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"The Prevalence, Experience and Management of Pain : Secondary Analysis of the Care & Support PHE" webinar presentation by Dr. Richard Harding, King's College London.

"The Prevalence, Experience and Management of Pain : Secondary Analysis of the Care & Support PHE" webinar presentation by Dr. Richard Harding, King's College London.

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  • MOS-HIV: medical outcomes survey-HIV, 35-item quality of life tool. Converted to physical health score (PHS) and mental health sore (MHS) POS: palliative outcomes scale. 10-item multidimensional tool, 7 items for patient, 3 for caregiver. ECOG: single item for physical function (0=fully active, 4=completely disabled)

The Prevalence, Experience and Management of Pain The Prevalence, Experience and Management of Pain Presentation Transcript

  • WHO Collaborating Centre for Palliative Care, Policy & Rehabilitation The prevalence, experienceThe prevalence, experience and management of painand management of pain Secondary analysis of theSecondary analysis of the Care & Support PHECare & Support PHE Dr Richard Harding Cicely Saunders Institute King’s College London www.csi.kcl.ac.uk
  • www.csi.kcl.ac.uk Background: pain in people with HIVBackground: pain in people with HIV • High prevalence of pain at all stages: – UK outpatients n=778 53% 7 day period prevalence (BMJ STI 2010) – Ugandan outpatients 47% (J Pain 2012) – Uganda newly diagnosed 76% (J Pall Med 2010) – Newly diagnosed 11-76% (J Pain Symptom Manage 2011)
  • www.csi.kcl.ac.uk Does pain persist with ART?Does pain persist with ART? • Systematic review of patients on treatment (in review) – muscle or joint 32.5%-72% – non-specified 19%- 57.3% • Among patients on ART in South Africa 51% (S African Med J 2012) • Analysis of UK sample showed no assoc between ART status and symptom burden (BMJ STI 2010) • Greater burden for those on ART controlling for CD4/VL (Int J STD AIDS 2006) View slide
  • www.csi.kcl.ac.uk Why is pain clinically important?Why is pain clinically important? • As a distressing phenomenon: – UK sample 14% of sample scored pain on worst 2/5 responses: “quite a bit” or “very much” (BMJ STI) – Uganda sample 41% (J Pall Med) – Severe pain in 80% of advanced patients (Solano 2006; J Pain Symptom Manage 2011) • Other clinical relevance – Symptom burden associated with sexual risk taking and poor adherence (AIDS Care 2009; BMJ STI 2010; AIDS & Behavior 2012) – Symptom burden associated with viral rebound (JAIDS 2010) View slide
  • www.csi.kcl.ac.uk Current focus on pain and symptomsCurrent focus on pain and symptoms • 13/8629 abstracts at IAS 2004 investigated pain/symptoms (Clin Infect Dis 2005) • Skills lost of assessment and control (i.e. palliation) integration (Lancet Infect Dis 2012) • The Care & Support PHE included self- reported multidimensional well being – report here pain dimension – unique dataset • Q: What do you see as the possibilities for USAID to drive forward the reduction of suffering?
  • www.kcl.ac.uk/palliative PEPFAR Care & Support Public Health EvaluationPEPFAR Care & Support Public Health Evaluation PHASE 1 Objective: Describe nature and scope of PEPFAR HIV care &support provision in Kenya/Uganda Method: Cross-sectional survey of service configuration and activity at stratified random sample of 10% of facilities inc pharmacy review (n=120) & pt focus gps PHASE 2 Objective: Evaluate costs and health outcomes Method: Longitudinal quantitative patient study (n=1337) among 12 largest facilities
  • www.kcl.ac.uk/palliative
  • www.csi.kcl.ac.uk 1. Analgesia availability1. Analgesia availability • 3/12 facilities reported availability onsite of strong opioids – In pharmacy review 2/12 had drug in pharmacy – 1/2 of these reported a stockout in previous six months • 6/12 reported weak opioids – Pharmacy review 6/12 – 3/6 stockout previous six months • 12/12 reported non-opioids – Pharmacy review 12/12 – 5/12 stockout previous six months (Pall Med In Press)
  • www.csi.kcl.ac.uk Quantitative cohortQuantitative cohort • N=1337 outpatients • Majority female (57.7-78.5%) • Modal age 30-39 • 8.3-91.6% on ART • N=1130 (84.5%) completed all time points
  • www.csi.kcl.ac.uk 2. Pain prevalence:2. Pain prevalence: 3 day POS pain3 day POS pain
  • www.csi.kcl.ac.uk MOS-HIV at T0: ‘How much bodily pain have you generally had during the past thirty days?’
