HIV Physicians and Chronic Opioid Therapy: It’s Time to Raise the Bar

Carroll, Jennifer; Colasanti, Jonathan; Lira, Marlene C.; Rı́o, Carlos del; Samet, Jeffrey H.

doi:10.1007/s10461-018-2356-2

Cited by 13 publications

(11 citation statements)

References 21 publications

(21 reference statements)

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“…Whether and how the observed immunosuppressive effects of prescribed opioids result in increased risk of other adverse outcomes, such as malignancy, merits investigation. In addition, enhanced efforts to decrease opioid prescribing(72) while promoting access to indicated treatments for pain (73) and opioid use disorder (74) in HIV treatment settings are urgently needed (75)(76)(77).…”

Section: Medication Classes Of Particular Concern Among Pwhmentioning

confidence: 99%

Polypharmacy in HIV: recent insights and future directions

Edelman¹,

Rentsch

Justice³

2020

Current Opinion in HIV and AIDS

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Purpose of review: Update findings regarding polypharmacy among people with HIV (PWH) and consider what research is most needed. Recent findings: Among PWH, polypharmacy is common, occurs in middle age, and is predominantly due to non-antiretroviral (ARV) medications. Many studies have demonstrated strong associations between polypharmacy and receipt of potentially inappropriate medications (PIMS), but few have considered actual adverse events. Falls, delirium, pneumonia, hospitalization, and mortality are associated with polypharmacy among PWH and risks remain after adjustment for severity of illness. Summary: Polypharmacy is a growing problem and mechanisms of injury likely include potentially inappropriate medications, total drug burden, known pairwise drug interactions, higher level drug interactions, drug-gene interactions, and drug-substance use interactions (alcohol, extra-medical prescription medication, and drug use). Before we can effectively design interventions, we need to use observational data to gain a better understanding of the modifiable mechanisms of injury. Because sicker individuals take more medications, analyses must account for severity of illness. Because self-report of substance use may be inaccurate, direct biomarkers such as phosphatidylethanol (PEth) for alcohol are needed. Large samples including electronic health records, genetics, accurate measures of substance use, and state of the art statistical and artificial intelligence techniques are needed to advance our understanding and inform clinical management of polypharmacy in PWH.

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Section: Medication Classes Of Particular Concern Among Pwhmentioning

confidence: 99%

Polypharmacy in HIV: recent insights and future directions

Edelman¹,

Rentsch

Justice³

2020

Current Opinion in HIV and AIDS

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“…While some of this opioid use may reflect use of prescribed opioids (i.e., provided by a clinician) for treatment of pain, findings from the Medical Monitoring Project (MMP), a national surveillance study of PWH, demonstrated that 3% of the sample had extra-medical opioid use largely driven by extra-medical prescription opioids use. 26 Given these data from the MMP combined with those from other studies 24,25,48,61 and a clinical context where opioid prescribing practices have been slowly changing, 62 our data raise concern that a substantial number of individuals are exposed to opioids and at risk for escalating opioid use. This is concerning as opioid use, and particularly a pattern of escalating use, is likely associated with greater potential harms, including falls, 63 infectious complications, 46 addiction, and overdose.…”

Section: Factors Associated With Opioid Use Trajectory Groupmentioning

confidence: 74%

“…12,14 Release of guidelines for opioid prescribing by the Centers for Disease Control and Prevention and Infectious Diseases Society of America 17,74 have stimulated more careful opioid prescribing. 62 Whether nonopioid psychoactive medication duration is a marker of symptom severity, treatment initiation or lack of response, or itself serves to promote escalating opioid use warrants further investigation. Regardless, these findings are concerning given that these medications may also be used extramedically to promote euphoria and/or recover from opioid use, 48,49 and in combination with opioids these drugs may contribute to risk of adverse events, particularly overdose.…”

Section: Factors Associated With Opioid Use Trajectory Groupmentioning

confidence: 99%

Trajectories of Self-Reported Opioid Use Among Patients With HIV Engaged in Care: Results From a National Cohort Study

