Maile Y. Karris, MD, on Managing Pain in Older Adults With HIV

In this podcast, Maile Karris, MD, talks about the impact of pain and pain medication use on older adults with HIV, strategies she has used to better care for her older patients with HIV and pain, and the research questions she hopes to answer in the future. 

Additional Resources:

• Karris M, Mazonson P, Loo T, Berko J, Spinelli F, Zolopa A. Characteristics associated with pain in older people living with HIV. Paper presented at: IDWeek 2020; October 21-25, 2020; Virtual. https://www.eventscribe.net/2020/idweek/fsPopup.asp?efp=VFhWUUpXVFA2ODg4&PosterID=290883&rnd=0.1108931&mode=posterinfo 
• Aging With Dignity, Health, Optimism and Community (ADHOC). ClinicalTrials.gov. Accessed October 30, 2020. ClinicalTrials.gov identifier NCT04311554. https://clinicaltrials.gov/ct2/show/NCT04311554
• Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain — United States, 2016. MMWR Recomm Rep. 2016;65(1):1-49. https://doi.org/10.15585/mmwr.rr6501e1 

Maile Young Karris, MD, is an associate professor in the Department of Medicine, Divisions of Infectious Diseases & Global Public Health and Geriatrics & Gerontology, at the University of California San Diego, as well as the associate director of the San Diego Center for AIDS Research Clinical Investigations Core.

TRANSCRIPT:

Amanda Balbi: Hello everyone, and welcome to another installment of Podcasts360—your go-to resource for medical news and clinical updates. I’m your moderator, Amanda Balbi with Consultant360 Specialty Network.

Previous studies estimate that pain impacts up to 55% of people with HIV and negatively impacts function. However, limited data exist regarding factors that contribute to pain in older adults with HIV. A new study, presented at IDWeek 2020, aimed to do just that—to better understand the contributing factors of pain in older adults with HIV.

With me today to discuss the study and its implications is the lead author, Dr Maile Young Karris, who is an associate professor in the Department of Medicine, Divisions of Infectious Diseases & Global Public Health and Geriatrics & Gerontology, at the University of California San Diego.


Thank you for joining me today, Dr Karris. To start, can you give us an overview of your research and what you found?

Maile Karris: Absolutely. In general, chronic pain or pain that lasts more than 3 months is very common in people living with HIV. In some studies, they cite up to 85% of a specific population experiences pain.

In the older adult population, we found that it's closer to 66%. This is an active outpatient, fairly healthy older adult population. Pain diagnoses often represent 3 out of the top 5 common comorbidities that older adults with HIV report that they're dealing with. So, these are common things, and they're very relevant to older adults with HIV.

I changed my pain-management practices as an HIV provider back in 2016 when the Centers for Disease Control published their chronic pain management guidance documents. Specifically, I began focusing on increasing my recommendations to my older adults with HIV to pursue non-pharmacological approaches to pain management, such as massage and physical therapy and chiropractic care. I tried to minimize opioid prescriptions.

What I realized is that a lot of the older adults with HIV that I was caring for were on really high doses of opioids. Many of them were much higher than the maximum recommended dose of 90 morphine milligram equivalents a day. And many of them had been on doses like that for decades.

A little bit of background for, maybe, the reasoning behind that is, historically AIDS care was hospice care. The majority of older adults who are living with HIV today are long-term survivors. So, they were started on these pain medications decades ago when people didn't know if they were going to survive, and they were really struggling with different types of conditions. And those prescriptions just continued.

In addition, most nonopioid medications that are used for pain, like muscle relaxants and nonsteroidal anti-inflammatory drugs like ibuprofen, are relatively contraindicated in older adults, because natural-age-related changes alter pharmacogenetics and pharmacodynamics of these medicines, which then results in the higher risk-to-benefit ratios of these drugs.

So, I found it really difficult to manage the pain of my older adults with HIV within the context of all of those competing issues. I also found it really difficult to get them access to nonpharmacological pain management approaches. A lot of that was related to some of the health inequities that exist in this population such as social isolation.

Again, a majority of older adults with HIV are survivors. Some of them did not expand their social circle because they didn't know that they're going to live to be old or older. They often lack transportation, and HIV stigma is still really prevalent.

An example of that, I ordered water physical therapy for one of my patients, and insurance rejected it. In the rejection letter, they specifically said—even though it was an indicated diagnosis—the letter specifically said that they would not approve it, because my patient was living with HIV and hepatitis C. We all know that you can't get HIV and hepatitis C from pool water. So, that clearly was HIV stigma contributing to an access issue for that particular person.

