Chronic Pain in HIV-Infected Patients: Relationship to Depression, Substance Use, and Mental Health and Pain Treatment

Association of Pain and Pain Medication Use with Multiple Characteristics of Older People Living with HIV

People living with HIV (PLWH) experience chronic pain that may impact function. Gaps in knowledge exist for factors that impact pain and pain medication use in older (age 50+) PLWH. Data for this study were obtained from the Aging with Dignity, Health, Optimism and Community (ADHOC) cohort, an observational study of older PLWH from 10 clinics across the United States. Participants self-reported socioeconomic, psychosocial, and health factors via an online questionnaire. Of 1,051 participants, 66% reported pain. In a multivariable regression model, multimorbidity and tobacco use were associated with a greater likelihood of experiencing pain, whereas being male, black, and having higher cognitive function were associated with a lower likelihood of experiencing pain. Of the 696 participants who reported pain, 46% reported using pain medication. In a multivariable regression model, pain medication use was associated with multimorbidity and with lower income. Recognition of the factors associated with pain and pain medication use in this vulnerable population may lead to strategies that mitigate negative health outcomes.

Predictors of worsening neuropathy and neuropathic pain after 12 years in people with HIV

OBJECTIVE

Distal sensory polyneuropathy (DSP) and neuropathic pain are important clinical concerns in virally suppressed people with HIV. We determined how these conditions evolved, what factors influenced their evolution, and their clinical impact.

METHODS

Ambulatory, community-dwelling HIV seropositive individuals were recruited at six research centers. Clinical evaluations at baseline and 12 years later determined neuropathy signs and distal neuropathic pain (DNP). Additional assessments measured activities of daily living and quality of life (QOL). Factors potentially associated with DSP and DNP progression included disease severity, treatment, demographics, and co-morbidities. Adjusted odds ratios were calculated for follow-up neuropathy outcomes.

RESULTS

Of 254 participants, 21.3% were women, 57.5% were non-white. Mean baseline age was 43.5 years. Polyneuropathy prevalence increased from 25.7% to 43.7%. Of 173 participants initially pain-free, 42 (24.3%) had incident neuropathic pain. Baseline risk factors for incident pain included unemployment (OR [95% CI], 5.86 [1.97, 17.4]) and higher baseline body mass index (BMI) (1.78 [1.03, 3.19] per 10-units). Participants with neuropathic pain at follow-up had significantly worse QOL and greater dependence in activities of daily living than those who remained pain-free.

INTERPRETATION

HIV DSP and neuropathic pain increased in prevalence and severity over 12 years despite high rates of viral suppression. The high burden of neuropathy included disability and poor life quality. However, substantial numbers remained pain-free despite clear evidence of neuropathy on exam. Protective factors included being employed and having a lower BMI. Implications for clinical practice include promotion of lifestyle changes affecting reversible risk factors.

Association Between Diagnoses of Chronic Noncancer Pain, Substance Use Disorder, and HIV-Related Outcomes in People Living With HIV

BACKGROUND

Chronic pain is common in people living with HIV (PLWH). Few studies have evaluated the association between the diagnoses of chronic pain, substance use disorder (SUD), and HIV-related outcomes in clinical settings over a 10-year period.

METHODS

Using electronic medical records, the study described psychiatric diagnoses, pain medication, and HIV-related variables in PLWH and examined the factors associated with pain diagnosis and HIV-related outcomes.

RESULTS

Among 3528 PLWH, more than one-third exhibited a chronic pain diagnosis and more than one-third a psychiatric disorder. Chronic pain diagnosis has been associated with SUD and mood and anxiety disorders and occurred before SUD or psychiatric disorders about half of the time. Opioids have been commonly prescribed for pain management, more often than nonopioid analgesic, without any change in prescription pattern over the 10-year period. A dual diagnosis of pain and SUD has been associated with more psychiatric disorders and had a negative impact on the pain management by requesting more health care utilization and higher frequency of both opioid and nonopioid medication prescriptions. Chronic pain and SUD had a negative impact on ART adherence. SUD but not chronic pain has been associated with an unsuppressed HIV viral load.

CONCLUSIONS

In the current intertwining opioid prescription and opioid epidemic, opioids are still commonly prescribed in PLWH in HIV care. A diagnosis of chronic pain and/or SUD worsened the HIV-related outcomes, emphasizing the potential risk of the HIV epidemic. These findings called for a better coordinated care program in HIV clinics.

An integrated videoconferencing intervention for chronic pain and heavy drinking among patients in HIV-care: a proof-of-concept study

Chronic pain and heavy drinking are common comorbid conditions among people living with HIV/AIDS (PLWHA). An integrated approach to address these co-occurring conditions in a manner that facilitates treatment utilization would represent an important advance in HIV-care. This study examined the acceptability and feasibility of a tailored, videoconferencing intervention to reduce chronic pain and heavy drinking among PLWHA. Participants in HIV-care (n = 8) completed baseline assessments and an in-person intervention session followed by 6 videoconferencing sessions. Acceptability and feasibility were assessed with patient satisfaction ratings and interview responses 8 weeks following baseline along with videoconferencing use during the intervention period. Treatment satisfaction and comprehensibility ratings were high and supported by interview responses indicating the value of the intervention content, treatment alliance, and format. All participants successfully enabled videoconferencing on their own smartphones and completed a median number of 4.5 (out of 6) video-sessions. Changes in heavy drinking and pain provided additional support for the potential utility of this approach. Results suggest that this videoconferencing intervention is an acceptable and feasible method of addressing chronic pain and heavy drinking among PLWHA. Findings provide the basis for future work to examine the efficacy of this approach in a Stage 1b trial.

Perceived Interrelations of Pain and Cigarette Smoking in a Sample of Adult Smokers Living With HIV/AIDS

INTRODUCTION

Persons living with HIV/AIDS (PLWH) have very high prevalences of both cigarette smoking and pain, yet little is known about the relationship between smoking and pain for PLWH. This study examined the factor structure, reliability, and validity of a measure of perceived interrelations of pain and smoking in a sample of PLWH.

