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Becker WC, Gordon K, Edelman EJ, Kerns RD, Crystal S, Dziura JD, Fiellin LE, Gordon AJ, Goulet JL, Justice AC, Fiellin DA. Trends in Any and High-Dose Opioid Analgesic Receipt Among Aging Patients With and Without HIV. AIDS Behav 2016; 20:679-86. [PMID: 26384973 PMCID: PMC5006945 DOI: 10.1007/s10461-015-1197-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Harms of opioid analgesics, especially high-dose therapy among individuals with comorbidities and older age, are increasingly recognized. However, trends in opioid receipt among HIV-infected patients are not well characterized. We examined trends, from 1999 to 2010, in any and high-dose (≥120 mg/day) opioid receipt among patients with and without HIV, by age strata, controlling for demographic and clinical correlates. Of 127,216 patients, 64 % received at least one opioid prescription. Opioid receipt increased substantially among HIV-infected and uninfected patients over the study; high-dose therapy was more prevalent among HIV-infected patients. Trends in high-dose receipt stratified by three age groups revealed an increasing trend in each age strata, higher among HIV-infected patients. Correlates of any opioid receipt included HIV, PTSD and major depression. Correlates of high-dose receipt included HIV, PTSD, major depression and drug use disorders. These findings suggest a need for appropriate balance of risks and benefits, especially as these populations age.
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Affiliation(s)
- William C Becker
- Internal Medicine, West Haven VA Medical Center, VA Connecticut Healthcare System, Mail Stop 151B, 950 Campbell Avenue, West Haven, CT, 06516, USA.
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
| | - Kirsha Gordon
- Internal Medicine, West Haven VA Medical Center, VA Connecticut Healthcare System, Mail Stop 151B, 950 Campbell Avenue, West Haven, CT, 06516, USA
| | - E Jennifer Edelman
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Robert D Kerns
- Psychology, VA Connecticut Healthcare System, West Haven, CT, USA
- Psychology, Yale University School of Medicine, New Haven, CT, USA
| | - Stephen Crystal
- Center for Health Services Research, Rutgers University, New Brunswick, NJ, USA
| | - James D Dziura
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Lynn E Fiellin
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Adam J Gordon
- University of Pittsburgh and Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Joseph L Goulet
- Psychology, VA Connecticut Healthcare System, West Haven, CT, USA
- Psychology, Yale University School of Medicine, New Haven, CT, USA
| | - Amy C Justice
- Internal Medicine, West Haven VA Medical Center, VA Connecticut Healthcare System, Mail Stop 151B, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - David A Fiellin
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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Binswanger IA, Koester S, Mueller SR, Gardner EM, Goddard K, Glanz JM. Overdose Education and Naloxone for Patients Prescribed Opioids in Primary Care: A Qualitative Study of Primary Care Staff. J Gen Intern Med 2015; 30:1837-44. [PMID: 26055224 PMCID: PMC4636555 DOI: 10.1007/s11606-015-3394-3] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The rate of fatal unintentional pharmaceutical opioid poisonings has increased substantially since the late 1990s. Naloxone is an effective opioid antidote that can be prescribed to patients for bystander use in the event of an overdose. Primary care clinics represent settings in which large populations of patients prescribed opioids could be reached for overdose education and naloxone prescription. OBJECTIVE Our aim was to investigate the knowledge, attitudes and beliefs about overdose education and naloxone prescription among clinical staff in primary care. DESIGN This was a qualitative study using focus groups to elucidate both clinic-level and provider-level barriers and facilitators. SETTING Ten primary care internal medicine, family medicine and infectious disease/HIV practices in three large Colorado health systems. METHODS A focus group guide was developed based on behavioral theory. Focus group transcripts were coded for manifest and latent meaning, and analyzed for themes using a recursive approach that included inductive and deductive analysis. RESULTS Themes emerged in four content areas related to overdose education and naloxone prescription: knowledge, barriers, benefits and facilitators. Clinical staff (N = 56) demonstrated substantial knowledge gaps about naloxone and its use in outpatient settings. They expressed uncertainty about who to prescribe naloxone to, and identified a range of logistical barriers to its use in practice. Staff also described fears about offending patients and concerns about increased risk behaviors in patients prescribed naloxone. When considering naloxone, some providers reflected critically and with discomfort on their own opioid prescribing. These barriers were balanced by beliefs that prescribing naloxone could prevent death and result in safer opioid use behaviors. LIMITATIONS Findings from these qualitative focus groups may not be generalizable to other settings. CONCLUSION In addition to evidence gaps, logistical and attitudinal barriers will need to be addressed to enhance uptake of overdose education and naloxone prescription for patients prescribed opioids for pain.
