by The Substance Use Warmline (SUW) received a call from a physician in a public clinic regarding a 54-year old HIV/HCV coinfected man. The caller had concerns about the patient’s adherence to HIV medications although the patient is currently prescribed a single-pill, once-daily antiretroviral regimen. He has a history of heroin and methamphetamine use and a psychiatric/social history complicated by PTSD and bipolar disorder, for which he takes psychotropic medications and receives intensive case management.
The caller was requesting suggestions on managing long-standing, severe back pain that has continued despite use of high dose opioids, including methadone, short-acting opioids, and long-acting morphine. Because of concerns for overdose, the patient was recently transitioned to a buprenorphine transdermal patch but remains in pain at the maximum allowable dose. He also remains on gabapentin 1200mg three times daily.
The SUW consultation team agreed that safely addressing pain is of primary importance, and that achievement of this balance will likely take time, given the patient’s extensive history. Further, the team acknowledged the importance of ensuring a coordinated approach to this patient’s care, given his HIV and psychiatric co-morbidities, all of which could affect the provider’s approach to (and patient response to) future pain management strategies. For example, if pain adversely affects ARV adherence and/or risk of drug use relapse, this could negatively impact HIV and HCV outcomes. The consultant specifically advised on use of, and regulatory issues surrounding, buprenorphine for the treatment of chronic pain versus opioid use disorder and encouraged the provider to carefully evaluate whether the patient met criteria for opioid use disorder. Transitioning to sublingual buprenorphine/naloxone would allow room for further titration of buprenorphine if necessary and decrease risk of overdose. Finally, adjuvant medications (e.g., anti-spasticity agents) and non-pharmacologic interventions for back pain should be considered to develop a multi-modal approach to addressing this patient’s pain.