METHODS

Participants in this study were 108 current cigarette smoking PLWH (64.8% reporting current pain) in the Bronx, NY. Participants completed assessments of demographics, smoking behaviors, and pain. Interrelations of pain and smoking were measured using the 9-item Pain and Smoking Inventory (PSI). The dimensionality of the PSI was evaluated using Horn's Parallel Analysis and exploratory factor analysis. Internal consistency was evaluated using Cronbach's alpha, and validity analyses evaluated the relationship between the PSI and demographics, HIV clinical characteristics, smoking, and pain in the total sample.

RESULTS

A single-factor structure was the best fit for the PSI. The internal consistency of the PSI total score was excellent in the total sample (α = 0.94) and among participants with pain (α = 0.93). The PSI total score was significantly higher for PLWH who smoke and had current pain versus no current pain. Among smokers with HIV and pain, higher PSI scores were associated with higher pain interference, pain severity, and certain neuropathic pain symptoms (ie, numbness and pain to touch).

CONCLUSIONS

Among a sample of PLWH, the PSI appeared to be a reliable and valid instrument as a one-factor measure to assess perceived interrelations among pain and cigarette smoking.

IMPLICATIONS

Even though PLWH have very high prevalences of both pain and cigarette smoking, little is known about the relationship between pain and smoking for PLWH. This study is the first to examine a measure of the perceived interrelations of pain and smoking in a sample of PLWH. The measure was reliable and valid, and higher scores, reflecting that higher perceived interrelations of pain and smoking, were associated with more intense pain and pain interference. Learning more about pain and smoking among PLWH will help to better target smoking interventions to this key subgroup of smokers.

Emotion dysregulation in the experience of pain among persons living with HIV/AIDS

Persons living with HIV and AIDS (PLWHA) report disproportionally high rates of pain. Pain among PLWHA has been associated with poor medication adherence and anxiety and depressive symptoms. This relationship may be primarily driven by elevated negative affect, and one factor that may be important to understanding elevated negative affect is emotion dysregulation. Therefore, the current study sought to examine emotion dysregulation (Difficulties in Emotion Regulation Scale) in terms of multi-dimensional pain experience (pain severity, pain interference, pain affective distress, pain life control; Multidimensional Pain Inventory; Turk and Rudy (1988) among a sample of 162 HIV+ individuals (Mage = 47.65, SD = 8.59, 35.2% female). Two-step hierarchical regression analyses revealed that emotion dysregulation total score was significantly associated with each of the pain variables. These results may suggest PLWHA who demonstrate greater emotion dysregulation struggle to effectively manage negative affect associated with their pain experience, exacerbating the severity of pain symptoms across numerous clinically-relevant domains. The novel findings may provide important assessment and intervention targets for PLWHA living with pain.

Special Topics in the Care of Older People with HIV

PURPOSE OF REVIEW

Antiretroviral therapy has enabled many people with HIV to live long lives with their infection, but the literature suggests that long term survivors are developing comorbidities and aging-related syndromes at earlier ages than their non-infected counterparts. In addition, there is evidence or sex-based differences in comorbidity risk.

RECENT FINDINGS

How to best care for people aging with HIV is not known, but the tools of comprehensive geriatric assessment can identify people at risk for decline. Newer antiretroviral therapies offer promise of fewer side effects and drug interactions. We will also discuss special needs of women aging with HIV.

SUMMARY

People with HIV and their providers are often unprepared to confront issues of aging, and each clinical program must develop methods to assess older patient and manage age-related complications and syndromes.

Pharmacologic and Non-Pharmacologic Interventions for HIV-Neuropathy Pain. A Systematic Review and a Meta-Analysis

Background and Objectives: Among HIV infection symptoms, sensory neuropathy (HIV-SN) remains a main cause of suffering, with incidence varying from 13-50%. So far, numerous pharmacological and non-pharmacological treatments have been tested, although few evidence-based analgesic options are available. We conducted an up-to-date systematic review and meta-analysis of the literature in order to evaluate the efficacy and safety of pharmacologic and non-pharmacologic treatments for pain control, in patients with HIV neuropathy. Materials and Methods: We searched MEDLINE, EMBASE, Scopus/Elsevier, The Cochrane Central Register of Controlled Trials (CENTRAL), USA Clinical Trials registry, and The International Web of Science up to April 2019. All randomized controlled trials evaluating efficacy and safety of non-pharmacologic and pharmacologic therapies were included. Efficacy was defined as pain reduction during the study period. Safety was estimated from adverse events. A meta-analysis was performed whenever possible. Results: 27 randomized controlled trials (RCTs) were included for analysis (7 evaluating non pharmacologic interventions, 20 pharmacologic therapies). Non-pharmacologic studies (n = 742) involved seven different therapeutic modalities. Only Acupuncture/Moxibustion showed pain reduction over placebo, Gracely Pain Scale Mean (SD): Acu/Moxa 0.85 (0.12), placebo 1.10 (0.09), p = 0.05. Pharmacologic studies, involving 2516 patients revealed efficacy for capsaicin 8% over placebo (mean difference -8.04 [95% CI: -14.92 -1.15], smoked cannabis (where pooling data for meta-analysis was not possible) and recombinant Nerve Growth Factor. Conclusion: Despite various modalities for pain control in HIV-SN, strongest evidence exists for capsaicin 8% and smoked cannabis, although of low methodological quality. Among non-pharmacologic modalities, only Acu/Moxa gave a marginal beneficial effect in one study, possibly limited by inherent methodological flaws.

Prevalence and correlates of depressive symptoms among adults living with HIV in rural Kilifi, Kenya

BACKGROUND

Published research on depression among people living with HIV/AIDS (PLWHA) from Africa is increasing, but data from Kenya remains scarce. This cross-sectional study measured the prevalence and correlates of depressive symptoms among PLWHA in rural Kilifi, on the Kenyan coast.