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Affiliation(s)
- Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, P.O Box 378066, Denver, CO, 80237-8066, USA. .,Division of General Internal Medicine, University of Colorado Denver School of Medicine, Aurora, CO, USA. .,Denver Health and Hospital Authority, Denver, CO, USA.
| | - Stephen Koester
- Department of Anthropology, University of Colorado Denver, Denver, CO, USA.,Department of Health and Behavioral Sciences, University of Colorado Denver, Denver, CO, USA
| | - Shane R Mueller
- Institute for Health Research, Kaiser Permanente Colorado, P.O Box 378066, Denver, CO, 80237-8066, USA.,Division of General Internal Medicine, University of Colorado Denver School of Medicine, Aurora, CO, USA.,Department of Health and Behavioral Sciences, University of Colorado Denver, Denver, CO, USA
| | | | - Kristin Goddard
- Institute for Health Research, Kaiser Permanente Colorado, P.O Box 378066, Denver, CO, 80237-8066, USA
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, P.O Box 378066, Denver, CO, 80237-8066, USA.,Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
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Uebelacker LA, Weisberg RB, Herman DS, Bailey GL, Pinkston-Camp MM, Stein MD. Chronic Pain in HIV-Infected Patients: Relationship to Depression, Substance Use, and Mental Health and Pain Treatment. PAIN MEDICINE 2015; 16:1870-81. [PMID: 26119642 DOI: 10.1111/pme.12799] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE As the advent of highly active antiretroviral therapy, HIV has become a chronic disease for most individuals in developed countries. Chronic pain is a common occurrence for HIV-infected patients and has an impact on quality of life and antiretroviral adherence. The objective of this study was to examine relationships between chronic pain and depression, substance use, mental health treatment, and pain treatment in HIV-infected patients. DESIGN Cross-sectional study. SETTING Three primary care sites where HIV+ patients receive treatment. SUBJECTS Two hundred and thirty eight HIV-infected primary care patients. METHODS We collected self-report and chart-review information on demographics, HIV clinical status, chronic pain, depression, substance use, mental health treatment, and pain treatment. We collected data between October 2012 and November 2013. RESULTS Of the patients enrolled in this study, 107 reported no chronic pain, 24 reported mild chronic pain, and 107 reported moderate-severe chronic pain. Participants in the moderate-severe pain group were more likely to have high levels of depressive symptoms than those in the no chronic pain group. Similarly, there was a significant relationship between chronic pain status and interference with life activities due to pain. Participants with moderate-severe chronic pain were more likely to be taking an antidepressant medication than those with mild chronic pain, and more likely to be taking a prescription opioid than the other two groups. We did not find a significant relationship between problematic substance use and chronic pain status. CONCLUSIONS Despite pharmacologic treatment, moderate-severe chronic pain and elevated depression symptoms are common among HIV-infected patients and frequently co-occur.
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Affiliation(s)
- Lisa A Uebelacker
- Butler Hospital, Providence, Rhode Island.,Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Risa B Weisberg
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island.,Boston VA Healthcare System, Boston, Massachusetts
| | - Debra S Herman
- Butler Hospital, Providence, Rhode Island.,Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Genie L Bailey
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island.,Stanley Street Treatment and Resources, Fall River, Massachusetts
| | - Megan M Pinkston-Camp
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island.,The Immunology Center, The Miriam Hospital, Providence, Rhode Island, USA
| | - Michael D Stein
- Butler Hospital, Providence, Rhode Island.,Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island.,The Immunology Center, The Miriam Hospital, Providence, Rhode Island, USA
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Merlin JS, Walcott M, Ritchie C, Herbey I, Kertesz SG, Chamot E, Saag M, Turan JM. 'Two pains together': patient perspectives on psychological aspects of chronic pain while living with HIV. PLoS One 2014; 9:e111765. [PMID: 25365306 PMCID: PMC4218809 DOI: 10.1371/journal.pone.0111765] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 09/14/2014] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE Chronic pain is common in HIV-infected individuals. Understanding HIV-infected patients' chronic pain experience not just from a biological, but also from a psychological perspective, is a critical first step toward improving care for this population. Our objective was to explore HIV-infected patients' perspectives on psychological aspects of chronic pain using in-depth qualitative interviews. METHODS Investigators engaged in an iterative process of independent and group coding until theme saturation was reached. RESULTS Of the 25 patients with chronic pain interviewed, 20 were male, 15 were younger than age 50, and 15 were African-American. Key themes that emerged included the close relationship between mood and pain; mood and pain in the context of living with HIV; use of alcohol/drugs to self-medicate for pain; and the challenge of receiving prescription pain medications while dealing with substance use disorders. CONCLUSIONS The results suggest that psychological approaches to chronic pain treatment may be well received by HIV-infected patients.
