HIV/AIDS Treatment and Care : Clinical protocols for the European ...

Fig. 2. who analgesic ladder for management of pain in plhiv
1
MILD
PAIN
Pain
persisting or
increasing
Non-opioid
+/– adjuvant
2
MODERATE
PAIN
Pain
persisting or
increasing
Weak opioid
+/– non-opioid
+/– adjuvant
3
SEVERE
PAIN
palliative care for people living with hiv
Strong opioid
+/– non-opioid
+/– adjuvant
PAIN RELIEF
+/–: with or without.
Mild pain: 1–3 on the 0–10 Numeric Pain Intensity Scale; moderate pain: 4–6; severe pain: 7–10.
Non-opioid analgesics: ibuprofen, indomethicin, acetylsalicyclic acid, paracetamol.
Adjuvants: amtriptyline, imipramine, gabapentin, carbamazepine, valproic acid.
Weak opioids: codeine, hydrocodone.
Strong opioids: morphine, oxycodone, methadone, hydromorphone, fentanyl.
Notes: Adjuvant medications are particularly helpful for neuropathic pain. Not all analgesics will be available in all settings.
Source: adapted from WHO (1).
Some specific considerations are worth noting:
• If possible, administer analgesics orally or (assuming no history of rectal abscesses, rectal infection,
etc.) rectally. Intramuscular pain management, though sometimes required for severe
pain not responding to oral regimens, can be painful in itself and may pose a risk of infection. If
necessary and available, intravenous or subcutaneous infusion of strong analgesics can be used
as an alternative route of administration, especially in hospital settings but also in the home if
resources permit.
• Tailor the analgesic regimen to patterns of sleep, i.e. if possible do not awaken the patient to give
pain medication.
• Administer analgesia before the effects of the previous dose have worn off.
• Start with a low dose and increase gradually until the patient is comfortable.
• For breakthrough pain, 1 give an extra dose (50–100% of the 4-hourly dose) in addition to the
regular schedule.
• While aspirin can be effective in controlling mild-to-moderate pain, care should be taken in using
it due to the increased bleeding tendencies of PLHIV, especially in patients with clinically
significant liver disease. Paracetamol may also be problematic in patients with active liver disease
and should be used cautiously, generally not exceeding 2 g/day in such patients.
1 Breakthrough pain is pain that “breaks through” a regular pain medicine schedule. Breakthrough pain comes hard and fast
and can last up to an hour. It may be an intensified all-over dull pain, or come as a localized sharp stab or fiery sensation.
Breakthrough pain differs from person to person and is often unpredictable.
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