METHODS

Between February and April 2018, we consecutively recruited and interviewed 450 adults living with HIV and on combination antiretroviral therapy (cART). Depressive symptoms were assessed with the 9-item Patient Health Questionnaire (PHQ-9), with a positive depression screen defined as PHQ-9 score ≥ 10. Measures of psychosocial, health, and treatment characteristics were also administered.

RESULTS

The overall prevalence of depressive symptoms was 13.8% (95% Confidence Interval (95%CI): 10.9, 17.3). Multivariable logistic regression analysis identified current comorbid chronic illness (adjusted Odds Ratio (aOR) 5.72, 95% CI: 2.28, 14.34; p < 0.001), cART regimen (aOR 6.93, 95%CI: 2.34, 20.49; p < 0.001), perceived HIV-related stigma (aOR 1.10, 95%CI: 1.05, 1.14, p < 0.001) and difficulties accessing HIV care and treatment services (aOR 2.37, 95%CI: 1.14, 4.91; p = 0.02) as correlates of depressive symptoms.

CONCLUSION

The prevalence of depressive symptoms among adults living with HIV on the Kenyan coast is high. Those at high risk for elevated depressive symptoms (e.g., with comorbid chronic illnesses, on second-line cART, experiencing perceived HIV-stigma or with problems accessing HIV care) may benefit from early identification, treatment or referral, which requires integration of mental health programmes into HIV primary care.

Using behavioral psychotherapy techniques to address HIV patients' pain, depression, and well-being

For persons with HIV (PWH), aims of psychotherapy can extend beyond HIV-related topics. Issues such as HIV stigmatization and disclosure and HIV-related self-care including treatment adherence might be ongoing concerns, but patients often need support to develop skills to manage other problems, whether functional or psychiatric. In the context of an ongoing randomized clinical trial, we delivered an individual, behavioral activation-based intervention to PWH with comorbid chronic pain and depression. Our primary treatment target was to reduce pain-related interference in physical and psychosocial functioning. Throughout the course of the 7-session intervention, clinicians used 4 core strategies to help patients improve a variety of domains related to their health and well-being: (a) teaching value-based goal setting, (b) developing skills to be an activated and informed patient, (c) focusing on changing behavior despite discomfort, and, (d) facilitating access to care (e.g., flexible scheduling and primarily phone sessions). The application of these strategies to HIV-related and non-HIV-related problems are presented to illustrate how and when clinicians can utilize these strategies. These practical lessons will inform a flexible approach to helping PWH address a myriad of health and functional issues related to their overall well-being. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Development of a tailored, telehealth intervention to address chronic pain and heavy drinking among people with HIV infection: integrating perspectives of patients in HIV care

BACKGROUND

Chronic pain and heavy drinking commonly co-occur and can influence the course of HIV. There have been no interventions designed to address both of these conditions among people living with HIV (PLWH), and none that have used telehealth methods. The purpose of this study was to better understand pain symptoms, patterns of alcohol use, treatment experiences, and technology use among PLWH in order to tailor a telehealth intervention that addresses these conditions.

SUBJECTS

Ten participants with moderate or greater chronic pain and heavy drinking were recruited from a cohort of patients engaged in HIV-care (Boston Alcohol Research Collaborative on HIV/AIDS Cohort) and from an integrated HIV/primary care clinic at a large urban hospital.

METHODS

One-on-one interviews were conducted with participants to understand experiences and treatment of HIV, chronic pain, and alcohol use. Participants' perceptions of the influence of alcohol on HIV and chronic pain were explored as was motivation to change drinking. Technology use and treatment preferences were examined in the final section of the interview. Interviews were recorded, transcribed and uploaded into NVivo^® v12 software for analysis. A codebook was developed based on interviews followed by thematic analysis in which specific meanings were assigned to codes. Interviews were supplemented with Likert-response items to evaluate components of the proposed intervention.

RESULTS

A number of themes were identified that had implications for intervention tailoring including: resilience in coping with HIV; autonomy in health care decision-making; coping with pain, stress, and emotion; understanding treatment rationale; depression and social withdrawal; motives to drink and refrain from drinking; technology use and capacity; and preference for intervention structure and style. Ratings of intervention components indicated that participants viewed each of the proposed intervention content areas as "helpful" to "very helpful". Videoconferencing was viewed as an acceptable modality for intervention delivery.

CONCLUSIONS

Results helped specify treatment targets and provided information about how to enhance intervention delivery. The interviews supported the view that videoconferencing is an acceptable telehealth method of addressing chronic pain and heavy drinking among PLWH.

Assessment of pain and associated factors in people living with HIV/AIDS

OBJECTIVE

to evaluate pain in people living with human immunodeficiency virus/acquired immunodeficiency syndrome and to relate it to sociodemographic and clinical factors, depressive symptoms and health-related quality of life.

METHOD

descriptive, analytical, observational, cross-sectional and quantitative study. Three hundred and two (302) people assisted at a specialized care service participated in the study. Instruments were used to evaluate sociodemographic and clinical data, depressive symptoms, and health-related quality of life. Descriptive, bivariate analysis and multiple logistic regression were used.

RESULTS

the incidence of pain of mild intensity was 59.27%, recurrent in the head, with interference in mood, mostly affecting females and individuals with no schooling/low schooling. Women were more likely to have moderate or severe pain. People aged 49 to 59 years had greater pain intensity than people aged 18 to 29 years. The variables depressive symptoms and pain were directly proportional. The higher the health-related quality of life and schooling, the lower was the possibility of presence of pain.

CONCLUSION

presence of pain is of concern and has association with female sex, lack of schooling/low schooling, worse level of health-related quality of life and presence of depressive symptoms.

Daily factors driving daily substance use and chronic pain among older adults with HIV: An exploratory study using ecological momentary assessment

BACKGROUND

Adults 50 and older make up approximately 50% of persons living with HIV. Multiple co-morbidities are common among this group, including chronic pain and substance abuse, yet little is known about the daily factors that either enhance or inhibit these experiences or behaviors. This study explored daily drivers of substance use, pain, and relief from pain among older adults living with HIV utilizing ecological momentary assessment (EMA).

