Palliative Care in HIV/AIDShttp://hivmanagement.org/palliative.html
James A Zachary MDLSU Health Sciences Center
Delta AETC
December 13, 2004
• Identify palliative care issues involved with HIV/AID
• Discuss tools of palliation• Hospice: purpose, goals, methods,
identifcation of barriers & overcoming them
• Case presentations• The Hospice Rx
HIV/AIDS Palliative Care Issues
• Dermatomal herpes zoster– 15x higher incidence than uninfected
• Post herpetic neuralgia– Approx 20% incidence without HIV– Increased incidence with HIV
• Distal sensory polyneuropathy 10-40%– HIV, drugs, infection (e.g. CMV)
HIV/AIDS Palliative Care Issues
• Miscellaneous pain– Chronic musculoskeletal
pain especially spinal pain– Chronic headaches– Trauma-related injuries– Chronic post-operative
pain
Pain Control Basics
• Believe the patient!• Thoroughly evaluate pain
– History and physical– Blood testing– Imaging– Consultants
• Always treat the cause if possible• Pain control during work-up and until resolved• Close follow-up!!!!
WHO Analgesic Ladder
Acute Pain• Apply analgesic ladder principle• Short acting analgesics• Adjuvant therapy with gabapentin• Avoid constipation• Examples: acute herpes zoster,
acute headache
Acute Pain• NSAIDs• Buprenorphene IM• Tramodol• Merperidine• Codeine/acetaminophen• Hydrocodone/acetaminophen or
ibuprofen• Oxycodone/acetaminophen or aspirin• Oxycodone• Hydromorphone• Immediate release morphine sulfate
Chronic PainPain >48 hours
• Begin with adequate supply of short acting analgesic: avoid acetaminophen combination drugs– Oxycodone tablets or suspension– Morphine sulfate immediate release
liquid or tablets• Allow patient to re-administer (and
slowly escalate) every 2-4 hours• At the end of 24-48 hours, begin a long-
acting opiate based on the previous 24 hour dosage of short-acting analgesic and continue short-acting
Chronic PainPain >48 hours
• Extended release morphine– MS Contin, Oramorph, generics: q8-12 hours– Avinza, Kadian: q24 hour
• Extended release oxycodone: OxyContin• Transdermal fentanyl• Methadone• Buprenorphene sublingual*
Neuropathic Pain
• Description: lancinating, numbness, burning, itching
• Palliative options– Nerve blocks – not too practical– Topical lidocaine (Lidoderm)– Gabapentin (or levacetram) up to
5600 mg per day or more– Opiates
Opiates• Use a consistent approach to your pain
assessment such as asking the patient to use the 1-10 scale
• Document clearly that you are doing your best to diagnose and treat the pain
• Don’t prescribe on the first visit with a new patient unless source of pain is very clear
• Addiction seldom occurs when used for pain control.
Pain In Addicts• Higher incidence of pain in addiction• Same principles apply as in nonaddicted
patients• Consider a pain contract• Consider urine toxicology testing if
suboptimal results are achieved– Look for prescribed substances
primarily– Evaluate and treat for nonprescribed
substances as you would normally
Pain In Addicts
Pain In Addicts• Higher incidence of pain in addiction• Same principles apply as in nonaddicted
patients• Consider a pain contract• Consider urine toxicology testing if
suboptimal results are achieved– Look for prescribed substances
primarily– Evaluate and treat for nonprescribed
substances as you would normally
Pain In Addicts• Boundary issues are extremely
important!• Consider a Pain Management
referral• Consider a Mental Health
referral
Opiates• Avoid constipation!
– Senna + stool softener = Senokot– Lactulose– Go-lytely or Miralax– Sorbitol
• To control possible nausea provide an antiemetic such as promethazine or metoclopropamide and administer it on a schedule
HIV/AIDS Palliative Care Issues
• Nausea– Drugs– CNS processes: meningitis, abscess,
tumor, increased intracranial pressure, motion sickness
– Metabolic processes: hepatitis, adrenal insufficiency
– GI: pancreatitis, gastritis, PUD, KS, microsporidiosis, cryptococcosis, CMV, DMAC
Nausea Control
• Be aggressive in approach!• Diagnose and treat underlying cause if
possible• Prevent nausea: much easier than
suppressing it once started!
Nausea Control
• Phenothiazines: promethazine (Phenergan), prochlorperazine (Compazine), etc.
• Metoclopropamide (Reglan)• Ondansetron (Zofran), granisetron (Kytril)• Dranabinol (Marinol)• Lorazepam• Haloperidol (Haldol)• Dexamethasone (Decadron)
Conclusions• Palliate aggressively even during active care• Close follow-up is probably helpful to patient and
provider• The approach and treatment of the addicted patient
is fundamentally no different from that of any other patient.
• The use of opiates can be simple and safe.• Adjuvant drugs such as gabapentin should be
frequently considered.
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