often experienced an often overwhelming succession of opportunistic infections, some of which caused or aggravated physical pain; emotional, social, and spiritual pain were also often intense, pervasive, and for some, unrelenting.

In less than two decades, the clinical landscape of AIDS has been completely transformed; remarkably, in the current HIV treatment era, rapid advances in disease treatment have provided the patient with HIV the potential for a normal or near-normal life span. However, the experience of chronic pain interferes with a patient's quality of life and physical functioning, impacts adherence to antiretroviral therapy and HIV primary care, and is associated with significant psychological and social distress and substance use disorders. Ironically, even as the incidence of opportunistic infections has decreased sharply, the incidence of chronic comorbidities in long-surviving patients with HIV has just as dramatically increased. Chronic inflammation, end-organ failure, systemic metabolic abnormalities, psychosocial, and other challenges of an aging and increasingly frail and disabled population, all have added to the complexity and necessity of having a new understanding of pain and its treatment in the antiretroviral era. Multifactorial health disparities further impact care and treatment for many HIV-infected patients, particularly those from vulnerable or disenfranchised populations. This specialized textbook addresses these complex issues that can influence pain care for the patient with HIV. It is both a primer and a comprehensive review defining the field of chronic pain management for patients with HIV.

Edited by Drs Merlin, Giovanniello, Treisman, and Selwyn—all of whom have had extensive experience with HIV/AIDS and pain/palliative care—each chapter is written by experts who provide a review of the relevant literature. Taken together, this book outlines a biopsychosocial model of care for the patient with HIV and chronic pain.

Yet this book does more than define the field—it offers front-line clinicians practical advice. It teaches healthcare professionals how to communicate with patients with chronic pain; provides the specific assessment tools that may help to routinize assessment of pain and psychologial distress; models shared decision-making in therapeutic planning; and describes the current effective pharmacologic and nonpharmacologic approaches to achieve rehabilitation, functioning, and health. Emphasis on psychiatric assessment and knowledge about substance use disorders as well as the discussions on the safe use of opioids in pain treatment for those with abuse histories are particularly valuable sections for all healthcare professionals to know and learn. Clinicians will find consolation in the chapter on the difficult patient that provides strategies for addressing these challenging patients in a professional manner and also helps them manage their own distress.

A unique feature of this text is its tone, which is evident in each of the chapters. Individuals with HIV are a vulnerable population with a high prevalence of mental illness, incarceration, homelessness, and injection drug use. Chronic pain is also a highly stigmatized disease; these dual stigmas often present a barrier to patient care. The authors articulate the need for positive regard for individuals with both HIV and chronic pain, who are stigmatized and marginalized in our healthcare system. The professionalism and compassion presented in a nonjudgmental format infuses the discourse about assessment and treatment options.

As a group, the authors support the integration of chronic pain treatment into routine HIV care but call out the current challenges and barriers—patient-related, provider-related, and systems-related—that are faced in accessing or implementing a care strategy. In this aspect, the book is aspirational in defining a quality standard of care that should become the norm for individuals with HIV and chronic pain.

While defining the field of chronic pain care in HIV, the book also serves to expose the dearth of detailed studies that limit definitive guideline development and encourage inadequate assessment and treatment. This issue is not specific to HIV pain research but is common to the field of chronic pain care in general, where the lack of a robust research agenda and funding stream thwarts the development of innovative therapies.

In his reflections on medical care, Anatole Broyard encourages physicians to take the sick man into his heart.[5] This book helps us to do so with the specific skills necessary to provide humane, competent, and compassionate care for the individual with HIV and chronic pain.

Kathleen Foley, MD and Peter Selwyn, MD

References

1 Merskey, H., et al. (1994) Part III: pain terms, a current list with definitions and notes on usage Classification of Chronic Pain, 2nd ed., IASP Task Force on Taxonomy, edited by H. Merskey and N. Bogduk, IASP Press.

