Causes of HIV-Related Pain

It may seem that the blog is being flooded with pain articles at the moment but as anybody with both HIV and neuropathy will know, putting your finger on the cause of your pain (or pains) is anything but straightforward. Today's excellent article from thewellproject.org (see link below) addresses the HIV-patient directly and explains that it's not that simple putting the correct neuropathic, or arthritic, or stomach-related or muscular, or whatever label on your pain. With a bit of luck, after reading this, you will be able to locate the source and reason for your pain before you take it to the doctor and have to explain the whole story again. It's also possible that you have more than one source of pain and it's important to know what causes what. Forewarned is forearmed and if you have a good idea of where the problem is and what's causing it, you'll help your doctor considerably to decide the appropriate tests and treatment. However, having read this, or an article like this, never go ahead and self-medicate! Drugs can very easily negatively interact with each other and it is very important that you talk everything over with your doctor before beginning any form of treatment. This may seem like a lecture but you know it makes sense!

HIV Related Pain
Updated November 2010

Pain is common in people living with HIV (HIV+ people). One study of HIV+ people found that more than 50 percent had pain. Pain can occur at all stages of HIV disease and can affect many parts of the body. Usually pain occurs more often and becomes more severe as HIV disease progresses. But each individual is different. Some people may experience a lot of pain, while others have little or none.

What Causes Pain?
HIV related pain can have many causes:

- A symptom of HIV itself
- A symptom of other illnesses or infections
- A side effect of HIV drugs

Regardless of the reason, pain should be evaluated and treated to help HIV+ people have a good quality of life.

Common Types of Pain
The first step in managing HIV related pain is identifying the type, and if possible, the cause of pain. Some common types of pain include the following:

Peripheral Neuropathy – Pain due to nerve damage, mostly in the feet and hands. It may be described as numbness, tingling, or burning. Nerve damage can be caused by HIV drugs or other medical conditions such as diabetes. The older HIV drugs that caused the most peripheral neuropathy are not commonly used today

Abdominal Pain – There are many possible causes of abdominal pain:
A side effect of some HIV drugs (for example cramps)
Infections caused by bacteria or parasites
Problems of the intestinal tract such as irritable bowels
Inflammation of the pancreas (pancreatitis) caused by some HIV drugs or by drinking alcohol.
Bladder or urinary tract infections (especially in women)
Menstrual cramps or conditions of the uterus, cervix, or ovaries

Headache – Head pain can be mild to severe, and may be described as pressure, throbbing, or a dull ache. The most common causes of mild headaches include muscle tension, flu-like illness, and HIV drug side effects. Moderate or severe headaches can be caused by sinus pressure, tooth infections, brain infections, brain tumors, bleeding in the brain, migraines, or strokes. Sometimes the cause cannot be determined.

Joint, Muscle and Bone Pain – This pain can also be mild to severe. It may be related to conditions such as arthritis, bone disease, injury, or just aging. It can also be a side effect of some HIV drugs and medications for other conditions like hepatitis or high cholesterol.

Herpes Pain – Herpes is a family of viruses common in HIV+ people. Herpes viruses stay in the body for life, going into hiding and flaring up later. The varicella-zoster herpes virus first causes chickenpox and later can cause shingles, a painful rash along nerve pathways. Herpes simplex virus types 1 and 2 cause painful blisters around the mouth (“cold sores”) or genital area. Even after a herpes sore heals, a person may still have persistent pain.

Other Types
- Painful skin rashes due to infections or HIV drug side effects
- Chest pain caused by lung infections such as TB, bacterial pneumonia or PCP pneumonia (Pneumocystis pneumonia)
- Mouth pain caused by ulcers (“canker sores”) or fungal infections like thrush
- Fibromyalgia or related chronic pain conditions
- Pain due to cancer anywhere in the body

Assessing Pain
Once the type of pain is identified, the next step is to evaluate its characteristics. The goals of pain assessment are to:

Define the severity of pain (how much it hurts): Your health care provider may ask you to assign a number to your pain, from one (very mild pain) to ten (the worst possible pain). Pictures can also describe pain. A smiling face represents little or no pain, while a crying face represents severe pain.
Describe details of your pain: Your health care provider may ask you to describe how your pain feels, for example sharp, dull, throbbing, or burning. Is it new (acute) or have you had it for a while (chronic)? Where is it located? Is it constant or does it come and go?

You may be having pain but do not want to complain. Talking about pain to your health care provider is not the same thing as complaining! Telling your health care provider exactly how you feel is the best thing you can do to find out what is wrong and get the right treatment.

