• New York State Department of Health. Pain in the HIV-infected substance user. New York (NY): New York State Department of Health; 2005 Aug. 8 p. [17 references]

This is the current release of the guideline.

• Human immunodeficiency virus (HIV) infection
• Substance abuse
• Pain

Diagnosis
Evaluation
Management
Treatment

Allergy and Immunology
Family Practice
Infectious Diseases
Internal Medicine

Advanced Practice Nurses
Health Care Providers
Physician Assistants
Physicians
Public Health Departments
Substance Use Disorders Treatment Providers

• To provide guidelines for diagnosis and management of pain in human immunodeficiency virus (HIV)-infected substance users
• To address special considerations for opioid use

Human immunodeficiency virus (HIV)-infected substance users who are in pain

Diagnosis/Evaluation

1. Assessment of nature and severity of pain by history and physical examination
2. Rating and documenting the patient's pain, function, and response to medication
3. Assessment of psychological status of patients presenting with pain

Management/Treatment

1. Referral to a pain management specialist
2. Nerve block, electrostimulation, antidepressants, membrane-stabilizing medications
3. Opioid pharmacotherapy in severe chronic pain
   • Individualizing, monitoring, and documenting prescriptions for opioid medication in patients with a history of opioid use
   • Determining whether effective alternatives are available
   • Weighing the risk-to-benefit ratio of opioid use
   • Discussing expected outcomes with patients
   • Considering periodic random urine drug testing with the consent of the patient

Benefits and risks of opioid treatment for pain in human immunodeficiency virus (HIV)-infected substance users

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Not stated

Not stated

Expert Consensus (Committee)

Not applicable

Review

Not stated

Expert Consensus

The Human Immunodeficiency Virus (HIV) Guidelines Program works directly with committees composed of HIV Specialists to develop clinical practice guidelines. These specialists represent different disciplines associated with HIV care, including infectious diseases, family medicine, obstetrics and gynecology, among others. Generally, committees meet in person 3-4 times per year, and otherwise conduct business through monthly conference calls.

Committees meet to determine priorities of content, review literature, and weigh evidence for a given topic. These discussions are followed by careful deliberation to craft recommendations that can guide HIV primary care practitioners in the delivery of HIV care. Decision making occurs by consensus. When sufficient evidence is unavailable to support a specific recommendation that addresses an important component of HIV care, the group relies on their collective best practice experience to develop the final statement. The text is then drafted by one member, reviewed and modified by the committee, edited by medical writers, and then submitted for peer review.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Peer Review

Not stated

General Recommendation

Clinicians should not withhold treatment for pain because a patient has a history of substance use. Rather, standard pain assessment and treatment protocols should be followed.

Key Point:

It may be more difficult for substance users to attempt to stop using drugs in the presence of severe pain. Furthermore, severe and/or chronic pain may precipitate an escalation in use or relapse following a period of recovery.

Pain Assessment and Diagnosis

Clinicians should ask human immunodeficiency virus (HIV)-infected patients about pain at each visit. The nature and severity of the pain should be defined by history and physical examination.

When the patient's pain is ongoing or severe, clinicians should rate and document the patient's pain, function, and response to medication at each visit.

Key Point:

Pain is subjective and affects each patient differently. Patient appearance and laboratory tests do not always correlate with a patient's report of pain.

Key Point:

Assessing the psychological status of patients who present with pain is essential because persistent pain is typically associated with depression, loss of self-esteem, and social isolation. Addressing these issues, verbally and/or with medication, may also help the patient cope with overall pain and dysfunction.

Pain Management

Clinicians should refer HIV-infected substance users with chronic pain to a pain management specialist.

Clinicians should offer concurrent treatment for both pain and substance use to patients with unstable substance use and significant pain.

The clinician should use the following factors to guide the decision of which modality to use to treat pain in substance users:

• Etiology of pain
• Pain severity
• Previous treatment response

Key Point:

HIV-infected patients with severe pain who either have a history of substance use or are active substance users may need higher doses of pain medication for longer periods of time because physiologic tolerance may be present.

Special Considerations for Treating Pain with Opioids

Clinicians should carefully individualize, monitor, and document prescriptions for opioid treatment of long-term pain in patients with a history of opioid use. The clinician should determine whether effective alternatives are available, and if not, weigh the risk-to-benefit ratio of opioid use (see Table 1 in the original guideline documentation).