2 Institute of Medicine (2011) Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. The National Academies Press, Washington, DC.

3 Burki, T.K. (2014) WHO resolution on access to palliative care. Lancet Oncology, 15 (3), e109.

4 Clark, D. (2000) ‘Total pain’: the work of Cicely Saunders and the Hospice movement. Bulletin of the American Physical Society, 10 (4), 13–15.

5 Broyard, A. (1992) Intoxicated by my illness. In: Broyard, A. (ed), Fawcett Columbine Book. Ballantyne Books.

About the editors

Jessica S. Merlin, MD, MBA

Dr Merlin is an Assistant Professor of Medicine in the divisions of Infectious Diseases and Gerontology, Geriatrics, and Palliative Care at the University of Alabama at Birmingham. She received her MD and MBA degrees, as well as her training in internal medicine and infectious diseases, at the University of Pennsylvania, and her palliative care training at the Mount Sinai School of Medicine. She runs one of a handful of HIV-focused chronic pain clinics in the United States. Her NIH-funded research focuses on the clinical epidemiology of chronic pain in individuals with HIV, developing behavioral interventions for chronic pain in this population, and addressing concerning behaviors that arise in individuals on long-term opioid therapy. She is the recipient of several national awards and was named an Inspirational Leader under 40 by the American Academy of Hospice and Palliative Medicine, and won the organization's Young Investigator award for her HIV/chronic pain research.

Peter A. Selwyn, MD, MPH

Dr Peter Selwyn received his MD degree from Harvard Medical School, his MPH degree from the Columbia University School of Public Health, and completed his residency training at Montefiore Medical Center, Bronx, NY. He is currently the Chairman of the Department of Family and Social Medicine, the Director of the Palliative Care Program, and the Professor of Family Medicine, Internal Medicine, and Epidemiology and Population Health at Montefiore Medical Center and Albert Einstein College of Medicine. He has been involved in clinical care, research, and education in the field of HIV and palliative care since the early AIDS epidemic.

Glenn J. Treisman, MD, PhD

Glenn Jordan Treisman is the Eugene Meyer III Professor of Psychiatry and Behavioral Sciences and Internal Medicine at the Johns Hopkins University School of Medicine. He is the Director of the AIDS Psychiatry Program and the Co-director of the Pain Treatment Program at Johns Hopkins Hospital. He is best known for his groundbreaking work in the field of HIV, where he has been described as the father of AIDS psychiatry. He has cared for patients with HIV since early in the epidemic and described the role of mental illness in the HIV epidemic. He is the author of The Psychiatry of AIDS, the first comprehensive textbook on the subject, as well as numerous articles on related subjects. He was recognized for this work by the American College of Physicians with the presentation of the William C. Menninger Memorial Award for Distinguished Contribution to the Science of Mental Health in 2006.

Angela G. Giovanniello, PharmD, AAHIVP

Angela Giovanniello received both her undergraduate and graduate pharmacy degrees from St John's University and completed her fellowship in HIV pharmacotherapy at the University at Buffalo. For over a decade, she has been an integral part of providing HIV care and resident education at a number of community health centers associated with Montefiore Medical Group and Albert Einstein College of Medicine. In addition to currently being the clinical coordinator of the office-based Buprenorphine Program that is continually expanding, she is pursuing a degree in acupuncture to provide alternative treatment options for pain management. She has written, edited, and reviewed a number of publications during her career including for the New York State Department of Health, peer reviewed journals, and patient education publications.

List of contributors

J. H. Atkinson, MD

Professor, Psychiatry Service, VA San Diego Healthcare System, San Diego, CA 92161, USA

Professor, Department of Psychiatry, University of California, San Diego, CA 92093, USA

Professor, HIV Neurobehavioral Research Program, University of California, San Diego, CA 92093, USA

Antje M. Barreveld, MD

Assistant Professor of Anesthesiology, Tufts University School of Medicine, Newton-Wellesley Hospital, Newton, MA 02462, USA

William C. Becker, MD

Assistant Professor, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06510, USA

R. Douglas Bruce, MD, MA, MS

Chief of Medicine, Cornell Scott-Hill Health Center, Department of Medicine, Yale University, New Haven, CT 06520, USA

Nu C. Chai, MD

Chief Resident, Department of Neurology, Johns Hopkins University, Baltimore, MD 21218, USA

C. Brendan Clark, PhD

Assistant Professor, Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL 35233, USA

Michael R. Clark, MD, MPH, MBA

Professor, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD 21218, USA

Catherine Deamant, MD

Division of General Internal Medicine and Primary Care, Cook County Health and Hospitals System, Chicago, IL 60612, USA

E. Jennifer Edelman, MD, MHS

Assistant Professor, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06510, USA

Olga Fermo, MD

Resident, Department of Neurology, Johns Hopkins University, Baltimore, MD 21218, USA

Kathleen Foley, MD

Professor, Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA

Angela G. Giovanniello, PharmD, AAHIVP

Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY 10461, USA

Burel R. Goodin, PhD

Assistant Professor, Department of Psychology, University of Alabama at Birmingham, Birmingham, AL 35233, USA

Assistant Professor, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL 35233, USA

Liz Gwyther, MD

Lecturer in Palliative Care, School of Public Health and Family Medicine, University of Cape Town, Chair, World Hospice and Palliative Care Alliance, Anzio Road, Observatory, Cape Town 7925, South Africa

Richard Harding, PhD

Reader in Palliative Care, Department of Palliative Care, Policy, & Rehabilitation, Cicely Saunders Institute, King's College London, London, United Kingdom

Christopher A. Hess, MD

Clinical Instructor, Harvard Medical School, Pain Medicine Fellow, Brigham and Women's Hospital, Boston, MA 02115, USA

Irene J. Higginson, MD, PhD

Professor of Palliative Care and Policy, Department of Palliative Care, Policy, & Rehabilitation, Cicely Saunders Institute, King's College London, London, United Kingdom

John R. Keltner, MD, PhD

Assistant Professor, Psychiatry Service, VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, USA

Assistant Professor, Department of Psychiatry, University of California, San Diego, CA, USA

Assistant Professor, HIV Neurobehavioral Research Program, University of California, 9500 Gilman Drive, La Jolla, San Diego, CA 92093, USA

David J. Kim, MD

University of Alabama at Birmingham, Birmingham, AL 35233, USA

Paula J. Lum, MD, MPH

Professor, Department of Medicine, University of California, San Francisco, San Francisco, CA 94143, USA

Justin C. McArthur, MBBS, MPH, FAAN, FANA

Professor of Neurology, Pathology, Medicine, and Epidemiology, Director, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA

Jennifer McNeely, MD, MS

Assistant Professor, Department of Population Health, Division of General Internal Medicine, New York University School of Medicine, New York, NY 10016, USA

Assistant Professor, Department of Medicine, Division of General Internal Medicine, New York University School of Medicine, New York, NY 10016, USA

Jessica S. Merlin, MD, MBA

Assistant Professor, Department of Medicine, Division of Infectious Diseases, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, AL 35233, USA

Susan Nathan, MD

Assistant Professor, Department of Internal Medicine, Division of Geriatrics, Section of Palliative Medicine, Rush University Medical Center, Chicago, IL 60612, USA

Michael A. Owens, BS

Doctoral Student, Department of Psychology, University of Alabama at Birmingham, Birmingham, AL 35233, USA

Meera Pahuja, MD, MSc

Assistant Professor, Department of Internal Medicine, Division of Hematology, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA 23284, USA

Shetal Patel, PhD

VA San Diego Healthcare System, San Diego, CA 92161, USA

Christine Ritchie, MD, MSPH

Professor, Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA 94143, USA

Jessica Robinson-Papp, MD

Assistant Professor, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA

Jason D. Rosenberg, MD

Assistant Professor, Department of Neurology, Johns Hopkins University, Baltimore, MD 21218, USA

