• 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.

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.

• 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.