Before prescribing opioids, the clinician should discuss expected outcomes, including symptom reduction and improved function, with the patient.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

General Benefits

Improved diagnosis, evaluation, management, and treatment of pain in human immunodeficiency virus (HIV)-infected substance users

Specific Benefits

Benefits of Opioid Use

• Effectively reduce pain and improve function
• Generally well tolerated
• Favorable side effect profile

Risks of Opioid Use

• Side effects: oversedation, delirium, constipation
• Dependency potential: in persons with past or current substance use, unstable psychopathology, or strong family history of abuse, risk for opioid dependency is higher than in persons without pre-existing risk factors
• Non-intended use: pharmaceutical opioids have significant "street value," thus, it is the joint responsibility of patient and clinician to minimize diversion
• Insufficient pain control: some patients paradoxically experience reduced pain control with opioids

Following the development and dissemination of guidelines, the next crucial steps are adoption and implementation. Once practitioners become familiar with the content of guidelines, they can then consider how to change the ways in which they take care of their patients. This may involve changing systems that are part of the office or clinic in which they practice. Changes may be implemented rapidly, especially when clear outcomes have been demonstrated to result from the new practice such as prescribing new medication regimens. In other cases, such as diagnostic screening or oral health delivery, however, barriers emerge which prevent effective implementation. Strategies to promote implementation, such as through quality of care monitoring or dissemination of best practices, are listed and illustrated in the companion document to the original guideline (HIV clinical practice guidelines, New York State Department of Health; 2003), which portrays New York's HIV Guidelines Program. The general implementation strategy is outlined below.

• Statement of purpose and goal to encourage adoption and implementation of guidelines into clinical practice by target audience
• Define target audience (providers, consumers, support service providers).
  • Are there groups within this audience that need to be identified and approached with different strategies (e.g., HIV Specialists, family practitioners, minority providers, professional groups, rural-based providers)?
• Define implementation methods.
  • What are the best methods to reach these specific groups (e.g., performance measurement consumer materials, media, conferences)?
• Determine appropriate implementation processes.
  • What steps need to be taken to make these activities happen?
  • What necessary processes are internal to the organization (e.g., coordination with colleagues, monitoring of activities)?
  • What necessary processes are external to the organization (e.g., meetings with external groups, conferences)?
  • Are there opinion leaders that can be identified from the target audience that can champion the topic and influence opinion?
• Monitor progress.
  • What is the flow of activities associated with the implementation process and which can be tracked to monitor the process?
• Evaluate.
  • Did the processes and strategies work?
  • Were the guidelines implemented?
  • What could be improved in future endeavors?

Getting Better
Living with Illness

Effectiveness

• New York State Department of Health. Pain in the HIV-infected substance user. New York (NY): New York State Department of Health; 2005 Aug. 8 p. [17 references]

Not applicable: The guideline was not adapted from another source.

2005 Aug

New York State Department of Health - State/Local Government Agency [U.S.]

New York State Department of Health

Substance Use Committee

Committee Chair: Marc N. Gourevitch, MD, MPH, Director, Division of General Internal Medicine, New York University School of Medicine

Committee Members: Bruce Agins, MD, MPH, Medical Director, AIDS Institute, New York State Department of Health; Julia H. Arnsten, MD, MPH, Associate Professor Medicine, Epidemiology and Population Health, and Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Montefiore Medical Center; Steven L. Batki, MD, Director, Addiction Psychiatry Clinic, Crouse Chemical Dependency Treatment Services, Interim Associate Chief of Staff for Research, Syracuse VA Medical Center, Professor and Director of Research, Department of Psychiatry, SUNY Upstate Medical University; Lawrence S. Brown, Jr., MD, MPH, Clinical Associate Professor of Public Health, Weill Medical College, Cornell University, President, American Society of Addiction Medicine, Senior Vice President, Division of Medical Services, Evaluation and Research, Addiction Research and Treatment Corporation; Brenda Chabon, PhD, Assistant Professor, Dept. of Psychiatry and Behavioral Sciences, Montefiore Medical Center/Albert Einstein College of Medicine; Barbara Chaffee, MD, MPH, Clinical Associate Professor of Medicine, Upstate Medical Center Clinical Campus at Binghamton, Binghamton, New York, Medical Director, Internal Medicine, Binghamton Family Care Center, United Health Services Hospitals; Steven Kipnis, MD, FACP, FASAM, Medical Director, New York State Office of Alcoholism & Substance Abuse Services; Nancy Murphy, NP, HIV Primary Care Provider, Center for Comprehensive Care, Room 14A36, St Luke's Roosevelt Hospital Center; David C. Perlman, MD, Chief, Infectious Diseases, Beth Israel Medical Center - Singer Division, Professor of Medicine, Albert Einstein College of Medicine, Director, AIDS Inpatient Unit, Beth Israel Medical Center; Benny Primm, MD, Executive Director, Division of Medical Services, Evaluation and Research, Addiction Research and Treatment Corporation; Sharon Stancliff, MD, Medical Director, Harlem East Life Plan, Medical Consultant, NYSDOH, AIDS Institute; Robert Whitney, MD, Erie County Medical Center

AIDS Institute: Diane Rudnick, Director, Substance Abuse Section, New York State Department of Health

Not stated

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI on September 19, 2005. This summary was updated by ECRI Institute on November 9, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs.