HIVers can be forgiven a collective snore at the media’s newest medicalobsession: the excruciatingly vague science of pain relief. Suddenly,pain afflicts the front cover of Time, The New York Times’science section and scores of TV news segments. It all began when Vioxxwas bumped off the market last December. Along with Celebrex andBextra—other Cox-2 inhibitors in the class of NSAIDs (non-steroidalanti-inflammatory drugs)—the blockbuster painkiller significantlyraised heart-attack and stroke risk. Typically missing from the pressfrenzy was any mention of what Cal Cohen, MD, research director ofBoston’s Community Research Initiative of New England, calls the“additional burdens in diagnosing and treating pain” that HIV—and itstreatments—place on patients and providers.

POZtook a look at how HIV pain experts shoulder those burdens, offering ashort list of HIVers’ most common hurts—and tips on top treatments.Plus, HIVers contribute remedies that aren’t on Doc’s formulary. “Manydrugs are useful in treating HIV-associated pains even if they’re notapproved for that purpose,” says Howard Rosner, MD, med head at LA’sCedars Sinai’s Pain Center. (You may have to go way off-label—and mixand match remedies—to keep your pain from going off the chart.) As forthe Cox-2 newsmakers, most HIV docs say they’ll prescribe ’em forheadaches and joint, muscle and back pain—but mostly for short-term use.

BIG PAIN #1:
Peripheral Neuropathy (PN)

WHYIT HURTS
: PN’s nerve damage numbs or inflicts a burning sensation onthe hands and feet of about 30 percent of HIVers. Linked to “d”nukes—d4T (Zerit), ddI (Videx) and ddC (Hivid)—it can also result fromHIV itself.
WHAT HELPS: David Simpson, MD, director of clinical
neurophysiologyat Mt. Sinai in New York City, both studies and treats HIV-related PN.He usually starts HIVers on the least invasive treatment, such asLidoderm, a lidocaine patch  for post-herpetic neuralgia (apainful shingles after-effect; see “What Else Hurts,” below). • Secondchoice: antidepressants like the new Cymbalta or anticonvulsants likethe new Lyrica (or the older Neurontin). • If you’re still hurting, Docmight try narcotics like percodan, vicodin or Tylenol with codeine.Studies show that drugs like the tricyclic antidepressant Elavil maysoothe diabetic PN, which stems from impaired bloodflow and high bloodsugar, but might not ease HIV PN, which has a different cause. • SomeHIVers swear by acupuncture; others try exercise, yoga, marijuana,hypnosis and anodyne infrared-light therapy. Ray, a 44-year-old NewYorker, says he got PN from Zerit. His doctor recommended B-12injections. “It took over a year, but that was the only thing thathelped,” he says.
WHAT’S COMING: Simpson is planning studies ofCymbalta and Lyrica (both FDA-OK’d for diabetic PN) on HIV PN. He warnsthat the body uses the same route to process Cymbalta and HIV proteaseinhibitors, so doses might need adjustment when the two are paired. •Trials of one pain-relief hope, Prosaptide, have been halted—at leastfor now—but high-dose capsaicin patches and carnitine are still in therunning. (To find a carnitine study: www.clinicaltrials.gov,312.572.4545.)

BIG PAIN #2:
Joint and Muscle Pain

WHYIT HURTS
: Along with all the aches and pains all flesh is heir to,HIVers get to experience their own HIV-related ones, caused by certaininfections, HIV arthritis, the meds or the virus itself. Two examples:Reactive arthritis (an after-effect of infection or injury) hits some50 percent of people with AIDS; osteonecrosis (bone death that causesjoint pain) affects about 4 percent. • Ariel Teitel, MD, arheumatologist at St. Vincent’s Hospital in New York City, saysosteonecrosis may link to long-term PI use. It’s also caused bysteroids that treat PCP pneumonia.
WHAT HELPS: For joint and musclepain, Teitel uses creams or patches like lidocaine. NSAIDs, Tylenol,acupuncture, massage and exercise are options. • Tom, a New York citygraphic artist positive since the early ’80s, suffers from HIV’sinflammatory joint pain. “Taken regularly, fish-oil supplements andanti-inflammatory herbs like turmeric reduce my pain,” he says.

BIG PAIN #3:
Headaches

WHYIT HURTS
: Many HIV doctors say almost all HIV drugs can cause plain oldheadaches. Pesty infections like herpes  can contribute; seriousones like CMV encephalitis and cryptococcal meningitis can createhorrid headaches. But most HIVer headaches are garden variety, notrelated to the virus.
WHATHELPS: No-brainers: aspirin, acetaminophen (Tylenol) orover-the-counter NSAIDs. But be sure to alert your doc to any new orsevere headaches—especially with a fever.

The biggest headacheto treating pain? It’s utterly subjective, varying from HIVer toHIver—as do remedies. “All treatments help a subset of people—one sizerarely fits all,” says Keith Henry, MD, a top Minneapolis HIV doc.Remember that study showing that the supplement glucosamine, touted forjoint pain, worked no better than a placebo? Don’t tell your friendswhose knees it eased. • LA’s Rosner urges relentlessly tryingtreatments—even in combination—until you find a winner. That’s whatGary, 55, positive since 1991, did. “I’d tried every med in the bookfor my PN. When I moved to New York City from Cleveland, I turned toneedles—a year of weekly acupuncture sessions finally got my feet towhere I could stand, walk and live my life.”

WHAT ELSE HURTS
Three more common HIV-related pain complaints:

NAME: Post-herpetic neuralgia (PHN) from shingles

WHY IT HURTS:PHN is a hangover of shingles—the blistering caused by herpes zostervirus—in which damaged nerve fibers continue to produce pain andburning.  

WHAT HELPS
: The topical Lidoderm patch is approved for PHN.
•Some HIVers reach for low-dose capsaicin cream, the anticonvulsantNeurontin or tricyclic antidepressants like Elavil and Pamelor. • Icingthe area continually as soon as nerves start tingling can shorten PHNbouts.


NAME: Myopathy

WHY IT HURTS: Muscle inflammation leading to cramps, stiffness, spasms and weakness. It can be a toxic side effect of HIV meds like AZT.

WHAT HELPS: Switching the offending med may be necessary.
• The amino acid carnitine may lessen the pain—and even repair muscle damage.


NAME: Psoriatic arthritis 

WHY IT HURTS:Painin the joints from inflammation caused by psoriasis, a skin rash commonin people with faulty immune systems: Your immune system attacks yourown skin; inflammation follows.

WHAT HELPS: Immunosuppressivedrugs like cyclosporine, methotrexate, Vitamin A derivative, TNFinhibitors or Amevive are used to block the out-of-whack immuneactivity. • UV light is used, too.




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