Report of an HIV clinic-based pain management program and utilization of health status and health service by HIV patients

Ahashta Johnson, MD; Kathleen DiGangi Condon, ANP-BC, MS, MA; Ann Celeste Mapas-Dimaya, MD; Judith Schrager, RN, PMHNP-BC; Robert Grossberg, MD; Rosalyn Gonzalez, BA, CASAC; Sean O’Mahony, MB, BCh, BAO, MS

doi:10.5055/jom.2012.0092

Authors

Ahashta Johnson, MD
Kathleen DiGangi Condon, ANP-BC, MS, MA
Ann Celeste Mapas-Dimaya, MD
Judith Schrager, RN, PMHNP-BC
Robert Grossberg, MD
Rosalyn Gonzalez, BA, CASAC
Sean O’Mahony, MB, BCh, BAO, MS

DOI:

https://doi.org/10.5055/jom.2012.0092

Keywords:

HIV, pain clinic, opioids, healthcare utilization

Abstract

Context: Current reports on human immunodeficiency virus (HIV) pain are limited to epidemiological data on neuropathic pain in HIV and most studies were conducted before the availability of highly active antiretroviral therapy. Complex pain was reported to be highly prevalent and associated with advanced disease.
Objectives: The authors conducted a retrospective review of the medical records of 81 patients from the Center for Positive Living (CPL) at Montefiore Medical Center who were newly referred to a pain management program in 2006 to identify the potential benefits of integrating a pain management team into the care of persons living with HIV and etiologies of pain.
Methods: A standardized chart abstraction tool was used to capture clinical data. Data related to health service utilization and viral outcomes were obtained from the clinical information systems.
Results: The most common pain diagnoses were multiple syndromes, degenerative disc disease or spinal stenosis, and neuropathy. There was a decrease in emergency room utilization in the 12 months following an initial pain management appointment (p < 0.0001) and an increase in use of primary care (p = 0.0017). The use of adjuvant medications increased after intake into the pain clinic (p < 0.0001). Having an opioid dose in excess of 200 mg/d oral morphine equivalents and maintenance of each palliative care and infectious disease clinic appointment were inversely associated with viral loads in excess of 75 copies: odds ratio (OR) = 0.21 (95% confidence interval [CI], 0.11-0.44), OR = 0.77 (95% CI, 0.68-0.86), and 0.94 (95% CI, 0.93-0.99), respectively.
Conclusions: The decrease in emergency room visits and increase in use of adjuvant analgesics and compliance with primary care and nonmedication approaches for the management of pain in the 12 months subsequent to initial palliative/pain clinic appointments highlight potential improved quality of care associated with the integration of a pain management team into the primary care of persons living with HIV disease.

Author Biographies

Ahashta Johnson, MD

Medical Director, Hospice and Palliative Care, Montgomery Hospital, Norristown, Pennsylvania.

Kathleen DiGangi Condon, ANP-BC, MS, MA

Nurse Practitioner, Palliative Care Service, Montefiore Medical Center, Bronx, New York.

Ann Celeste Mapas-Dimaya, MD

Physician, Internal Medicine, Geriatrics, Hospice and Palliative Medicine, Cornell Scott-Hill Health Corporation, West Haven, Connecticut.

Judith Schrager, RN, PMHNP-BC

Psychiatric Nurse Practitioner, Center for Positive Living/ID Clinic, Montefiore Medical Center, Bronx, New York.

Robert Grossberg, MD

Assistant Professor of Medicine, Department of Medicine, Albert Einstein College of Medicine Bronx, New York; Medical Director, Center for Positive Living/ID Clinic, Montefiore Medical Center, Bronx, New York.

Rosalyn Gonzalez, BA, CASAC

Substance Abuse Counselor, Center for Positive Living/ID Clinic, Montefiore Medical Center/ID Clinic, Bronx, New York.

Sean O’Mahony, MB, BCh, BAO, MS

Director, Palliative Medicine Section, Division of Geriatric Medicine, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois.

References

Breitbart W: Pain in AIDS: An overview. Pain Rev. 1998; 5: 247-272.

Hewitt DJ, McDonald M, Portenoy RK, et al.: Pain syndromes and etiologies in ambulatory AIDS patients. Pain. 1997; 70: 117-123.

Nair SN, Mary TR, Prarthana S, et al.: Prevalence of pain in patients with HIV/AIDS: A cross-sectional survey in a South Indian state. Indian J Palliat Care. 2009; 1: 67-70.

Dobalian A, Tsao JCI, Duncan RP: Pain and the use of outpatient services among patients with HIV. Med Care. 2004; 42: 129-138.

Breitbart W, McDonald MV, Rosenfeld B, et al.: Pain in ambulatory AIDS patients. I. Pain characteristics and medical correlates. Pain. 1996; 68: 315-321.

Frich LM, Borgjberg FM: Pain and pain treatment in AIDS program: A longitudinal study. J Pain Symptom Manage. 2000; 19: 339-347.

Glare PA, Cooney NJ: Managing HIV, Part 5: Treating secondary outcomes. HIV and palliative care. Med J Aust. 1996; 164: 612-615.

Gray GE, Laher F, Lazarus E: The management of pain in adults and children living with HIV/AIDS. In Kopf A, Patel NB (eds.): Guide to Pain Management in Low-Resource Settings. Seattle: IASP, 2010: 195-204.

Richardson JL, Heikes B, Karim R, et al.: Experience of pain among women with advanced HIV disease. AIDS Patient Care STDS. 2009; 23: 503-511.