METHOD

Participants (N = 55), ages 49-71, completed seven consecutive days of daily EMA online surveys prior to treatment initiation within a randomized controlled trial. Multilevel modeling tested predictors of pain, substance use, and relief from pain by examining within- and between-person relationships.

RESULTS

Results revealed an associational, reciprocal relationship between daily worst pain and daily drinking, where greater worst pain ratings predicted heavier drinking and heavier drinking predicted greater daily and overall pain. Greater happiness and poorer quality of sleep predicted greater daily worst pain. Exercising and overall confidence to cope with pain without medication were associated with lower levels of daily worst pain. Finally, spending less time with a loved one over time and reporting any coping behavior were associated with relief from pain.

CONCLUSION

Investigation of daily factors that drive pain and substance use behaviors among this unique population help inform which daily factors are most risky to their health and well-being. Alcohol use emerged as the only substance associated with both driving pain and responding to pain. Findings suggest key points for prevention and intervention.

HIV Physicians and Chronic Opioid Therapy: It's Time to Raise the Bar

Clinical practice that utilizes chronic opioid therapy has been recognized as one major cause of the opioid crisis. Among patients living with HIV, the risks associated with chronic opioid therapy may be complicated by factors such as co-occurring mental health diagnoses, substance use, and economic marginalization. Improving opioid prescribing practices in HIV clinics requires attention to these and other characteristics common to HIV care. In the context of a randomized controlled trial testing an intervention to improve opioid prescribing practices in HIV outpatient clinics, we interviewed physicians about their perspectives on chronic opioid therapy. Overwhelmingly, physicians voiced ambivalence about their own knowledge and comfort with prescription opioids. They raised concerns about the impact of opioid prescribing on patient-provider relationships and the increasing workload associated with prescribing and monitoring patients. In this report, we explore these concerns and propose several strategies for improving clinical care in which chronic opioid therapy is addressed.

Moment-to-moment changes in perceived social support and pain for men living with HIV: an experience sampling study

Research suggests that people living with HIV experience levels of pain disproportionate to the general population. Pain is a stressor that can negatively impact health-related quality of life. As the number of people aging with HIV increases, we must understand the dynamics of pain experiences among people living with HIV and how to effectively harness evidence-based treatments and supportive resources to enhance adaptive coping. We used an experience sampling method (also called Ecological Momentary Assessment) to assess moment-to-moment experiences of pain and social support 3 times a day for 7 days in a sample of 109 men living with HIV. Participants also responded to questionnaires assessing attachment-related insecurity and social support. In hierarchical linear modeling analyses controlling for age, race, sexual orientation, and socioeconomic status, we found that experiences of social support were associated with lower subsequent pain within-persons. On the other hand, experiences of pain were not associated with later experiences of social support. Men with higher levels of attachment-related avoidance reported more pain on average. Attachment-related avoidance also moderated the association between moment-to-moment experiences of felt social support on pain. Results suggest that within-persons, experiences of daily social support reduce experiences of pain. Between-persons, attachment style may influence how individuals make use of social support in coping with experiences of pain. These findings imply a need to assess social well-being at the clinic level and also support tailored biopsychosocial approaches to pain management in HIV care settings.

Understanding and treating opioid use disorders in lesbian, gay, bisexual, transgender, and queer populations

Although little is known about the specific burden of the opioid epidemic on lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations, there is evidence to suggest that opioid use disorders are disproportionately prevalent in the LGBTQ community. In this commentary, we present an overview of the current state of evidence on opioid use and misuse among LGBTQ-identified people in the United States and suggest ways to adapt behavioral health interventions to the specific needs of this population. Programs that integrate behavioral health with primary care, address minority stress, and use a trauma-informed approach have the most potential to produce effective, long-term benefits for LGBTQ-identified people with opioid use disorders.

Socioeconomic Vulnerability to Depressive Symptoms in Patients with Chronic Hepatitis B

Depression is considered one of the most prevalent psychiatric disorders among patients with hepatitis B virus (HBV)-related liver disease and has adverse effects on the disease progression. However, there is a scarcity of studies contributing to the assessement of depression in hepatitis B patients. There is also little research into risk factors, particularly underlying socio-economic factors in Vietnam where the prevalence of hepatitis B is high. This study aimed to examine depression and identify whether differences in socio-economic status is related to the level of depression amongst chronic hepatitis B patients. A cross-sectional study was conducted on 298 patients with chronic hepatitis B at The Chronic Hepatitis Clinic in the Viet-Tiep Hospital, Hai Phong, Vietnam. The Patient Health Questionnaire-9 (PHQ-9) and EuroQol-5 dimensions-5 levels (EQ-5D-5L) were used to assess the severity of depression and health-related quality of life (HRQOL). Of chronic hepatitis B patients, 37.5% experienced depressive symptoms and most of them suffered minimal depressive symptoms (31.4%). According to the result of the multivariate logistic regression model, we found that higher age, lower income level, unemployement, living with spouse/partners were positively associated with having depression. Furthermore, having physical health problems and lower health-related quality of life were also related to a higher risk of depression. We recommend family support, financial support and active participation in consultation should be conducted during treatment to improve the quality of life and the emotional state of HBV patients.

Chronic Pain Mitigation and Opioid Weaning at a Multidisciplinary AIDS Clinic: A Case Report

Background and Purpose

Chronic pain has emerged as a treatment priority among people living with HIV (PLHIV). Recent studies indicate the use of physical therapy (PT) for chronic pain mitigation among PLHIV, however there is a paucity of literature regarding PT as part of multidisciplinary collaboration to address the intersection of HIV, chronic pain and opioid use.

Case Description

This case report examined the effect of a 24-session PT intervention aimed at decreasing chronic pain and opioid weaning for a 64 year-old patient at a multidisciplinary AIDS clinic in Atlanta, Georgia. The PT intervention focused on pain mitigation, utilizing using pain-relief techniques such as a home TENS unit, home stretching regimen, diaphragmatic breathing techniques. In addition, the physical therapist communicated regularly with the patient's primary HIV provider regarding patient progress.