Pain Management
Once the type and characteristics of pain are identified, you and your health care provider will decide how to manage or treat it. The following factors will play a role in selecting the right type of treatment for you:

- Cause, type, and severity of pain
- Whether it is short-term or long-term
- History of substance abuse
- If your pain is being caused by a medication you are taking or another illness, your health care provider will want to take care of that first. If you are still experiencing pain, there are many options for pain relief.

Non-medicinal Therapies
Pain relief without medications such as:

- Massage
- Relaxation techniques
- Physical therapy
- Acupuncture
- Heat and cold therapy
- Hypnosis
- Mental imagery or visualization

While these may be enough to relieve pain, they are often used along with pain medications.

Non-opioid Medications
Pain relief medicines that do not contain narcotics (opiates). They are available over-the-counter or by prescription. These medicines relieve mild to moderate pain related to inflammation or swelling. Some people with a history of drug addiction prefer non-opioid pain medicines such as:

- Tylenol (acetaminophen)
- Non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen (for example Advil)
- COX-2 inhibitor, a type of NSAID that is less likely to cause stomach problems, for example Celebrex (celecoxib)
- Steroids, natural or manufactured hormones that reduce inflammation. Examples include prednisone and hydrocortisone

Non-opioid pain medicines can cause side effects including liver damage (Tylenol), easy bleeding (aspirin), stomach pain or damage (aspirin and other NSAIDs), and heart problems (COX-2 inhibitors).

Opioids/Narcotics
Narcotics and related drugs known as opioids are the strongest pain relievers, available only by prescription. They are used to treat moderate to severe pain.

Opioids are classified by how fast and how long they work.

Immediate release opioids – act rapidly but pain relief lasts for a shorter period of time
Sustained-released opioids – take longer to start working but pain relief lasts longer

Opioids are also classified by their strength.

Mild to moderate pain relievers (they are often mixed with non-opioid medicines to improve their action):
- Hydrocodone
- Vicodin (hydrocodone plus acetaminophen)
- Codeine
- Tylenol with codeine (acetaminophen plus codeine)
- Ultram (tramadol)
- Severe pain relievers:
- Morphine
- Fentanyl
-OxyContin (oxycodone)
- Methadone or Buprenorphine (not commonly prescribed in first-line pain reliever treatment)
Opioids can cause side effects including drowsiness, nausea, and constipation. Overdoses can slow down breathing and cause death. Opiates can lead to dependence or addiction and may be a problem for people with a history of substance use.

Topical or Local Therapies
These are medications that are injected or applied to the skin around a painful area. Examples include the local anesthetic Xylocaine (lidocaine) and capsaicin, which comes from chili peppers.

Other Therapies
There are medicines prescribed for other purposes that also have pain-relieving properties.

Anti-depressants – relieve neuropathic pain such as peripheral neuropathy. An example is Cymbalta (dulozetine).
Anti-convulsants – usually used to treat seizures, some of these drugs work for peripheral neuropathy. An example is Neurontin (gabapentin).

Determine if the Pain Treatment Works
Once you start medication or other pain treatment, your health care provider should assess your pain regularly to see if treatment is working. Sometimes pain medications can stop working over time.

What to Do if You Have Pain?
When you experience pain, it is important to know how to get fast, safe relief.

Do not ignore your pain – Pain is the body’s way of telling us something is wrong. Ignoring pain often makes matters worse and can cause more damage in the long run.
Assess your pain – When pain occurs ask yourself the following questions:
- How long have I had the pain?
- Did it happen suddenly or over time?
- Is the pain sharp or dull?
- What makes the pain worse?
- Does anything ease the pain?
- Is the pain limited to one place or does it spread out to other areas?
- Are there other symptoms (for example numbness, cough or fever)?
Notify your health care provider – Report pain to your provider without delay. Describing your pain will help find the cause and how best to treat it.
Take your pain medicine as directed – If you need pain medications, make sure you take them exactly as prescribed. Pain medications work best if they are taken at the first sign of pain. Breaking the cycle of pain means taking medications before your pain is at its worst.
Be responsible – Pain medications are very effective when taken as prescribed. Taking them incorrectly can be dangerous. Opioids are addictive, meaning you can develop physical and emotional dependence on a drug. High doses can cause breathing problems. In the worst cases, incorrect use of opioids can be fatal.
Tell your health care provider if treatment does not work – If your pain medicine is not relieving your pain, talk to your providers. You may be taking a medication that will not work for you, or you may have built a tolerance to the drugs over time. You may need to change doses or switch to a new medication.
Pain is common among HIV+ people. But it can be managed using a variety of methods. Talk to your health care provider if you are having pain. He or she can work with you to find the cause, manage the pain, and improve your quality of life.

http://www.thewellproject.org/en_US/Living_Well/Health/HIV_Pain_Mgmt.jsp