All in all, it was difficult to adhere to these CDC pain management recommendations, and I noticed that as I was trying to do it, the relationship that I had with the people that I cared for was being harmed. They were struggling, and they were experiencing a lot of difficulties. I thought that there has to be a better way to do this—to be safely prescribing medications for people and allow them to still have a good quality of life and preserve the therapeutic relationship between physician and patient.

In order to develop any types of new approaches or innovations in clinical management, you often have to first start with better understanding the factors that contribute to chronic pain and chronic pain medication use.

I just happened to already be a participating investigator in a multicenter longitudinal cohort study that's focused on older adults with HIV. The study’s called ADHOC, which stands for aging with dignity, health, optimism, and community. I approached that group to see if they would be interested and willing to evaluate the questions of, “What factors contribute to chronic pain in older adults, and what factors contribute to chronic pain medication use in older adults with HIV?”

This is a fairly large cohort. There's 11 different centers across the country. There's over 1000 or so persons that are enrolled in this cohort. Of those, 696 persons reported that they had chronic pain. So, we were able to take that population of persons and performed bivariate analyses, as well as some multivariate logistic regression, to determine what factors are associated with pain and pain medication use.

Amanda Balbi: What factors impact pain and pain medication use in adults with HIV who are aged 50 years or older?

Maile Karris: For those that are not aware, we consider an older adult with HIV 50 years and older, primarily because of the epidemiologic evidence that suggests that they accumulate common age-associated conditions about a decade earlier than HIV seronegative comparators. That includes things like heart disease and osteoarthritis and cancers and things of that sort.

In the study that we performed, we actually found some really interesting findings with just using the bivariate analysis. In older adults with HIV who had chronic pain, we found that an annual household income less than $50,000, unemployment, having 6 or more medical conditions or multi-morbidity, tobacco use, and low or no alcohol use was associated with pain. Pain was also more common in people that reported anxiety, depression, loneliness, lower social wellbeing, and lower cognitive function.

However, when we applied those factors into a multivariate logistic regression model, we found that only multi-morbidity and tobacco use increased the odds of having pain. We also discovered some protective factors. So, if you were male gender, black race, or had higher cognitive function, you were less likely to have pain.

On the other hand, older adults with HIV, of those that had pain, about 46% of them are using some sort of pain medication. Unfortunately, we weren't able to determine what type of pain medication people were using. That wasn't captured in this specific cohort. It's just pain medication use in general, and that can be anything from taking acetaminophen all the way to taking opioids.

And the bivariate analysis of that population showed that pain medication use was higher among heterosexuals, persons with lower education levels, annual income less than $50,000, unemployment, multi-morbidity, low or no alcohol use, as well as the similar conditions of anxiety and depression, low interpersonal support, and lower cognitive function.

But again, when multivariate logistic regression models were applied to that, only multi-morbidity and low annual household income was associated with pain medication use.

Amanda Balbi: What other knowledge gaps exist among this patient population?

Maile Karris: I would love to further explore some of the reasons behind these findings. Why does tobacco use increase the odds of chronic pain? Why is annual household income associated with pain medication use?

I'm also interested in further looking at chronic pain self-management strategies of older adults living with HIV, particularly as it relates to substance use of different forms. That comes from some clinical observations where I've noticed a couple of my older adults reusing substances that they had used in the very distant past around management of their pain.

I have an 85-year-old woman who was admitted to the hospital for hypotension, and she was acutely intoxicated with alcohol. She had not drunk alcohol for many, many years. When I inquired about what prompted that, she said that she was in pain and her pain medicines, which were already at the maximum of 90 morphine milligram equivalents, were just not cutting it.

Similarly, I had another woman who was admitted with a stroke, and she admitted that she'd use some cocaine, again, because of her pain. So, these are anecdotal findings in the clinic but, I think, maybe indicative of a greater problem. I'm really interested in exploring that further.

I'm also interested in better understanding the psychosocial factors that contribute to the pain experience of older adults, particularly social isolation and past trauma.

I think there's some interesting biologic questions too, such as what happens to the brain when it's been exposed to decades of chronic opioid use?

How does that change their experience of pain? How does that change their relief of pain? And is it even possible to taper people off of these medications once they've been on them for so long?

Amanda Balbi: How do your current findings add to the existing body of knowledge?