Outcomes

After the intervention, outcomes included: decreased pain from 10/10 to 0/10, independent pain management, and increased independence in functional activities. In addition, the patient decreased opioid usage from 15 to 2.5 mg Hydrocodone, an 83.3% decrease.

Discussion

In a complex chronic pain case with a patient on chronic opioid therapy, multidisciplinary communication is key in successful management. To truly address opiate weaning in the context of pain management, physical therapists' expertise in pain management should ideally be complemented by close communication with the patient's primary medical provider. This allows for open dialogue, and acknowledges the importance of various specialty areas committed to a joint effort of not simply opioid weaning, but of patient-centered, multidisciplinary chronic pain control.

Depression and Quality of Life among Patients Living with HIV/AIDS in the Era of Universal Treatment Access in Vietnam

Although antiretroviral treatment (ART) access has been universal in recent years, few studies have examined if this policy contributes to the mental health of the patients. This study assessed depression and its relations with health-related quality of life (HRQOL), which is defined as the status of general well-being, physical, emotional, and psychological, among HIV patients. A cross-sectional study was conducted in 482 patients at five outpatient clinics. Patient Health Questionnaire-9 (PHQ-9) and EuroQol-5 dimensions-5 levels (EQ-5D-5L) were used to assess the severity of depression and HRQOL. About one-fifth of patients reported symptoms of depression. According to the result of a multivariate logistic regression model, patients who had a lower number of CD4 cells at the start of ART, who received ART in the clinic without HIV counseling and testing (HCT) services, who had a physical health problem, and who experienced discrimination were more likely to have depression. Depression was associated with significantly decreased HRQOL. Depression is prevalent and significantly negatively associated with HRQOL of HIV/AIDS patients. We recommend screening for depression and intervening in the lives of depressed individuals with respect to those who start ART late, and we also recommend community-based behavioral change campaigns to reduce HIV discrimination.

Older HIV-infected adults. Complex patients (III): Polypharmacy

Polypharmacy is a well-described problem in the geriatric population. It is a relatively new problem for people living with HIV (PLWH), as this group now has a life expectancy approaching that of the general population. Defining polypharmacy for PLWH is difficult, since the most common traditional definition of at least five medications would encompass a large percentage of PLWH who are on antiretrovirals (ARVs) and medications for other medical comorbidities. Even when excluding ARVs, the prevalence of polypharmacy in PLWH is higher than the general population, and not just in resource-rich countries. Using a more nuanced approach with "appropriate" or "safer" polypharmacy allows for a better framework for discussing how to mitigate the associated risks. Some of the consequences of polypharmacy include adverse effects of medications including the risk of geriatric syndromes, drug-drug interactions, decreased adherence, and over- and undertreatment of medical comorbidities. Interventions to combat polypharmacy include decreasing pill burden-specifically with fixed-dose combination (FDC) tablets- and medication reconciliation/deprescription using established criteria. The goal of these interventions is to decrease drug interactions and improve quality of life and outcomes. Some special populations of interest within the community of PLWH include those with chronic pain, substance abuse, or requiring end of life care. A final look into the future of antiretroviral therapy (ART) shows the promise of possible two-drug regimens, which can help reduce the above risks of polypharmacy.

Williams AC. Psychosocial factors associated with persistent pain in people with HIV: a systematic review with meta-analysis

Chronic pain remains a prevalent and disabling problem for people living with HIV in the current antiretroviral treatment era. Psychosocial treatments may have promise for managing the impact of this pain. However, research is needed to identify psychosocial processes to target through such treatments. The current systematic review and meta-analysis examined the evidence for psychosocial factors associated with pain, disability, and quality of life in people living with HIV and persistent pain. Observational and experimental studies reporting on the association between one or more psychosocial factors and one or more pain-related variables in an adult sample of people living with HIV and pain were eligible. Two reviewers independently conducted eligibility screening, data extraction, and quality assessment. Forty-six studies were included in the review and 37 of these provided data for meta-analyses (12,493 participants). "Some" or "moderate" evidence supported an association between pain outcomes in people with HIV and the following psychosocial factors: depression, psychological distress, posttraumatic stress, drug abuse, sleep disturbance, reduced antiretroviral adherence, health care use, missed HIV clinic visits, unemployment, and protective psychological factors. Surprisingly, few studies examined protective psychological factors or social processes, such as stigma. There were few high-quality studies. These findings can inform future research and psychosocial treatment development in this area. Greater theoretical and empirical focus is needed to examine the role of protective factors and social processes on pain outcomes in this context. The review protocol was registered with PROSPERO (CRD42016036329).

Pain in people living with HIV and its association with healthcare resource use, well being and functional status

OBJECTIVE

We describe the prevalence of pain and its associations with healthcare resource utilization and quality-of-life.

DESIGN

The POPPY Study recruited three cohorts: older people living with HIV (PLWH; ≥50 years, n = 699), younger demographically/lifestyle similar PLWH (less than 50 years, n = 374) and older demographically/lifestyle similar HIV-negative (≥50 years, n = 304) people from April 2013 to February 2016.

METHODS

Current pain and pain-related healthcare use was collected via a self-reported questionnaire. Logistic regression assessed between-group differences in the prevalence of pain in the past month and current pain after controlling for potential confounders. Associations between current pain and healthcare resource use, reported joint problems, depressive symptoms, quality-of-life and functional status were assessed in PLWH using Mann-Whitney U and chi-squared tests.

RESULTS

Pain in the past month was reported by 473 out of 676 (70.0%) older PLWH, 224 out of 357 (62.7%) younger PLWH and 188 out of 295 (63.7%) older HIV-negative controls (P = 0.03), with current pain reported in 330 (48.8%), 134 (37.5%) and 116 (39.3%), respectively (P = 0.0007). Older PLWH were more likely to experience current pain, even after adjustment for confounders. Of those with pain in the past month, 56 out of 412 (13.6%) had missed days of work or study due to pain, and 520 (59%) had seen a doctor about their pain. PLWH experiencing current pain had more depressive symptoms, poorer quality-of-life on all domains and greater functional impairment, regardless of age group.