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Affiliation(s)
- Jessica S. Merlin
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Melonie Walcott
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Christine Ritchie
- Division of Geriatrics, Department of Medicine, University of California at San Francisco, San Francisco, California, United States of America
- Jewish Home of San Francisco Center for Research on Aging, San Francisco, California, United States of America
| | - Ivan Herbey
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Stefan G. Kertesz
- Birmingham VA Medical Center, Birmingham, Alabama, United States of America
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Eric Chamot
- School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Michael Saag
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Janet M. Turan
- School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
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Merlin JS, Turan J, Herbey I, Westfall AO, Starrels JL, Kertesz SG, Saag M, Ritchie CS. Aberrant drug-related behaviors: a qualitative analysis of medical record documentation in patients referred to an HIV/chronic pain clinic. PAIN MEDICINE (MALDEN, MASS.) 2014; 15:1724-33. [PMID: 25138608 PMCID: PMC4208944 DOI: 10.1111/pme.12533] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Due to rising rates of opioid addiction and overdose among individuals on chronic opioid therapy, aberrant drug-related behaviors (ADRBs) are an important and challenging issue. Our objective was to qualitatively investigate the documentation of ADRBs in the medical record. METHODS Manually abstracted provider notes from an HIV primary care clinic were analyzed using content analysis methods. RESULTS Categories of ADRBs identified included patients requesting opioids, obtaining nonprescribed opioids, and becoming emotional about opioids. We also identified several types of provider language used when documenting ADRBs, including purely descriptive language and emotional language such as labeling, frustration, and concern, and responses such as setting conditions for opioid prescription and action-oriented language. CONCLUSIONS The impact of including emotional language in the medical record is unknown. Development of instruments that can be used to facilitate ADRB documentation, as well as evidence-based approaches to addressing ADRBs, is needed.
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Affiliation(s)
- Jessica S. Merlin
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Janet Turan
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Ivan Herbey
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Andrew O. Westfall
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Joanna L. Starrels
- Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Stefan G. Kertesz
- Birmingham VA Medical Center
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Michael Saag
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Christine S. Ritchie
- San Francisco VA Medical Center, San Francisco, CA
- Jewish Home of San Francisco Center for Research on Aging, San Francisco, CA
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Qian HZ, Mitchell VJ, Bebawy S, Cassell H, Perez G, McGowan CC, Sterling TR, Vermund SH, D'Aquila R, Hulgan T. Current drug use and lack of HIV virologic suppression: point-of-care urine drug screen versus self-report. BMC Infect Dis 2014; 14:508. [PMID: 25234368 PMCID: PMC4175271 DOI: 10.1186/1471-2334-14-508] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 09/15/2014] [Indexed: 12/29/2022] Open
Abstract
Background There have been inconsistent findings on the association between current drug use and HIV disease progression and virologic suppression. Drug use was often measured using self-report of historical use. Objective measurement of current drug use is preferred. Methods In this cross-sectional study, we assessed drug use through Computer-Assisted Self Interviews (CASI) and point-of-care urine drug screen (UDS) among 225 HIV-infected patients, and evaluated the association between current drug use and virologic suppression. Results About half (54%) of participants had a positive UDS, with a lower self-reported rate by CASI (42%) (Kappa score = 0.59). By UDS, 36.0% were positive for marijuana, 25.8% for cocaine, 7.6% for opiates, and 2.2% for methamphetamine or amphetamine. Factors associated with virologic suppression (plasma HIV RNA <50 copies/mL) were Caucasian race (P = 0.03), higher CD4 count (P < 0.01), current use of antiretroviral therapy (ART) (P < 0.01), and a negative UDS (P < 0.01). Among 178 current ART users, a positive UDS remained significantly associated with lower likelihood of virologic suppression (P = 0.04). Conclusions UDS had good agreement with CASI in detecting frequently used drugs such as marijuana and cocaine. UDS at routine clinic visits may provide “real-time” prognostic information to optimize management.
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Affiliation(s)
- Han-Zhu Qian
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, USA.
