Aberrant behaviors with prescription opioids and problem drug use history in a community-based cohort of HIV-infected individuals

Housing status and the health of people living with HIV/AIDS

Individuals who are homeless or living in marginal conditions have an elevated burden of infection with HIV. Existing research suggests the HIV/AIDS pandemic in resource-rich settings is increasingly concentrated among members of vulnerable and marginalized populations, including homeless/marginally-housed individuals, who have yet to benefit fully from recent advances in highly-active antiretroviral therapy (HAART). We reviewed the scientific evidence investigating the relationships between inferior housing and the health status, HAART access and adherence and HIV treatment outcomes of people living with HIV/AIDS (PLWHA.) Studies indicate being homeless/marginally-housed is common among PLWHA and associated with poorer levels of HAART access and sub-optimal treatment outcomes. Among homeless/marginally-housed PLWHA, determinants of poorer HAART access/adherence or treatment outcomes include depression, illicit drug use, and medication insurance status. Future research should consider possible social- and structural-level determinants of HAART access and HV treatment outcomes that have been shown to increase vulnerability to HIV infection among homeless/marginally-housed individuals. As evidence indicates homeless/marginally-housed PLWHA with adequate levels of adherence can benefit from HAART at similar rates to housed PLWHA, and given the individual and community benefits of expanding HAART use, interventions to identify HIV-seropositive homeless/marginally-housed individuals, and engage them in HIV care including comprehensive support for HAART adherence are urgently needed.

Characteristics of an ambulatory palliative care clinic for HIV-infected patients

BACKGROUND

Many HIV-infected patients in the current treatment era have substantial symptom burden, but few HIV palliative care clinics have been described. Our objective was to describe the University of Alabama at Birmingham (UAB) HIV palliative care clinic (HPCC) and compare it to the overall HIV clinic.

METHODS

We conducted a chart review of patients referred to the HPCC between April 2008 and June 2011. We evaluated the reason for referral and other issues addressed during palliative care visits. Patient Reported Outcome (PRO) data was used to assess depression (PHQ-9), anxiety (PHQ-A), and substance abuse (ASSIST).

RESULTS

Among 124 patients, mean age was 44 (range 27-64), and median CD4 count was 352 cells/mm(3) (IQR 209-639). Depression (43, 35%), anxiety (40, 32%), and current 8 (7%) or prior 68 (56%) substance abuse occurred at higher rates than in the overall HIV clinic (p<0.05). Pain was the most common reason for referral (118, 95%); most was chronic (113, 90%) and included back pain (26, 21%) and neuropathic pain (15, 12%). Other problems commonly addressed by the palliative team included nonpain symptoms such as depression (39, 48%) and anxiety (17, 21%), insomnia (25, 30%), and constipation (26, 32%).

CONCLUSIONS

This is the first description of a palliative care clinic embedded within an HIV primary care clinic in a developed country that sees patients at all stages of illness. Chronic pain and nonpain symptom management in patients with psychiatric and substance abuse comorbidities are important components of ambulatory palliative care for HIV-infected patients.

Problematic prescription opioid use in an HIV-infected cohort: the importance of universal toxicology testing

BACKGROUND

Providers treating chronic pain must attempt to relieve suffering, while minimizing problematic prescription opioid use, including addiction and diversion. Previously described risk factors for problematic use include history of substance use, younger age, male sex, psychiatric comorbidity, and lower education level.

METHODS

We examined these risk factors in HIV-infected individuals, using cross-sectional and longitudinal data from the Manhattan HIV Brain Bank. Problematic use was defined as illicit substance use (documented by urine toxicology or structured psychiatric interview), while receiving prescription opioids.

RESULTS

Among 173 participants prescribed opioids, 62% had problematic use, the majority of which was discovered by urine toxicology. Problematic use was associated with past substance use, current psychiatric disorder, and poorer adherence to antiretrovirals. However, when participants without problematic use at baseline were followed longitudinally, these factors were not predictive. Furthermore, the cumulative incidence of problematic use behaviors was no greater than in a similar group of participants who were not prescribed opioids.

CONCLUSIONS

Problematic prescription opioid use is common among HIV-infected individuals and is associated with history of substance use, current psychiatric disorder, and poor adherence to antiretrovirals. However, these factors do not predict future problematic use in those who are not currently using illicit substances, and the prescription of an opioid does not seem to predispose patients toward a future substance use disorder. Rather than attempting to assess risk for problematic prescription opioid use in HIV-infected individuals, we recommend baseline and follow-up urine toxicology.

Attitudinal Barriers to Analgesic Use among Patients with Substance Use Disorders

Attitudinal barriers towards analgesic use among primary care patients with chronic pain and substance use disorders (SUDs) are not well understood. We evaluated the prevalence of moderate to significant attitudinal barriers to analgesic use among 597 primary care patients with chronic pain and current analgesic use with 3 subscales from the Barriers Questionaire II: concern about side effects, fear of addiction, and worry about reporting pain to physicians. Concern about side effects was a greater barrier for those with opioid use disorders (OUDs) and non-opioid SUDs than for those with no SUD (OR (95% CI): 2.30 (1.44–3.68), P < 0.001 and 1.64 (1.02–2.65), P = 0.041, resp.). Fear of addiction was a greater barrier for those with OUDs as compared to those with non-opioid SUDs (OR (95% CI): 2.12 (1.04–4.30), P = 0.038) and no SUD (OR (95% CI): 2.69 (1.44–5.03), P = 0.002). Conversely, participants with non-opioid SUDs reported lower levels of worry about reporting pain to physicians than those with no SUD (OR (95% CI): 0.43 (0.24–0.76), P = 0.004). Participants with OUDs reported higher levels of worry about reporting pain than those with non-opioid SUDs (OR (95% CI): 1.91 (1.01–3.60), P = 0.045). Concerns about side effects and fear of addiction can be barriers to analgesic use, moreso for people with SUDs and OUDs.