CONCLUSION

Even in the effective antiretroviral therapy era, pain remains common in PLWH and has a major impact on quality-of-life and associated healthcare and societal costs. Interventions are required to assist clinicians and PLWH to proactively manage pain.

Trajectories of Depressive Symptoms Among a Population of HIV-Infected Men and Women in Routine HIV Care in the United States

Depressive symptoms vary in severity and chronicity. We used group-based trajectory models to describe trajectories of depressive symptoms (measured using the Patient Health Questionnaire-9) and predictors of trajectory group membership among 1493 HIV-infected men (84%) and 292 HIV-infected women (16%). At baseline, 29% of women and 26% of men had depressive symptoms. Over a median of 30 months of follow-up, we identified four depressive symptom trajectories for women (labeled "low" [experienced by 56% of women], "mild/moderate" [24%], "improving" [14%], and "severe" [6%]) and five for men ("low" [61%], "mild/moderate" [14%], "rebounding" [5%], "improving" [13%], and "severe" [7%]). Baseline antidepressant prescription, panic symptoms, and prior mental health diagnoses were associated with more severe or dynamic depressive symptom trajectories. Nearly a quarter of participants experienced some depressive symptoms, highlighting the need for improved depression management. Addressing more severe or dynamic depressive symptom trajectories may require interventions that additionally address mental health comorbidities.

Comparison of pain burden and psychological factors in Brazilian women living with HIV and chronic neuropathic or nociceptive pain: An exploratory study

Psychological factors including pain catastrophizing and resilience associate with adjustment and quality of life in people living with chronic pain. Nevertheless, their presentation among females living with HIV and chronic pain has been poorly studied. Given that chronic pain in those living with HIV might occur due to different mechanisms (nociceptive or neuropathic), we hypothesize that the associated psychological states could also differ between these groups. We aimed to compare pain frequency and interference, psychological factors and sleep quality between females living with chronic nociceptive or neuropathic pain. Also, we explored correlations between psychological factors, pain severity and interference in females living with HIV and chronic pain. We performed a cross sectional study assessing females living with HIV and chronic pain, and compared it with a female HIV-positive, pain-free control sample in Brazil. To discriminate the most likely underlying mechanism for the chronic pain, we applied the Leeds Assessment for Neuropathic Signs and Symptoms (LANSS). Forty-nine females living with HIV and chronic pain were assessed, and divided in control (n = 12), nociceptive (n = 10) and neuropathic pain (n = 27) groups. Using validated scales, their pain catastrophizing, resilience, depression, anxiety and sleep disorders were assessed between May 2014 and August 2015. Compared to controls, females living with HIV and neuropathic chronic pain had higher pain frequency (p<0.001), interference on activities (p = 0.002), interference with emotions (p<0.001), catastrophizing (p<0.001), depression (p = 0.015), and lower resilience (p = 0.011). Catastrophizing was also significantly correlated to the burden of chronic pain. The type of chronic pain in females living with HIV should raise concerns regarding significant burden in psychological states in this population (particularly neuropathic pain). Using scales such as the LANSS to identify the type of choric pain, could be of use to address relevant issues for the patients, and to propose tailored therapies.

Psychological Factors Associated With Painful Versus Non-Painful HIV-Associated Sensory Neuropathy

HIV-associated sensory neuropathy (HIV-SN) is a common, and frequently painful complication of HIV, but factors that determine the presence of pain are unresolved. We investigated: (i) if psychological factors associated with painful (n = 125) versus non-painful HIV-SN (n = 72), and (ii) if pain and psychological factors affected quality of life (QoL). We assessed anxiety and depression using the Hopkins Symptoms Checklist-25. Pain catastrophizing and QoL were assessed using the Pain Catastrophizing Scale and Euroqol-5D, respectively. Presence of neuropathy was detected using the Brief Neuropathy Screening Tool, and pain was characterised using the Wisconsin Brief Pain Questionnaire. Overall, there was a high burden of pain, depression and anxiety in the cohort. None of the psychological variables associated with having painful HIV-SN. Greater depressive symptoms and presence of pain were independently associated with lower QoL. In those participants with painful HIV-SN, greater depressive symptom scores were associated with increased pain intensity. In conclusion, in a cohort with high background levels of psychological dysfunction, psychological factors do not predict the presence of pain, but both depression and presence of pain are associated with poor quality of life.

Positive affect skills may improve pain management in people with HIV

Non-opioid pain management strategies are critically needed for people with HIV. We therefore conducted a secondary analysis of pain-related outcomes in a randomized controlled trial of a positive affect skills intervention for adults newly diagnosed with HIV (N = 159). Results suggest that, even if pain prevalence rises, positive affect skills may reduce pain interference and prevent increased use of opioid analgesics by people living with HIV. Future research should replicate and extend these findings by conducting trials that are specifically designed to target pain outcomes.

Pain in Patients with Dystrophic Epidermolysis Bullosa: Association with Anxiety and Depression

OBJECTIVE

We investigate the presence and the quality of pain in patients with dystrophic epidermolysis bullosa (DEB), and its correlation with the level of anxiety and depression.

METHODS

We collected data from 27 DEB patients and 26 healthy individuals. DEB patients and controls completed 1 scale for the quality of pain, and 1 scale for anxiety and depression. Pain was assessed with the short form of the McGill Pain Questionnaire, whereas anxiety and depression were assessed with the Hamilton rating scale for anxiety and depression.