Durga Roy, MD, MS

Assistant Professor, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD 21218, USA

Peter Selwyn, MD, MPH

Professor, Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY 10461, USA

Joanna L. Starrels, MD, MS

Associate Professor, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY 10461, USA

Glenn Treisman, MD, PhD

Professor, Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA

Alen Voskanian, MD, MBA

Assistant Clinical Professor of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA

Regional Medical Director, VITAS Healthcare, Los Angeles, CA, USA

Chapter 1

Epidemiology of chronic pain in HIV-infected individuals

Meera Pahuja

Department of Internal Medicine, Division of Hematology, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, USA

Introduction

Chronic pain is increasingly recognized as an important comorbidity of HIV-infected patients. In the current treatment era, HIV-infected patients who adhere to highly active antiretroviral therapy (HAART) and are engaged and retained in HIV primary care can achieve near-normal life expectancy [1]. Although patients with HIV can lead long lives, they often suffer from high rates of medical and psychiatric comorbidities. Due to a myriad of factors, chronic pain has also emerged as an important chronic condition in HIV-infected patients. This chapter focuses on the prevalence, etiology, and impact of comorbid chronic pain in HIV-infected individuals.

A changing HIV epidemic

Early in the epidemic, HIV infection inevitably progressed to AIDS, often shortly after diagnosis. Pain and other physical symptoms were largely related to sequelae or opportunistic infections, uncontrolled HIV replication [2], and early antiretroviral therapies such as the d-drugs, which cause peripheral neuropathy [3]. Although there is no data on the prevalence of chronic pain in this early era, given the relatively rapid progression of disease, much of the pain experienced was acute. Like other forms of acute pain, it was managed by treating the underlying cause when possible, and symptomatically using opioids [4].

In 1996, the discovery of effective, well-tolerated antiretroviral therapy changed HIV infection from an inevitably fatal disease to a complex, chronic infection. The key steps in maintaining HIV as a chronic infection involve timely HIV diagnosis, linkage to care, adherence to treatment, and ultimately viral suppression. These steps are otherwise known as the HIV treatment cascade and navigation through the cascade is key to successful treatment [5]. As HIV becomes a chronic infection, studies have found that life expectancy of infected patients has increased. A study of US national HIV surveillance data from 25 states including 220,646 people from 1996 to 2005 found that life expectancy at diagnosis had increased from 10.5 to 22.5 years [6]. This increase in life expectancy has contributed to a surge in the number of people living with HIV and to shift the age distribution of the epidemic. By 2015, half of the HIV-infected population in the United States will be older than 50 [7]. The interaction of HIV disease with the aging process can cause accentuated aging and earlier development of comorbid conditions frequently seen in older adults [7].

With decreasing mortality, increased life expectancy, and consequent increasing comorbid illnesses, pain syndromes have emerged as a chronic condition with HIV infection. Chronic pain is defined as pain lasting longer than 3–6 months, beyond the period of normal healing [8]. Chronic pain is a major health problem in the United States, affecting about 100 million adults [9]. Pain is the most common symptom for which patients seek care [10], and costs the nation up to $635 billion each year in medical treatment and lost productivity [9]. A recent cross-sectional Internet-based survey in the United States found that about a third of adults experienced chronic pain, most commonly lower back pain and osteoarthritis pain [11].

Chronic pain in the HAART era

Though there are no studies designed to directly compare the prevalence of chronic pain in HIV-infected patients versus the general population, the range of chronic pain observed in HIV-infected patients tends to be higher than that in the general population. Studies from the HIV treatment era document high levels of pain in HIV-infected patients with prevalence estimates of anywhere from 39% to as high as 85% [12–20]. Studies also show that patients' pain is often underdiagnosed and inadequately treated. A study of 34 HIV treatment facilities found that 30% of outpatients and 62% of inpatients reported pain due to HIV disease and the pain severity significantly decreased patients' quality of life. They also found that doctors underestimated pain severity in 52% of patients. Of the patients reported moderate-to-severe pain, 57% did not receive any treatment and 22% received weak opioids. Doctors were more likely to give an opiate prescription if they estimated the pain to be severe or if they thought the patients were sicker [2].