Maile Karris: It's really interesting. Despite pain being a very common condition, not just for older adults with HIV, but people living with HIV across the board, it's really understudied. Not a lot of people have a good understanding or done a lot of research on it.

Dr Jessica Merlin has probably done the most work in this space, and she's really expanded our understanding of pain in HIV. If you read anything of hers, it will be revelatory. I mean, she just does amazing work. But what's different about this study is that we really are specifically focused on older adults living with HIV and evaluating pain and pain management from that specific perspective.

I said earlier that there are some limitations in pain management of older adults because it's not safe to use medications like NSAIDS or muscle relaxants, because of increased risk of GI bleeds for the NSAIDs and increased risk of falls and confusion for muscle relaxants.

It is a unique population with some unique challenges. And I think that this work will help us move forward in developing better interventions.

Amanda Balbi: And you mentioned before some research questions that you hoped to answer in the next study or two. But what is the next step in your research, what are you currently working on?

Maile Karris: I am currently performing a small pilot study that is evaluating group acceptance and commitment therapy for pain that's provided by like paraprofessionals and comparing that to group pain education. The impetus of this study—and forgive me for telling so many stories, but really a lot of the work that I do is influenced by the people that I care for and my frustrations about our current medical system—but I have a patient who I inherited, and he was on pretty high doses of oxycodone for his neuropathy.

He when they when the CDC guidance documents came out, I started asking everybody about “How does your pain impact your function,” as was recommended. He told me that he doesn't know because he doesn't do anything. He said, basically I spend all day every day sitting alone in my apartment, not doing anything. And I just casually asked him, “Oh, don't you get lonely?” And he burst into tears.

And basically, he said, “I am terribly lonely. Unfortunately, I don't have any connection with my family. I have not had any connections with my family because of past behaviors. I miss them terribly, but I have no idea how to connect with them. They live across the country.” And then he just cried. This shocked me because this man is so stoic, and he just was bawling in my office.

He did tell me that he knew the name of his niece, and he knew that she had recently got married, and he knew that she was on Facebook. So, we decided that we were going to try to reach out to her in that office visit. I just sent a Facebook message to her—we found her—just providing his name and his phone number and that he was interested in reconnecting with his family.

I scheduled a follow-up 3-month visit. Unfortunately, he didn't show up, but I noticed that he wasn't asking me for refills of his oxycodone. He ultimately ended up back in clinic probably about 6 months later. And I asked him about the oxycodone refills, if he was getting his medications from another physician.

He told me that since the last visit, he'd reconnected with his family, that he and his brother were talking almost every day, and that he didn't need his oxycodone anymore, and that he was able to manage his pain better just through those social interactions. He was a little bit more active and getting out.

I think that just struck me about how great, at least in that one person's life, these issues of isolation and loneliness and that connection impacted his pain. From that point on, I've been in hot pursuit of developing strategies to help people better cope to connect with others. And that led to this study that I'm currently doing.

The reason why I'm also specifically doing it, using paraprofessionals, is because access is an issue. Access is a major issue to therapy, not just for the older adults with HIV, but a lot of people that are underfunded from an insurance standpoint. I am trying to figure out ways to enhance that so that more people are able to get the treatment that they need.

So that's one study that I've currently got funded. I just submitted two grants to look at leveraging technology to try to address some of these issues as well. One of them is focused on the development of and subsequent evaluation of a home-based nerve stimulator for pain. I really hope that that study gets funded because it could provide a lot of relief for folks. This is a strategy that's already been proven to work but historically has to be given in a clinic setting and moderated by trained personnel. But we're hoping that we can design it so that it's safe and easy to use in the home setting by older adults with HIV.

I also submitted another grant that is proposing to develop an electronic smart pill dispenser to enhance safety of opioid prescriptions, if needed, and pair it with the provision of self-management strategies for chronic pain, such as meditation and relaxation.

Both of those depend on the NIH to fund them if I move forward with those.

Amanda Balbi: Very exciting stuff in the works, and I definitely can see your connection with your patients and how they affect the work that you do, which is really great.

Maile Karris: Thank you. You know, it's tough being a doctor nowadays. We are limited a lot of times, and we're losing our autonomy. Our administrators and health insurance companies are often dictating what we can and cannot do for the patients that we care for.

And research really allows me to step out of that box and try to find new ways to do that in a way so that the health care we provide is more equitable.

Amanda Balbi: Great, thank you again for speaking with me today and answering all my questions.

Maile Karris: Thank you for your interest and for the opportunity to really amplify this problem.