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Chronic Pain in HIV

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Treatment Management ➤ HIV medical providers should develop and participate in interdisciplinary teams to care for patients with complex chronic pain and especially for patients with co-occurring substance use or psychiatric disorders (S-VL). ➤ For patients whose chronic pain is controlled, any new report of pain should be carefully investigated and may require added treatments or adjustments in the dose of pain medications, while the new problem is being evaluated (S-H). Remark: Providers should clearly document the new symptom and consult, if possible, with a provider experienced with pain management in persons living with HIV or a pain specialist. ➤ As persons living with HIV age, their pain experience may change as other age-related and HIV-related comorbidities develop. It is recommended that the clinician address these changes in pain experience in the context of this disease progression (S-M). ➤ Critical to maintaining pain control, it is recommended that medical providers and an integrated multidisciplinary team engage in frequent communication with the patient and the patient's support system (e.g., family, caregiver) (S-L). Remark: Communications should occur at a health literacy level appropriate to the patient and patient's support system. The scheduling of longer appointment times may be necessary to allow both patients and providers to establish and clarify the goals of care. ➤ Consultation with a palliative care specialist to assist with pain management and non-pain symptoms and to address goals of care is recommended (S-L). ➤ Patients with advanced illness require a support system beyond the clinic, and timely referrals for palliative or hospice care are recommended. The primary care provider must remain in communication with the patient and family through the end of life to assure accurate continuity and to preclude a sense of abandonment (S-L). Non-Pharmacological Treatments ➤ Cognitive behavioral therapy (CBT) is recommended for chronic pain management (S-M). Remark: CBT promotes patient acceptance of responsibility for change and the development of adaptive behaviors (e.g., exercise), while addressing maladaptive behaviors (e.g., avoiding exercise due to fears of pain). ➤ Yoga is recommended for the treatment of chronic neck/back pain, headache, rheumatoid arthritis and general musculoskeletal pain (S-M). ➤ Physical and occupational therapy is recommended for chronic pain (S-L). ➤ Hypnosis is recommended for neuropathic pain (S-L).

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