RESULTS

DEB patients and healthy control individuals were homogeneous for age and gender (p>0.05). A statistically significant difference in the two groups was seen for sensory pain rating scale (p<0.001), affective pain rating scale (p=0.029), total pain rating scale (p<0.001), visual analogue scale (p=0.012) and present pain intensity (p=0.001), but not for anxiety (p=0.169) and depression (p=0.530). The characteristics of pain that showed a significant difference between DEB patients and healthy controls were shooting, splitting, tender and throbbing (p<0.05). In DEB patients pain was not correlated with anxiety or depression (p>0.05), whereas a slight correlation between pain and anxiety was found in healthy controls (p<0.05). No difference was found between quality of pain and anxiety-depression in DEB patients (p>0.05), but was between the DEB dominant and the recessive form of DEB (p=0.025).

CONCLUSION

The perception of pain in DEB patients appears greater than in healthy individuals, with splitting and tender characteristics being the most significant ones, but was not associated with anxious and/or depressive symptoms.

Chronic Pain, Patient-Physician Engagement, and Family Communication Associated With Drug-Using HIV Patients' Discussing Advanced Care Planning With Their Physicians

CONTEXT

In the era of effective antiretroviral therapy, persons living with HIV/AIDS (PLWHA) are living longer, transforming HIV into a serious chronic illness, warranting patient-provider discussion about advanced care planning (ACP). Evidence is needed to inform physicians on how to approach ACP for these patients. Chronic pain is common in PLWHA, particularly in those who have substance use disorders; although it is known that this population is at risk for poorer patient-physician engagement, the effects on ACP are unknown.

OBJECTIVES

To further characterize factors associated with successful ACP in PLWHA, we examined associations between patient-physician relationship, chronic pain, family communication and problem-solving skills, and rates of patients discussing ACP with their physicians.

METHODS

Data were from the Affirm Care study (N = 325), which examined social and environmental factors associated with health outcomes among PLWHA and their informal caregivers.

RESULTS

In multivariate analysis, higher odds of patient reports of discussing ACP with their physicians were associated with their higher rating of their relationship with their physician (adjusted odds ratio [AOR] 1.73; P < 0.05), higher levels of chronic pain (AOR 2.16; P < 0.05), experiencing prior family arguments about end-of-life medical decisions (AOR 2.43; P < 0.01), and feeling comfortable talking to family members about problems (AOR 1.33; P < 0.05).

CONCLUSION

These results suggest that interventions to increase ACP among HIV patients and their physicians should promote patient-centered patient-provider relationships and PLWHAs' family communication and family problem-solving skills. The findings also suggest that PLWHA with chronic pain and prior family discord over end-of-life medical decisions may be primed for ACP.

Altered Associations between Pain Symptoms and Brain Morphometry in the Pain Matrix of HIV-Seropositive Individuals

Pain remains highly prevalent in HIV-seropositive (HIV+) patients despite their well-suppressed viremia with combined antiretroviral therapy. Investigating brain abnormalities within the pain matrix, and in relation to pain symptoms, in HIV+ participants may provide objective biomarkers and insights regarding their pain symptoms. We used Patient-Reported Outcome Measurement Information System (PROMIS®) pain questionnaire to evaluate pain symptoms (pain intensity, pain interference and pain behavior), and structural MRI to assess brain morphometry using FreeSurfer (cortical area, cortical thickness and subcortical volumes were evaluated in 12 regions within the pain matrix). Compared to seronegative (SN) controls, HIV+ participants had smaller surface areas in prefrontal pars triangularis (right: p = 0.04, left: p = 0.007) and right anterior cingulate cortex (p = 0.03) and smaller subcortical regions (thalamus: p ≤ 0.003 bilaterally; right putamen: p = 0.01), as well as higher pain scores (pain intensity-p = 0.005; pain interference-p = 0.008; pain-behavior-p = 0.04). Furthermore, higher pain scores were associated with larger cortical areas, thinner cortices and larger subcortical volumes in HIV+ participants; but smaller cortical areas, thicker cortices and smaller subcortical volumes in SN controls (interaction-p = 0.009 to p = 0.04). These group differences in the pain-associated brain abnormalities suggest that HIV+ individuals have abnormal pain responses. Since these abnormal pain-associated brain regions belong to the affective component of the pain matrix, affective symptoms may influence pain perception in HIV+ patients and should be treated along with their physical pain symptoms. Lastly, associations of lower pain scores with better physical or mental health scores, regardless of HIV-serostatus (p < 0.001), suggest adequate pain treatment would lead to better quality of life in all participants.

Attitudes towards exercise among substance using older adults living with HIV and chronic pain

Chronic pain and substance use disorders occur commonly among HIV-infected persons. Recent CDC guidelines recommend non-pharmacologic approaches over opioid medications for the management of chronic pain. This is particularly relevant for persons with substance use disorders. Structured physical activity may be an effective strategy for pain reduction. We developed a combined cognitive-behavioral therapy (CBT) + exercise intervention to reduce pain, pain-related disability and substance use and improve physical function in older HIV-infected adults with chronic pain and substance use. We employed established CBT protocols for the intervention, and sought feedback from potential end users when developing the exercise component of the intervention. A total of 27 HIV-infected adults ≥ 50 years of age participated in four focus group sessions. Transcripts were analyzed using thematic analysis. Participant demographics: mean age 54 years; male 81%; Hispanic 48%, Black 33%; treated for substance abuse in the past 52%. Exercise was seen as a desirable activity, but many participants expressed barriers to exercise including fear of pain exacerbation, low physical fitness, and lack of availability of perceived safe spaces for HIV-infected persons. Most participants were receptive to exercise for pain reduction, particularly modalities that provide added psychological benefits of reducing stress and anxiety. Exercise for pain management among older HIV-infected adults with chronic pain and substance use was found to be highly acceptable. However, interventions need to be tailored to the unique needs of this population to address their fears and concerns.

Brief Report: Longitudinal Opioid Use Among HIV-Infected Patients, 2000 to 2014

Longitudinal opioid prescription use is unknown among HIV-infected patients. Group-based trajectory modeling followed by multinomial logistic regression was used to identify distinct trajectories and their association with baseline characteristics among 1239 HIV-infected UNC CFAR HIV Clinical Cohort participants, 2000-2014. Three trajectories were identified: (1) 72% never/sporadic opioid use (referent group), (2) 11% episodic use (associated with female sex, depression, drug-related diagnoses, antiretroviral therapy use, and undetectable HIV RNA), and (3) 16% chronic use (associated with older age, female sex, and mental health diagnoses). Overall, opioid prescription decreased substantially with longer time in HIV care among both episodic and chronic users.

