Abstract
Persons with HIV (PWH) are a population at risk for adverse sequelae of opioid use. Yet, few studies have examined correlates of chronic high risk opioid use and its impact on HIV outcomes. Trends in prescribing patterns and identification of factors that impact the use of opioid prescriptions among PWH are crucial to determine prevention and treatment interventions. This study examined electronic medical records (EMR) of patients receiving HIV care to characterize prescribing patterns and identify risk factors for chronic high risk prescription opioid use and the impact on HIV outcomes among PWH in primary care from July 1, 2016–December 31, 2017. EMR were analyzed from 8,882 patients who were predominantly male and ethnically and racially diverse with half being 50 years of age or older. The majority of the 8,744 prescriptions (98% oral and 2% transdermal preparations) given to 1,040 (12%) patients were oxycodone (71%), 8% were morphine, 7% tramadol, 4% hydrocodone, 4% codeine, 2% fentanyl, and 4% were other opioids. The number of monthly prescriptions decreased about 14% during the study period. Bivariate analyses indicated that most demographic and clinical variables were associated with receipt of any opioid prescription. After controlling for patient socio-demographic characteristics and clinical factors, the odds of receipt of any prescription were higher among patients with pain diagnoses and opioid use and mental health disorders. In addition, the odds of receipt of high average daily morphine equivalent dose (MED) prescriptions were higher for patients with pain diagnoses. Lastly, patients with substance use disorders (SUD) had an increased likelihood of detectable viral load compared to patients with no SUD, after adjusting for known covariates. Our findings show that despite opioid prescribing guidelines and monitoring systems, additional efforts are needed to prevent chronic high risk prescriptions in patients with comorbid conditions, including pain-related, mental health and substance use disorders. Evidence about the risk for chronic high risk use based on prescribing patterns could better inform pain management and opioid prescribing practices for patients receiving HIV care.
Highlights
Despite large-scale investments at the national, state and local levels to address the opioid epidemic in the U.S, including efforts to promote judicious opioid prescribing, persons with HIV (PWH) remain at risk for adverse sequelae of prescription opioid use, including chronic opioid use, dependence, and overdosage
electronic medical records (EMR) documented clinical encounters occurring between July 1, 2016–December 31, 2017 for patients who met the following study inclusion criteria we included for analysis: 1) age ≥18 years, 2) confirmed HIV diagnosis, and 3) at least one primary care visit during the study period
EMR documentation of recent substance use during primary care visits was made for approximately 30% of patients (2694/8882); 16% (454/2694) of those screened reported alcohol or drug use in the 6 months prior to a visit, representing 5% (454/8882) of all patients
Summary
While guidelines emphasize the primary role of non-pharmacologic and non-opioid pharmacologic interventions to promote safe and effective chronic pain management, PWH are more likely to have received opioid prescriptions, at higher doses, and for longer periods compared to the general population (Edelman et al, 2013; Canan et al, 2018; Merlin et al, 2018; Canan et al, 2019; Lemons et al, 2019). Jurisdictions and health care providers face challenges in ensuring effective chronic pain management while preventing and addressing opioid misuse, OUD and opioid related morbidity and among PWH
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