Compounding this underdiagnoses suboptimal treatment of chronic pain are the racial disparities associated with the domestic HIV epidemic. HIV infection disproportionately affects vulnerable populations such as racial/ethnic minorities, women, and people of low socioeconomic status [21]. In 2009, the rate of new HIV infections was eight times higher for blacks and three times higher for Hispanics than whites. In addition to this, HIV/AIDS mortality was nine times higher for blacks than whites. Also, in 2009, 280,000 women were estimated to be living with HIV in the United States, with 15 times higher rates of new infections in black women and three times higher rates in Hispanic women [22]. Studies suggest that these vulnerable groups have higher rates of pain and more likely to be undertreated for their pain [23–26]. A recent telephone survey found that race, ethnicity, and socioeconomic factors influenced access to care for chronic pain [27]. Studies have also suggested in other chronic disease states that opioids were less likely to be prescribed for Black and Hispanic patients than White patients [28, 29]. A recent study looking at the indigent HIV-infected population found chronic pain prevalence as high as 90% and 92% of these patients were found to have moderate-to-severe pain [20].

Pain is seen with increasing frequency in HIV-infected patients who have comorbid substance use and psychological disorders [30]. A recent study of 156 ambulatory HIV-infected patients in the United States found that 48.7% reported pain, of whom 51.3% had moderate-to-severe pain intensity and 57.3% of participants felt that their pain caused moderate-to-severe interference with their lives. This study further found that patients with psychiatric illness were 40% more likely to have pain and patients with a history of IV drug use who had pain were more likely to have severe or moderate pain than patients without a history of IV drug use. The authors suggested that comorbid IV drug use and psychiatric illness need to be addressed when treating pain and symptoms [12]. In fact, studies suggest that psychiatric illness can be more difficult to treat without concurrent pain treatment [31].

Etiology of chronic pain in HIV

The etiology of chronic pain in the current treatment era is multifactorial and likely related to direct effects of HIV or HAART, opportunistic infections, increasing number of chronic comorbid conditions, the aging HIV-infected population, and other conditions unrelated to HIV [32]. HIV infection and HAART can cause pain by direct toxicity to the nervous system. Neuropathic pain is an important component of HIV-infected patients' pain in the pre-HAART and current treatment era. Distal sensory polyneuropathy, the most common cause of neuropathic pain in HIV-infected patients, can be related to exposure to older ART regimens including stavudine, didonosine, and zalcitabine, or current protease inhibitor therapy and simple HIV infection [33] and prevalence estimates in the current treatment era range from 4.3% to 21.8% [34–36]. Headaches are also a common symptom of HIV-infected patients and in a recent cross-sectional study of 200 HIV-infected patients in an outpatient setting, 53.5% of patients reported headache symptoms, of which 85% met criteria for migraine and 14.5% met criteria for tension headaches. Severity of HIV was associated with headache severity, frequency, and disability [37]. In addition, as in the general population, low back pain is a common complaint in HIV-infected patients. In a recent study of 124 patients followed at an ambulatory palliative care clinic in the United States found that pain was the most common reason for referral and 21% of patients complained of low back pain [38] (see Chapter 4, Musculoskeletal pain in individuals with HIV and Chapter 2, Pathophysiology of chronic pain in individuals with HIV).

