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• W2602954266 abstract "HIV INFECTS 47,000 individuals annually in the United States.1 Although advances in treatment have improved quality of life for these patients, there's no cure for or vaccine to prevent HIV. Over the years, HIV has transformed from an acute disease to a chronic illness; patients are living longer with the disease and its many complications. This places a burden on the patient and healthcare system, necessitating careful monitoring of medications to prevent toxic effects and minimize complications. Of the myriad complications that result from HIV infection, the most commonly reported is pain.2,3 Many patients with HIV who report pain rate it as severe and say it decreases their quality of life.3 Alternative therapies, such as acupuncture and cognitive behavioral therapy (CBT), are emerging as viable interventions for pain management in this population. This article highlights challenges and nonpharmacologic options in the management of pain in patients with HIV. Literature review Pain in HIV. Research indicates pain, both neuropathic and nociceptive, is a significant complication of HIV, affecting nearly 80% of patients with this diagnosis.3 Pain may be related to the effects of the virus on the body, antiretroviral therapy, opportunistic infections, or a combination of the three.4 Additionally, patients report pain in multiple body areas with differing degrees of severity. Research suggests this is caused by multiple pathologic processes at one time.4 The multifactorial nature of the etiology of pain in this population contributes to pain intensity and treatment challenges. Patients with HIV also report fatigue, sleep disturbance, and depression due to chronic pain.5 These symptoms negatively affect quality of life and the ability to fulfill functional and emotional roles. A survey of HIV-positive adults reveals patients describe the pain as “frightful, unbearable, and intense” and report a loss of independence as a result.6 The combination of HIV infection and depression increases the likelihood of nonadherence to medication regimens, posing a serious threat to patients' health and well-being.7 Current pain management practices. Current treatment of pain in patients with HIV varies. Research indicates pain is often undertreated due to many factors, including fear of addiction by patients and providers.8 Some patients express concern that healthcare providers don't take reports of pain seriously.6 Others are hesitant to report pain for fear of being labeled as difficult.4 According to research, most patients with HIV in the United States have a low socioeconomic status, are members of ethnic minority groups, and are females.3 Traditionally these groups experience more pain and are undertreated for it.3 These demographic factors play an important role in the prevalence of HIV-related pain and its treatment. Because HIV is a chronic disease, patients are living longer with it and its comorbidities. Renal and hepatic impairment, which are common complications of HIV infection, pose additional problems for pain management. Due to their hepatotoxic and nephrotoxic effects, acetaminophen and nonsteroidal anti-inflammatory drugs can't be safely used by all patients.9 As a result, clinicians must look elsewhere for pharmaceutical solutions to pain management. Additionally, several opioid analgesics, including fentanyl, morphine, codeine, and hydrocodone, have the potential to interact with some antiretroviral medications used to treat HIV.10 These issues complicate the management of pain in this population. Providers are recommended to follow the World Health Organization (WHO) guidelines for cancer pain in addressing pain in this population. Per these guidelines, the most common treatment for chronic pain in this population is opioids.11 However, only a small percentage of patients with HIV receive long-acting opioids for chronic pain, and even fewer indicate their pain is relieved by medications.8 This may be due to the fact that opioids have been suggested as a third-line treatment for neuropathic pain, which many in this population experience, according to recent studies.12 Treatment with opioids is problematic in this population due to the high incidence of substance abuse and the potential for interactions with other medications.10 Research indicates that HIV-positive patients with substance use disorders have lower pain tolerance, requiring higher doses of opioids to relieve pain.13 While the etiology of decreased pain tolerance in individuals with substance abuse remains under review, one landmark study offers a few explanations.14 First, patients with HIV and substance abuse may suffer from withdrawal from opioids and other drugs, resulting in increased pain. Additionally, pain in this subset of the population may be related to a history of physical or sexual abuse. Finally, patients in this group frequently present with higher levels of somatization of psychological issues and hypervigilance to pain, increasing pain levels and lowering tolerance to it.14 Although opioids remain the cornerstone of WHO treatment guidelines, emerging research indicates they aren't the safest solution.11 The use of opioids in these patients promotes neuronal damage and neuropathic pain.11 Although the exact mechanism remains unclear, researchers believe inflammation, viral infection, and neuronal hyperexcitability by opioids lead to neuronal damage over time. Patients diagnosed with HIV and opioid use disorders report more neuropathic pain than those without such disorders.15 Although opioids are recommended as a third-line treatment for neuropathic pain, according to a recent consensus report they remain first-line treatment in HIV-related pain, which is often neuropathic in nature.12 More research is needed to determine the safety and efficacy of opioids for managing pain in this population. Nonpharmacologic pain management therapies Acupuncture. Complementary and alternative medicine (CAM), which includes acupuncture, is a reasonable substitute for medication in patients with HIV-related pain. Acupuncture is used to treat chronic and acute pain, and complex regional pain syndrome.16 WHO recognizes acupuncture as a primary method of pain relief with minimal adverse reactions.17 Researchers have found that acupuncture improves