  • www.csi.kcl.ac.uk MOS-HIV at T0: During the past thirty days, how much did pain interfere with your normal work?’
  • www.csi.kcl.ac.uk Analgesia receipt: KenyaAnalgesia receipt: Kenya Timepoi nt T0 T1 T2 T3 n 696 634 613 592   fac else fac else fac else fac else Non- opioids 24.9 21.6 31.9 11.5 29.7 11.6 28.9 12.3 Weak opioids 1.6 1.6 1.1 0.5 1.1 0.3 0.0 0.0 Strong opioids 1.4 1.0 1.1 0.6 0.7 0.2 0.0 0.0
  • www.csi.kcl.ac.uk Analgesia receipt: UgandaAnalgesia receipt: Uganda Timepoint T0 T1 T2 T3 n 641 615 583 538   fac else fac else fac else fac else Non-opioids 27.0 29.7 38.4 16.1 35.7 13.7 31.6 12.1 Weak opioids 2.2 2.2 1.6 1.1 0.9 0.7 0.9 0.4 Strong opioids 0.8 2.0 0.5 0.8 0.3 1.2 0.4 0.2
  • www.csi.kcl.ac.uk Pain over time: POS 3 daysPain over time: POS 3 days
  • www.csi.kcl.ac.uk MOS-HIV pain experience 30 daysMOS-HIV pain experience 30 days
  • www.csi.kcl.ac.uk MOS-HIV pain interference 30 daysMOS-HIV pain interference 30 days
  • www.csi.kcl.ac.uk Who presents with severe pain?Who presents with severe pain? • Multivariable analysis: – At any point in study those reporting severe pain were likely to have lower wealth quintile (OR 0.80 (0.74-0.88) p<0.001 – and lower functional status OR=2.86 (2.38-3.43, p<0.001) – No assoc with gender, age, education, ART, CD4
  • www.csi.kcl.ac.uk Affect of pain at baselineAffect of pain at baseline • POS pain score associated with – physical health (F=117.56, p<0.001) – mental health (F=48.87, p<0.001) • MOS HIV pain item associated with – physical health (F=1316.2, p<0.001) – mental health (F=297.8, p<0.001)
  • www.csi.kcl.ac.uk Affect of pain over time on mental health:Affect of pain over time on mental health: from baseline severe pain groupfrom baseline severe pain group
  • www.csi.kcl.ac.uk Random effects model testing qualityRandom effects model testing quality of life on mental health score over timeof life on mental health score over time Coefficient 95% CIs Z p Mental health score at T0 0.33 0.29 to 0.36 19.47 <0.001 Combined pain score -6.60 -7.21 to -6.00 -21.43 <0.001 Functional status -3.06 -3.48 to -2.62 -13.89 <0.001 Wealth quintile 0.28 0.07 to 0.50 2.57 0.010 Constant 37.90 .
  • www.csi.kcl.ac.uk Who receives analgesia?Who receives analgesia? • Weak/strong opioid at any point: – n=114 (8.5%) an opioid (n=23 morphine, n=49 codeine, n=42 both) – Not assoc with gender, age, education, CD4, wealth, ART use – Assoc with functional status (OR=1.83, 95% CI 1.40-2.38) • Non-opioid at any point: – 63.2-100% depending on site – Older people (OR 1.02 95% CI 1.00-1.04, p=0.010) and poorer physical function (i.86, 1.42-2.44 P<0.001) assoc with receipt
  • www.csi.kcl.ac.uk Pain over timePain over time Combined pain score Time point T0 T1 T2 T3 Low 22.4 34.9 43.4 51.9 Moderate 40.2 36.7 36.5 31.6 Severe 37.4 28.4 20.1 16.5 a) 687 participants (51.4%) reported severe pain on at least one of the three outcome variables in the study b) Only 11% reported consistently low pain c) 14.6% of those who reported severe pain never received a Step 1 analgesic. 9.5 % received a Step 2, and 6.3% a step 3.