Medical comorbidities such as cardiovascular disease [39], metabolic bone disease [40], diabetes [40], non-AIDS defining malignancies [41], and frailty [7] occur with increasing prevalence in HIV-infected populations. There are many theories as to why these non-AIDS events are occurring in greater numbers and at an earlier age than a noninfected population. First, among the HIV-infected community, traditional modifiable risk factors such as smoking, alcohol abuse, and substance use are more prevalent than in the noninfected population [42]. Direct toxic effects of ART or metabolic changes related to exposure to ART have also been shown to increase the risk for non-AIDS events. Finally, there is a rapidly growing body of evidence that HIV infection itself is a proinflammatory state and can contribute to the early development of many of these non-AIDS events [43] (see Chapter 7, Common medical comorbid conditions and chronic pain in HIV).

It is likely that aging and high burden of medical comorbidities contribute to chronic pain in HIV-infected patients. A recent telephone survey of HIV-infected patients older than 50 years assessing quality of life and chronic illness burden found that pain-related syndromes were second only to hypertension and 45% of the participants noted chronic pain other than back pain and headache, 35% had arthritis, 33% had chronic back pain, and 17% had chronic headaches [44]. Lower health-related quality of life (HRQOL) [45] and faster decline of physical functioning [46] have been shown to be associated with older age in HIV-infected patients.

Impact of chronic pain on HIV health behavior

Given recent recognition of comorbid chronic pain in HIV-infected patients, several studies have investigated the relationship between chronic pain and HIV health behaviors such as adherence to HAART and retention in care. One study of 70 HIV-infected outpatients on methadone maintenance found that 57% of participants reported pain and that participants with pain were 87% less likely to be adherent to ART compared to those without pain [47].

Another important indicator of successful management of HIV infection along the treatment cascade is retention in care, and a recent study of 2811 patients in the United States found that patients with greater than one missed visit in the first year following diagnosis had a 71% increased mortality risk [48]. Another study in the United States of 1521 HIV-infected patients found that the presence of pain increased the odds of a no-show visit in participants without substance abuse and pain conversely reduced the odds of a no-show visit in participants with substance abuse. The authors suggest that the presence of pain negatively affected retention in care because patients may have felt too sick to come to their office or they prioritized pain relief over HIV management. They also suggest that patients with substance abuse maybe have been more likely to attend their appointments because of increasing pain management needs. The authors conclude that further research is necessary into evidence-based approaches to pain management in HIV-infected patients [13].

Chronic pain in HIV-infected patients can also impact physical function. Physical function is an important component of HRQOL and one of the most important clinical outcomes in chronic pain care (see Chapter 10, Pharmacologic and Nonpharmacologic Treatment of Chronic Pain). A recent study of 1903 HIV-infected outpatients found that 37% of patients had pain, 27% of patients had mood disorders, and 8% were substance abusers. Pain was independently associated with up to 10 times greater odds of impaired physical function [49]. The authors suggest that appropriate management of pain is paramount to HIV disease management given that impaired physical function has been linked to increased mortality in HIV-infected patients [50].

Pain is also associated with increased healthcare utilization in the general population. A recent study at a large US academic health center, evaluating healthcare utilization, compared HIV-infected patients with chronic pain on opiates versus similar patients not on opiates. They used emergency room visits and hospitalizations as a measure of utilization and found that there was trend to increased emergency room visits and hospitalization in patients on opiates [51].

Conclusion

Here one can start to see the framework of how chronic pain has emerged as a frequent and important chronic condition in HIV-infected patients in the current treatment era. Unique to our HIV patients suffering from chronic pain, pain can negatively impact adherence to lifesaving medications and decrease retention in care—both vital components of the HIV treatment cascade. Treating pain while taking into account comorbid psychiatric disease and substance abuse is of utmost importance to successfully caring for our HIV-infected community. The rest of the book will delve deeper into mechanisms of chronic pain, specific and common pain syndromes, comorbid conditions additive effect to chronic pain, special populations of HIV-infected patients with concurrent substance abuse or psychiatric disorders, and finally pharmacologic and nonpharmacologic treatment of chronic pain. In addition, the book will touch on opioid risk mitigation strategies, approaches to difficult patients and further tools for educating providers about chronic pain.

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