patients' sense of well-being and functional status.17 The incidence of pain in patients with HIV may be due to nerve damage, which can be reduced by acupuncture.18 Additionally, acupuncture is used to treat nausea caused by antiretroviral therapy for HIV.19 Research has indicated acupuncture has a strong positive effect on mortality and attrition in this population.20 Acupuncture improves patients' quality of life by promoting resilience and fostering an environment of holistic, patient-centered care.21 Many patients indicate a lack of patient-centeredness leads to nonadherence to treatment plans and dissatisfaction with the patient-provider relationship. However, in settings where acupuncture is incorporated into care plans, patients report increased empowerment, stronger relationships with healthcare providers, and better medication adherence.21 Despite acceptance of acupuncture by WHO as an effective method of pain relief, few studies have examined its use in this population. One landmark study found no improvement in pain when acupuncture was used in individuals with HIV.22 However, this study was conducted nearly 20 years ago, and its results haven't been replicated. Given acupuncture's potential benefits and minimal adverse effects, it's reasonable to support exploration into its use in pain management for patients with HIV. Cognitive behavioral therapy (CBT). Many patients with HIV experience depression and insomnia in addition to chronic pain. The combination of these disorders increases the risk of suicide and nonadherence to antiretroviral medications.7 Additionally, insomnia may exacerbate pain.23 Studies show that CBT and mindfulness therapy, which are commonly used to treat depression, are also effective in reducing chronic pain and insomnia.23 Performed by a psychologist or other healthcare professional, this intervention uses cognitive and behavioral modification techniques to target negative thoughts and maladaptive behavior.24 The result of CBT is a change in the individual's emotions and resulting behaviors; when used for pain management it effectively reduces pain.24 Researchers have examined the effects of CBT on patient reports of pain, as well as the feasibility of incorporating CBT in care at HIV clinics.9 In this study, the CBT program included education about chronic pain, relaxation techniques, sleep management, cognitive restructuring, and problem-solving skills.9 Participants in the study met with the psychologist for CBT during primary care visits. After participating in the CBT program, participants reported a decrease in pain intensity and pain-related anxiety, and reported their pain interfered with their daily functioning to a lesser extent than it had before the therapy. Patients also reported an increased acceptance of their pain.9 A similar study indicated the incorporation of CBT programs at primary care visits decreased patient reports of pain while increasing engagement in enjoyable activities, strengthening relationships with primary care providers, and improving treatment adherence.25 CBT programs in this study included education regarding daily goal setting and pacing of activities to reduce the incidence of pain, in addition to cognitive restructuring regarding the pain experience.25 This intervention improved quality of life and helped patients regain functionality. Another study concluded that weekly CBT sessions provided via telephone with a trained therapist may significantly reduce chronic widespread pain in patients with fibromyalgia.26 Such an intervention may be ideal for the HIV-positive patients who can't travel to therapy appointments due to socioeconomic restrictions, but further study is required. Psychotherapies such as CBT and mindfulness therapy may be safer alternatives for treatment than opioid analgesics and should be considered for patients with HIV. Given these promising new treatment options and potential damage caused by opioids, it's imperative that new studies be conducted regarding the effectiveness of CAM for pain relief in this population. CAM could augment pharmaceutical interventions for pain, reducing risks of interactions, substance dependence issues, and neuronal damage. Educational interventions Patient education is one of the primary roles for nurses, regardless of the healthcare setting, including medications and lifestyle modifications. A recent study suggests educating patients with HIV and their caregivers about the cause of the patients' pain may help reduce it.27 In this study, patients participated in nurse-led pain education groups. During the group sessions, patients and their caregivers received information about the cause of pain associated with HIV infection, methods to assess pain, myths about pain, and pharmacologic and nonpharmacologic methods for treating pain. Following these sessions, patients reported a decrease in pain and an increase in their quality of life.27 Although further studies are needed to verify the impact of patient education on reports of pain, this intervention has the potential to be a safe and effective addition to pain management in this population. Implications for nursing The role of the nurse is to provide holistic, patient-centered care. When caring for patients with HIV, nurses must understand the implications of treatment modalities and their impact on quality of life and functional status. Nurses must advocate for treatments such as CAM that effectively relieve pain while causing minimal adverse reactions. Bonus content! Head to www.nursing2017.com for the pain management information you need to avoid complications and keep patients safe. Here are some additional resources from our Controlling Pain online collection. Postoperative neuropathic pain in adults http://journals.lww.com/nursing/Fulltext/2016/12000/Postoperative_neuropathic_pain_in_adults.16.aspx The ethics of opioids for chronic noncancer pain http://journals.lww.com/nursing/Fulltext/2016/10000/The_ethics_of_opioids_for_chronic_noncancer_pain.19.aspx Evaluating pain management in older adults http://journals.lww.com/nursing/Fulltext/2016/06000/Evaluating_pain_management_in_older_adults.17.aspx" @default.
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• W2602954266 title "HIV pain management challenges and alternative therapies" @default.
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