Page 39 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 10 of 26 Guideline

Tests to confirm the diagnosis are important but must not be line oral treatment of chronic HIV-associated neuropathic
allowed to delay the treatment of the pain, which works best pain (the authors note that somnolence occurs in 80% and
when given by an interdisciplinary team. Ideally, the team can be problematic). The serotonin-noradrenaline reuptake
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should offer, in addition to good medical and nursing care, inhibitors, tricyclic antidepressants and pregabalin
most or all of the following: received only weak or moderate support.
• Despite the absence of RCTs in HIV-related pain
• physical rehabilitation
• exercise therapy syndromes, Alpha-lipoic acid (ALA) received support for
• cognitive restructuring that emphasises self-management, neuropathic pain treatment in view of its confirmed role
self-efficacy and resourcefulness, that is, activity rather in diabetic neuropathy, a condition that also targets the
than passivity, reactivity, dependency and hopelessness peripheral nerves.
• behavioural treatment, for example, relaxation and/or • Opioid analgesics are not indicated for first-line control of
engagement in activities that enhance functionality neuropathic pain or chronic pain syndromes. Tramadol, a
• vocational rehabilitation if long-term survival is not in combination opioid, that is, a serotonin + noradrenaline
reuptake inhibitor + a µ-opioid agonist, received support,
doubt
• drug management – in particular, the avoidance or however, for use in several non-cancer pain syndromes,
including osteoarthritis, fibromyalgia and the neuropathic
reduction of opioid dependency. Nota bene evidence- pain syndromes.
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based support for opioids as improvers of chronic pain
and functionality is weak; therefore, their use must be
measured against their risks, for example, addiction, Opioid therapy
hypogonadism, falls and fractures, depression, overdose Opioid therapy is often the treatment of choice for patients
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and death. with cancer and those having moderate to severe pain. 38,39
Although the WHO analgesic ladder recommends different
It is common to treat pain in a stepwise manner, starting with opioids for different levels of pain, for example, codeine for
non-opioid medication such as paracetamol (acetaminophen), moderate pain and morphine for severe pain, cautious dose
aspirin and the non-steroidal anti-inflammatory drugs escalation using the initial opioid may avoid an unnecessary
(NSAIDs) and ending with the opioids or combinations of switch. 38,40 Morphine can be given by several routes and
opioids and non-opioids 37,38 (Table 2). subcutaneous, intramuscular and intravenous injection
should be considered for those unable to swallow. Fentanyl is
The 2017 Chronic Pain Guideline of the HIV Medicine given by injection and transdermal skin patch but is not
Association of the Infectious Diseases Society of America widely available to public sector patients in SA. Unwelcome
(IDSA) provides an evidence-based evaluation of pain and its respiratory complications can be avoided with careful
management in the HIV-infected people. In this assessment, monitoring of opioid dose increases, which is particularly
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only the following aspects of pain care received unanimous important where patients and families have expressed a
– ‘strong quality, high level’ – support: desire for a pain-free yet lucid end to life.
• Any ‘new pain’ in a patient with previously controlled Drug–drug interactions are important to note. Many drugs
pain needs fresh re-assessment. used in pain control, for example, opioids, benzodiazepines,
• Acetaminophen and NSAIDs are the first-line agents for antidepressants and sedatives, are substrates of the
the treatment of musculoskeletal pain in persons living cytochrome P450 (CYP450) family of enzymes. Strong
with HIV. inducers or inhibitors of CYP450 will reduce (inducers) or
• Topical capsaicin is indicated for chronic HIV-associated potentiate (inhibitors) serum levels (efficacy and toxicity) of
peripheral neuropathy in conjunction with additional these drugs. Several antiretrovirals (ARVs) – especially the
analgesics and supportive therapies and adequate viral non-nucleoside reverse transcriptase inhibitors (NNRTIs –
control. usually inducers), protease inhibitors (PIs – inhibitors) and
• Screen all with chronic pain syndromes for depression, drugs commonly used in the management of the HIV-sick,
that is, direct questioning, via a depression questionnaire for example, rifampicin (inducer) for TB, carbamazepine and
and/or through a psychiatric referral. phenytoin sodium (inducers) for seizures, will influence the
activity of substrates of this enzyme pathway (see Appendix 6,
Additional remarks that scored well (viz. for their strong Table 2-A6 and Table 3-A6).
quality of evidence) but did not secure unanimous support
from reviewers included: The non-medical use of prescription opioids, which has become
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• The re-evaluation of pain among those with a ‘changing a major public health issue in the United States and Europe,
experience of pain’. should not be withheld from people in need in low- and middle-
• The ‘immediate or early’commencement of ART in those income countries (LMICs), for example, Africa and Asia. The
with a sensory polyneuropathy believed to be caused by authors of a recent Lancet Commission on Palliative Care and
HIV infection. Pain Relief provide data to show that this happens:
• Gabapentin, with dose escalation up to a maximum of 2400 The fact that access to such an inexpensive, essential and effective
mg daily po in divided doses, is recommended as the first- intervention – opioid use for pain relief – is denied to most

http://www.sajhivmed.org.za 32 Open Access