  • www.csi.kcl.ac.uk What is pain?What is pain? • A complex multidimensional concept • “Pain is what the patient says it is” • Requires detailed assessment especially in HIV: – Underlying disease, infections, cancer, treatment, psychological, social and spiritual dimensions
  • www.csi.kcl.ac.uk PhysicalPhysical • “My whole body hurts and I spend a lot of time in bed; I have no energy and I am not able to get out of bed.” P6 Fac E, female, not on ART, urban area, Kenya • “In fact I don’t complain about these problems such take an example of this problem with my legs, I haven’t complained about it because I realized that they were not painful as a whole but I mostly experience pains in the joint.” P4 Fac L, female, age 42, on ART, urban area, Uganda
  • www.csi.kcl.ac.uk Psychosocial painPsychosocial pain • “One neighbour commented recently, ‘I am surprised this lame woman contracted HIV, do they also engage in sex? Funny!’ Others keep reckoning ‘That one has a soil notice, she is a moving grave... You go in for her, be ready for death.’” P1 Fac L, male, age 37, on ART, urban area, Uganda • “I have never done so because none of them has ever asked me about that. However, if they had asked I would have explained as I have done it to you.” P5 Fac H, male, age 38, not on ART, urban area
  • www.csi.kcl.ac.uk Spiritual/ existential painSpiritual/ existential pain • “One thing that has really brought grief and pain to me is that I acquired HIV at an early age before even having a child that is what hurts me.” P3 Fac K, Uganda • “My biggest worry is about my future. I have no child and my dreams are shuttered down and it hurts lots. It is an inner most pain which I can’t explain to anybody and when you see people who have died because of this disease and yet they have been on ARVs and yet they die mysteriously, I feel weighed down and lose hope most often.” P3 Fac L, male, age 36, on ART, urban area, Uganda
  • www.csi.kcl.ac.uk Staff challenges to pain reliefStaff challenges to pain relief • “What we don’t have is pain relief, we do not have strong opioids like morphine but use weak opioids like Ibrufene, diclofenac both injection we have them but some strong opioids like morphine syrup we don’t have but we have pethedine injection.” S1 Fac G, Nurse counsellor, 24 years’ experience, Uganda
  • www.csi.kcl.ac.uk • Interviewer: “Is pain managed well?” • Respondent: “Yes” • Interviewer: “What medicines do you use for pain?” • Respondent: “We have brufen” • Interviewer: “What about cases of severe pain?” • Respondent: “We don’t have any other except brufen.” S6 Fac A, Nurse counsellor, 6 years’ experience, Kenya
  • www.csi.kcl.ac.uk DiscussionDiscussion • Pain and symptom control are essential components of HIV care – WHO, UNAIDS • Highly prevalent, distressing, and affect other outcomes such as treatment efficacy and transmission • Pain can be effectively controlled using existing knowledge (STI 2005)
  • www.csi.kcl.ac.uk AssessmentAssessment • We know that – patients are not disclosing, clinicians are not asking (Justice 2001, 2012), – there is an expectation that pain should be expected and endured in HIV (Harding 2005) – ART has often refocused care and support to virological control (Selwyn 20012)
  • www.csi.kcl.ac.uk Simple assessment is possibleSimple assessment is possible • Pain relief in Africa is cheap safe and inexpensive (Logie at al 2005; 2012) • Clinicians ask about what they feel able to manage • Simple clinical tools such as POS exist and are rolled out in routine practice (“It helps me to remember to ask about the things that matter” HQLO 2008) • All clinicians need basic skills, we can refer for complex cases
  • www.csi.kcl.ac.uk Drug availabilityDrug availability • Need to have access to the WHO pain ladder • Drug availability is a challenge (Harding 2005)- but analgesics are cheap • Patients are “shopping around” for analgesic access
  • www.csi.kcl.ac.uk We can change simple things withinWe can change simple things within existing HIV clinic staffexisting HIV clinic staff • 37% scored in worst 3 responses for help or advice for their family to plan for the future • 29% “severe”, “very severe” or “overwhelming” pain • 28% had not been able to share their feelings with family or friends • 21% had never, rarely or occasionally felt at peace • 16% experienced severe, very severe or overwhelming symptoms • 12% had never, rarely or occasionally, felt that life was worthwhile • 11% had been worried a lot, most, or all of the time • In response, TOPCare Trial in Kenya & South Africa (BMC Infect Dis 2012)
