Letter to the Editor

2017 HIVMA of IDSA Clinical Practice Guideline for the Management of Chronic Pain in Patients Living With HIV

Pain has always been an important part of human immunodeficiency virus (HIV) disease and its experience for patients. In this guideline, we review the types of chronic pain commonly seen among persons living with HIV (PLWH) and review the limited evidence base for treatment of chronic noncancer pain in this population. We also review the management of chronic pain in special populations of PLWH, including persons with substance use and mental health disorders. Finally, a general review of possible pharmacokinetic interactions is included to assist the HIV clinician in the treatment of chronic pain in this population.It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The Infectious Diseases Society of American considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Experience of methadone therapy in 100 consecutive chronic pain patients in a multidisciplinary pain center

OBJECTIVE

The objective of the study was to describe the experience of methadone use in 100 consecutive chronic pain patients managed in a single multidisciplinary center.

DESIGN

A chart review of chronic pain patients on methadone therapy initiated at the Wasser Pain Management Center from January 2001 to June 2004. SETTING, PATIENTS, AND INTERVENTION: Outpatients receiving methadone for chronic pain management in a tertiary multidisciplinary pain center.

OUTCOME MEASURE

Effects on pain relief and function, conversion ratio from other opioids, side effects, and disposition were reviewed.

RESULTS

Charts of 100 methadone patients (age 45 +/- 11 years old; M/F: 3/7; duration of pain 129 +/- 110 months) managed by five physicians and one nurse were reviewed. The main reason for the initiation of methadone therapy was opioid rotation (72%). The average oral morphine equivalent dose was 77 mg/day before methadone therapy, and the methadone dose after initial stabilization was 42 mg with no consistent conversion ratio observed. The mean duration of methadone therapy was 11 months. Most of the patients (91%) were taking concomitant adjuvant analgesics or psychotropic agents, mostly antidepressants and anticonvulsants. The average Numeric Verbal Rating Score before and after methadone treatment was 7.2 +/- 1.7 and 5.2 +/- 2.5 (P < 0.0001). Thirty-five patients discontinued their methadone treatment mainly because of side effects, ineffectiveness, or both.

CONCLUSION

From our experience, methadone is an effective alternative to conventional opioids for chronic pain management when used by experienced clinicians in a setting that allows for close monitoring and careful dose initiation and adjustment.

Review article: Perioperative pain management of patients on methadone therapy

PURPOSE

Methadone, an opioid traditionally associated with the management of opioid addictive disorders, has been prescribed increasingly as an analgesic for the management of various chronic pain conditions. Despite the increasing popularity of methadone, most anesthesiologists are not familiar with its complex pharmacology. The purpose of this article is to review the pharmacology of methadone and to suggest a management algorithm for the perioperative care of methadone patients.

SOURCE

A Medline search was performed to obtain the published literature on the pharmacology of methadone and its use perioperatively.

PRINCIPAL FINDINGS

The complexity of methadone's pharmacology is characterized by a high inter-individual variability, a potential for interaction with other medications, and a long elimination half-life. The postoperative management of methadone patients may be difficult as they are often 'opioid-tolerant' but may be 'pain-intolerant'. For those patients who are taking part in methadone-maintenance programs, there is a potential for the problematic use of opioids or other substances. The management plan for patients taking methadone may differ depending on the type of surgery and the associated perioperative differences in fasting status and gastrointestinal function. In consideration of all the factors listed above, a management algorithm is outlined for the perioperative care of methadone patients.

CONCLUSION

Methadone is an opioid with complex properties, and a patient that is taking methadone can represent a unique challenge to the anesthesiologist. A good understanding of the pharmacology of methadone and of the type of patients on this medication will help to improve their perioperative care.