Mathews WC, May S: EuroQOL (EQ-5D) measures of quality of life predict mortality, emergency department utilization, and hospital discharge rates in HIV infected individuals. Health Qual Life Outcomes. 2007; 5: 5-9.

Breitbart W, Rosenfeld BD, Passik SD, et al.: The under treatment of pain in ambulatory AIDS patients. Pain. 1996; 65: 243-249.

Gray G, Berger P: Pain in women with HIV/AIDS. Pain. 2007; 132: S13-S21.

Breitbart W, Kaim M, Rosenfeld B: Clinicians’ perceptions of barriers to pain management in AIDS. J Pain Symptom Manage. 1999; 18: 203-212.

Passik SD, Kirsh KL, McDonald MV, et al.: A pilot survey of aberrant drug-taking attitudes and behaviors in a sample of cancer and AIDS patients. J Pain Symptom Manage. 2000; 19: 274-286.

Basu S, Bruce RD, Barry DT, et al.: Pharmacological pain control for human immunodeficiency virus-infected adults with a history of drug dependence. J Subst Abuse Treat. 2007; 32: 399-409.

Kaplan R, Slywka J, Slagle S, et al.: A titrated morphine analgesic regimen comparing substance users and non-users with AIDS-related pain. J Pain Symptom Manage. 2000; 19: 265-273.

Passik SD, Kirsh KL, Donaghy KB, et al.: Pain and aberrant drug-related behaviors in medically ill patients with and without a history of substance abuse. Clin J Pain. 2006; 22: 173-181.

Tsao JCI, Stein JA, Dobalian A: Pain, problem drug history, and aberrant analgesic use behaviors in persons living with HIV. Pain. 2007; 133: 128-137.

Josephs JS, Fleishman JA, Korthius PT, et al.: Emergency department utilization among HIV-infected patients in a multisite multi-state study. HIV Med. 2010; 11: 74-84.

Metsch LR, Pereyra M, Brewer TY: Use of HIV health care in seropositive crack cocaine smokers and other active drug users. J Subst Abuse. 2001; 13: 155-167.

Leserman J, Whettan K, Lowe K, et al.: How trauma, recent stressful events, and PTSD affect functional health status and health utilization in HIV-infected patients in the south. Psychosom Med. 2005; 67: 500-507.

O’Clarigh CO, Skeer M, Mayer KH, et al.: Functional impairment and health care utilization among HIV-infected men who have sex with men: The relationship with depression and posttraumatic stress. J Behav Med. 2009; 32: 466-477.

Smith MY, Egert J, Winkel G, et al.: The impact of PTSD on pain experience in persons with HIV/AIDS. Pain. 2002; 98: 9-17.

Tsao JCI, Dobalian A, Naliboff BD: Panic disorder and pain in a national sample of persons living with HIV. Pain. 2004; 109: 172-180.

Chan S: Progress is reported in Bronx HIV testing campaign. The New York Times. June 24, 2009. Available at cityroom. blogs.nytimes.com/2009/06/24/progress-is-reported-in. Accessed November 29, 2011.

Altman A, Pickert K: A battle in the Bronx over HIV testing. Time. July 11, 2008. Available at http://www.time.com/time/nation/article/0%2C8599%2C1822013%2C00.html. Accessed March 18, 2010.

Stein Marcus K, Kerns RD, Rosenfeld B, et al.: HIV/AIDS-related pain as a chronic pain condition: Implications of a biopsychosocial model for comprehensive assessment and effective management. Pain Med. 2000; 1: 260-273.

Newshan G: Pain management in the addicted patient: Practical considerations. Nurs Outlook. 2000; 48: 81-85.

Dunbar SA, Katz NP: Chronic opioid therapy for non malignant pain in patients with a history of substance abuse: Report of 20 cases. J Pain Symptom Manage. 1996; 11: 163-171.

McNagny SE, Parker RM: High prevalence of recent cocaine use and the unreliability of patient self-report in an inner-city walk-in clinic. JAMA. 1992; 267(8): 1106-1108.

Harden RN: Neuropathic pain. In Von Roenn JH, Paice JA, Preodor ME (eds.): Current Diagnosis and Treatment of Pain. New York: Lange Medical Books/McGraw Hill, 2006: 122-135.

Centers for Disease Control and Prevention: HIV/AIDS Surveillance Report, 2007. Vol. 19. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2009: 1-63. Available at http://cdc.gov/hiv/topics/surveillance/basic.htm. Accessed April 20, 2010.

Blamey R, Jolly K, Greenfield S, et al.: Patterns of analgesic use, pain and self efficacy: A cross-sectional study of patients attending a hospital rheumatology clinic. BMC Musculoskelet Disord. 2009; 10: 137.

George SZ, Valencia C, Zeppieri G Jr, et al.: Development of a self-reported measure of fearful activities for patients with low back pain: The Fear of Daily Activities Questionnaire. Phys Ther. 2009; 89: 969-979.

Briscoe ME: Why do people go to the doctor? Sex differences in the correlates of GP consultation. Soc Sci Med. 1987; 25(5): 507-513.

Kapur N, Creed F, Hunt I, et al.: Primary care consultation predictors in men and women: A chart study. Br J Gen Pract. 2005; 55: 108-113.

Fillingim RB, King CD, Ribeiro-Dasilva MC, et al.: Sex, gender and pain: A review of recent clinical and experimental findings. J Pain. 2009; 10: 447-485.

US Census Bureau: State and County Quick Facts. Available at http://quickfacts.census.gov. Accessed April 20, 2010.