  • www.csi.kcl.ac.uk Monthly analysisMonthly analysis Psychological well-being (MOS-HIV)Psychological well-being (MOS-HIV) There is evidence for initial improvement in intervention study arm, which attenuates over time. Regression coefficient for effect of study arm on MHSS data at monthly intervals throughout the study period adjusting for baseline differences in partner status, TB treatment, time since diagnosis, time on ART and baseline MHSS score Multivariate regression analysis Coefficient (CI) p value Baseline 0.25 (-0.76-1.25) 0.63 Month 1 4.12 (1.17-7.07) 0.01 Month 2 2.52 (-1.56-5.61) 0.11 Month 3 3.36 (0.30- 6.42) 0.03 Month 4 1.83 (-0.81-4.48) 0.17
  • www.csi.kcl.ac.uk Monthly analysisMonthly analysis Psychological well-being (GHQ-12)Psychological well-being (GHQ-12) Multivariate regression analysis Coefficient (CI) p value Baseline -0.22 (-1.63- 1.20) 0.76 Month 1 -1.23 (-2.46- 0.01) 0.05 Month 2 -1.12 (-2.26- 0.02) 0.05 Month 3 -0.71 (-1.86- 0.45) 0.23 Month 4 -0.65 (-1.73- 0.42) 0.23 Initial more rapid improvement at one and two month time points attenuated over time. Regression coefficient for effect of study arm on GHQ data at monthly intervals throughout the study period adjusting for partner status, TB treatment, time since diagnosis, time on ART and baseline score
  • www.csi.kcl.ac.uk Monthly analysisMonthly analysis Social well-being (interpersonal factor)Social well-being (interpersonal factor) There is evidence for improvement in the intervention arm from baseline throughout the study period Multivariate regression analysis Coefficient (CI) p value Baseline -0.82 (-0.53- 2.16) 0.23 Month 1 1.71 (0.50-2.93) 0.01 Month 2 1.79 (0.57-3.01) <0.01 Month 3 2.00 (0.68-3.33) <0.01 Month 4 1.87 (0.46-3.29) 0.01 Regression coefficient for effect of study arm on APCA African POS interpersonal factor data at monthly intervals throughout the study period adjusting for baseline difference in partner status, TB treatment, time since diagnosis, time on ART and baseline score.
  • www.csi.kcl.ac.uk Area under curve (AUC) –Area under curve (AUC) – psychological well-beingpsychological well-being Variable Regression coefficient (CI) p value Gender 0.77 (-9.46-11.01) 0.88 Age -0.21 (-0.67-0.24) 0.36 Wealth -3.84 (-7.56- -0.13) 0.04 Baseline score 19.02 (15.45-22.59) <0.001 Study arm 9.76 (2.21-17.31) 0.01 Variable Regression coefficient (CI) p value Age 0.07 (-0.10-0.24) 0.43 Wealth 1.37 (-0.02-2.76) 0.05 Baseline score -1.41 (-1.81- -1.00) <0.001 Study arm -3.26 (-6.08- -0.42) 0.02 •Multivariate regression of MOS-HIV MHSS AUC and variables which were statistically significant at bivariate analysis. •Longitudinal improvement is statistically significantly and negatively associated with wealth and positively associated with baseline score and study arm. •Multivariate regression of GHQ-12 AUC and variables which were statistically significant at bivariate analysis. •Improved psychiatric morbidity is statistically significantly and negatively associated with wealth and positively associated with baseline score and study arm*
  • www.csi.kcl.ac.uk Area under the curve (AUC) –Area under the curve (AUC) – social well-beingsocial well-being Variable Regression coefficient (CI) p value Gender -2.33 (-4.22- -0.45) 0.02 Partner status 0.04 (-0.05-0.13) 0.40 Number of children 0.22 (-0.17- 0.60) 0.27 Baseline score 1.33 (1.12-1.54) <0.001 Study arm 4.40 (2.92-5.87) <0.001 • Multivariate regression of APCA POS interpersonal factor and variables which were statistically significant at bivariate analysis. • Social wellbeing is statistically significantly and positively associated with being male, baseline score and study arm
  • www.csi.kcl.ac.uk Future directionsFuture directions • What are the patterns of – drug availability – drug access – policy facilitation/barriers • What simple interventions can enhance pain assessment? • What can improve effectiveness of management? – particularly in Home Based Care • What do we know about pain in the common HIV presentations of TB/MDRTB and cancer? (Lancet Oncol 2013; Lancet Infect Dis 2012) • How can we ensure we give equal clinical focus to the aspects of wellbeing that matter to patients and families? • How do we ensure that care and support optimises essential virological outcomes by addressing the self-report needs of patients, including pain and symptom control? • Q: What do you see as the possibilities for USAID to drive forward the reduction of suffering?