1. 2012;15;ES157-ES168Opioids in the Management of HIV-Related Pain
   Narrative Review
   Daniel L. Krashin, MD, Joseph O Merrill, MD, and Andrea M. Trescot, MD.

BACKGROUND: Human Immunodeficiency Virus (HIV) patients have an increased rate of chronic pain, particularly peripheral neuropathy. This disease burden causes considerable disability and negatively affects quality of life. Pain is undertreated and more complex to manage in these patients for a number of reasons, including complex anti-retroviral drug regimens, higher risks of side effects, and higher rates of comorbid psychiatric illness and substance abuse. Pain management must take these factors into account and use all available modalities, including nonopioid pain relievers, adjuvant medications, and psychosocial therapies in addition to opioid analgesics. Here we review recent recommendations regarding acute and chronic opioid treatment of pain and the treatment of opioid dependence in HIV-infected patients, and provide suggestions regarding aberrant behavior in pain treatment.

OBJECTIVES: The objective of this comprehensive review is to assess and summarize the complicating factors involved in treating HIV patients’ pain with opioid analgesics.

STUDY DESIGN: This is a narrative review without a systematic quality assessment of the literature discussion.

METHODS: A comprehensive review of the literature relating to pain and pain treatment in HIV patients. The literature was collected from electronic databases, textbooks, and other sources. The scientific literature reviewed includes randomized trials, observational studies, systematic reviews, guidelines, and government reports.

RESULTS: This patient population is heterogeneous and diverse in their medical issues and comorbidities, but a systematic, stepwise approach to assessing and managing pain in HIV patients is described. Chronic opioid treatment has proven to be problematic and considerations and alternatives to this treatment are described. Management of pain in patients with opioid addiction, a frequent comorbidity of HIV infection, requires special awareness and different prescribing practices. Screening and identifying patients who are at special risk for developing medical or behavior complications of pain treatment is essential, and approaches to this, and common forms of aberrant behavior, are described.

LIMITATIONS: The scientific literature on opioid treatment in this population is limited. The population of HIV patients is heterogeneous and differs in significant ways based on ethnicity, national origin, and mode of transmission, making it difficult to generalize about pain treatment in such a diverse group.

CONCLUSIONS: Pain management in HIV patients must take these factors into account and use all available modalities for treatment, including nonopioid analgesics, adjuvant medications, and psychosocial therapies. Opioid analgesics should be prescribed with caution in accordance with current guidelines and after careful risk assessment.