The therapeutic potential of targeting chemokine signalling in the treatment of chronic pain

Chronic pain is a distressing condition, which is experienced even when the painful stimulus, whether surgery or disease related, has subsided. Current treatments for chronic pain show limited efficacy and come with a host of undesirable side-effects, and thus there is a need for new, more effective therapies to be developed. The mechanisms underlying chronic pain are not fully understood at present, although pre-clinical models have facilitated the progress of this understanding considerably in the last decade. The mechanisms underlying chronic pain were initially thought to be neurocentric. However, we now appreciate that non-neuronal cells play a significant role in nociceptive signalling through their communication with neurons. One of the major signalling pathways, which mediates neuron/non-neuronal communication, is chemokine signalling. In this review, we discuss selected chemokines that have been reported to play a pivotal role in the mechanisms underlying chronic pain in a variety of pre-clinical models. Approaches that target each of the chemokines discussed in this review come with their advantages and disadvantages; however, the inhibition of chemokine actions is emerging as an innovative therapeutic strategy, which is now reaching the clinic, with the chemokine Fractalkine and its CX3 CR1 receptor leading the way. This article is part of the special article series "Pain".

Chronic pain disorders in HIV primary care: clinical characteristics and association with healthcare utilization

Chronic pain is common in HIV, but incompletely characterized, including its underlying etiologies, its effect on healthcare utilization, and the characteristics of affected patients in the HIV primary care setting. These data are needed to design and justify appropriate clinic-based pain management services. Using a clinical data warehouse, we analyzed one year of data from 638 patients receiving standard-of-care antiretroviral therapy in a large primary care HIV clinic, located in the Harlem neighborhood of New York City. We found that 40% of patients carried one or more chronic pain diagnoses. The most common diagnoses were degenerative musculoskeletal disorders (eg, degenerative spinal disease and osteoarthritis), followed by neuropathic pain and headache disorders. Many patients (16%) had multiple chronic pain diagnoses. Women, older patients, and patients with greater burdens of medical illness, and psychiatric and substance use comorbidities were disproportionately represented among those with chronic pain diagnoses. Controlling for overall health status, HIV patients with chronic pain had greater healthcare utilization including emergency department visits and radiology procedures. In summary, our study demonstrates the high prevalence of chronic pain disorders in the primary care HIV clinic. Colocated interventions for chronic pain in this setting should not only focus on musculoskeletal pain but also account for complex multifaceted pain syndromes, and address the unique biopsychosocial features of this population. Furthermore, because chronic pain is prevalent in HIV and associated with increased healthcare utilization, developing clinic-based pain management programs could be cost-effective.

Pilot Randomized Trial of Collaborative Behavioral Treatment for Chronic Pain and Depression in Persons Living with HIV/AIDS

In this pilot study, we assessed feasibility and acceptability of a behavior therapy intervention for pain and depressive symptoms in persons living with HIV/AIDS (PLWH). We randomly assigned 23 participants to HIV-PASS (HIV-Pain and Sadness Study) or a health education control arm for 3 months. On average, participants attended more than 5 sessions (of 7 possible) in both arms. Qualitative data suggest HIV-PASS participants understood key messages and made concrete behavioral changes. HIV-PASS was associated with effects in the expected direction for three of four outcomes, including the primary outcome (pain-related interference with functioning). Findings suggest that HIV-PASS is promising.

The role of chronic pain and current substance use in predicting negative social support among disadvantaged persons living with HIV/AIDS

Chronic pain and substance use can strain the supportive relationships of persons with serious chronic illness, which may increase the likelihood of receiving negative, rather than positive, social support from informal caregivers and social network members. To our knowledge, this is the first study to longitudinally examine the effects of chronic pain and substance use on negative social support. The sample (N = 383) comprised disadvantaged, primarily African-American, persons living with HIV/AIDS with a history of injection drug use, 32.4% of whom reported frequent or constant pain in the prior 6 months. Using factor analysis and structural equation modeling, current substance use and greater levels of chronic pain positively predicted negative social support 12 months later, after controlling for baseline negative support, viral load, age and sex. We also found a significant interaction effect such that among those not using substances, there was a significant positive association between pain and negative support, but no such association among those currently using substances. The findings emphasize the importance of treatment of chronic pain and substance use in the supportive functioning of social networks of a disadvantaged population with serious chronic conditions and persistent health disparities.

Perspectives and Trends in Pharmacological Approaches to the Modulation of Pain

Pharmacological approaches to our understanding and treatment of pain have had a long history and have traditionally relied on very few drugs that either have significant side effects and abuse liability, such as the nonsteroidal anti-inflammatory drugs or the opioids, respectively, or those that have been developed for other conditions such as the tricyclic antidepressants. The pathophysiology of pain is undoubtedly complex, complicated in part by the fact that it is not a singular condition, and has a variety of etiologies and a number of associated comorbidities that make treatment interventions challenging. Moreover, there are changes in the central nervous system during the course of the development of chronic pain that, in a manner parallel to neurodegenerative disorders, likely require different pharmacological approaches in the early stages of acute pain compared to those that would be effective when pain has become chronic. This chapter reviews the current status of the field of pain research focusing on some relatively underdeveloped areas, such as pain and its associated comorbidities, and the use of transgenic animals and drug self-administration procedures in the context of analgesic assessment. This chapter also incorporates more recent developments and emerging trends in the area of epigenetics, biomarkers, and the use of induced pluripotent stem cells for pharmacological evaluation, target identification, and validation. Recent progress in the study of "organs-on-a-chip" will also be included in this overview, setting expectations for future progress that integrates these advances for deeper insights into mechanisms, novel treatments, and facilitated efforts in drug discovery.