Edelman

Liu

Barry

et al. 2020

JAIDS Journal of Acquired Immune Deficiency Syndromes

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Background: No prior studies have characterized long-term patterns of opioid use regardless of source or reason for use among patients with HIV (PWH). We sought to identify trajectories of selfreported opioid use and their correlates among a national sample of PWH engaged in care. Setting: Veterans Aging Cohort Study, a prospective cohort including PWH receiving care at eight US Veterans Health Administration (VA) sites. Methods: Between 2002 and 2018, we assessed past year opioid use frequency based on selfreported "prescription painkillers" and/or heroin use at baseline and follow-up. We used groupbased trajectory models to identify opioid use trajectories and multinomial logistic regression to determine baseline factors independently associated with escalating opioid use compared to stable, infrequent use. Results: Among 3,702 PWH, we identified four opioid use trajectories: 1) no lifetime use (25%); 2) stable, infrequent use (58%); 3) escalating use (7%); and 4) de-escalating use 11%). In bivariate analysis, anxiety; pain interference; prescribed opioids, benzodiazepines and gabapentinoids; and marijuana use were associated with escalating opioid group membership compared to stable, infrequent use. In multivariable analysis, illness severity, pain interference, receipt of prescribed benzodiazepine medications and marijuana use were associated with escalating opioid group membership compared to stable, infrequent use. Conclusion: Among PWH engaged in VA care, one in 15 reported escalating opioid use. Future research is needed to understand the impact of psychoactive medications and marijuana use on opioid use and whether enhanced uptake of evidence-based treatment of pain and psychiatric symptoms can prevent escalating use among PWH.

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“…7,52 However, adopting LTOT guidelines is challenging for HIV providers. 53 They report low levels of satisfaction for pain management aspects of clinical care, as well as low confidence in their abilities to treat chronic pain. 54,55 Few physicians follow standard protocol regarding assessment and may lack resources to closely monitor patients, [55][56][57][58][59][60] resulting in wide variation in opioid prescribing patterns, similar to primary care.…”

Section: Introductionmentioning

confidence: 99%

Study protocol for the targeting effective analgesia in clinics for HIV (TEACH) study – a cluster randomized controlled trial and parallel cohort to increase guideline concordant care for long-term opioid therapy among people living with HIV

Lira

Tsui

Liebschutz

et al. 2019

HIV Research & Clinical Practice

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Background: People living with HIV (PLWH) frequently experience chronic pain and receive long-term opioid therapy (LTOT). Adherence to opioid prescribing guidelines among their providers is suboptimal. Objective: This paper describes the protocol of a cluster randomized trial, Targeting Effective Analgesia in Clinics for HIV (TEACH), which tested a collaborative care intervention to increase guideline-concordant care for LTOT among PLWH. Methods: HIV physicians and advanced practice providers (n=41) were recruited from September 2015-December 2016 from two HIV clinics in Boston and Atlanta. Patients receiving LTOT from participating providers were enrolled through a waiver of informed consent (n=187). After baseline assessment, providers were randomized to the control group or the year-long TEACH intervention involving: 1) a nurse care manager and electronic registry to assist with patient management; 2) opioid education and academic detailing; and 3) facilitated access to addiction specialists. Randomization was stratified by site and LTOT patient volume. Primary outcomes (≥2 urine drug tests, early refills, provider satisfaction) were collected at 12-months. In parallel, PLWH receiving LTOT (n=170) were recruited into a longitudinal cohort at both clinics and underwent baseline and 12-month assessments. Secondary outcomes were obtained through patient self-report among participants enrolled in both the cohort and the RCT (n=117). Conclusion: TEACH will report the effects of an intervention on opioid prescribing for chronic pain on both provider and patient-level outcomes. The results may inform delivery of care for PLWH on LTOT for chronic pain at a time when opioid practices are being questioned in the US.

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HIV Physicians and Chronic Opioid Therapy: It’s Time to Raise the Bar

Cited by 13 publications

References 21 publications

Polypharmacy in HIV: recent insights and future directions

Polypharmacy in HIV: recent insights and future directions

Trajectories of Self-Reported Opioid Use Among Patients With HIV Engaged in Care: Results From a National Cohort Study

Study protocol for the targeting effective analgesia in clinics for HIV (TEACH) study – a cluster randomized controlled trial and parallel cohort to increase guideline concordant care for long-term opioid therapy among people living with HIV

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