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57
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Gaither JR, Goulet JL, Becker WC, Crystal S, Edelman EJ, Gordon K, Kerns RD, Rimland D, Skanderson M, Weisberg DF, Justice AC, Fiellin DA. Guideline-concordant management of opioid therapy among human immunodeficiency virus (HIV)-infected and uninfected veterans. THE JOURNAL OF PAIN 2014; 15:1130-1140. [PMID: 25152300 DOI: 10.1016/j.jpain.2014.08.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 08/04/2014] [Accepted: 08/14/2014] [Indexed: 12/11/2022]
Abstract
UNLABELLED Whether patients receive guideline-concordant opioid therapy (OT) is largely unknown and may vary based on provider and patient characteristics. We assessed the extent to which human immunodeficiency virus (HIV)-infected and uninfected patients initiating long-term (≥ 90 days) OT received care concordant with American Pain Society/American Academy of Pain Medicine and Department of Veterans Affairs/Department of Defense guidelines by measuring receipt of 17 indicators during the first 6 months of OT. Of 20,753 patients, HIV-infected patients (n = 6,604) were more likely than uninfected patients to receive a primary care provider visit within 1 month (52.0% vs 30.9%) and 6 months (90.7% vs 73.7%) and urine drug tests within 1 month (14.8% vs 11.5%) and 6 months (19.5% vs 15.4%; all P < .001). HIV-infected patients were also more likely to receive OT concurrent with sedatives (24.6% vs 19.6%) and a current substance use disorder (21.6% vs 17.2%). Among both patient groups, only modest changes in guideline concordance were observed over time: urine drug tests and OT concurrent with current substance use disorders increased, whereas sedative coprescriptions decreased (all Ps for trend < .001). Over a 10-year period, on average, patients received no more than 40% of recommended care. OT guideline-concordant care is rare in primary care, varies by patient/provider characteristics, and has undergone few changes over time. PERSPECTIVE The promulgation of OT clinical guidelines has not resulted in substantive changes over time in OT management, which falls well short of the standard recommended by leading medical societies. Strategies are needed to increase the provision of OT guideline-concordant care for all patients.
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Affiliation(s)
- Julie R Gaither
- Yale School of Public Health, Yale University, New Haven, Connecticut; Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, Connecticut.
| | - Joseph L Goulet
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - William C Becker
- VA Connecticut Healthcare System, West Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Stephen Crystal
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, New Jersey
| | - E Jennifer Edelman
- Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Kirsha Gordon
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Robert D Kerns
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - David Rimland
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia; Atlanta VA Medical Center, Decatur, Georgia
| | | | - Daniel F Weisberg
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Amy C Justice
- Yale School of Public Health, Yale University, New Haven, Connecticut; Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - David A Fiellin
- Yale School of Public Health, Yale University, New Haven, Connecticut; Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
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Abstract
SUMMARY Opioids are very useful analgesics but reports of abuse, addiction and occasionally death have led to an increase in scrutiny, particularly for chronic opioid therapy. The development of effective antiretroviral therapy has changed the focus of treatment of people living with HIV from palliative care to the management of a chronic disease. It is appropriate, therefore, to review the issues around opioid prescribing in HIV in light of this and recent research, and to review the guidance available. This review briefly examines the epidemiology of pain in people living with HIV and then the use and issues around strong opioid prescribing in this group.
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Affiliation(s)
- Sarah Cox
- Chelsea & Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK.
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Pergolizzi JV, Ben-Joseph R, Chang CL, Hess G. Predicting medication persistence to buprenorphine transdermal system. Pain Pract 2014; 15:140-9. [PMID: 24444055 DOI: 10.1111/papr.12155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 11/07/2013] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Persistence, the duration a patient remains on therapy, in chronic, symptomatic conditions plays an important role in therapy effectiveness. Understanding the duration and patient factors associated with prescribed medication persistence is, therefore, an important step toward better treatment and health outcomes for patients. In the following study, an analysis of such factors associated with buprenorphine transdermal system (BTDS) persistence was conducted utilizing a large US private practitioner and pharmacy claims database and is herein reported. METHODS Patients aged ≥ 18 years initiating BTDS during January 1, 2011-November 30, 2011 were identified in the IMS Private Practitioner Medical Claims and Pharmacy Claims databases. An index date was defined as the first prescription of BTDS during the studied interval. During the preindex period, Charlson Comorbidity Index (CCI), chronic pain-related conditions, and prior medication use were assessed. Concomitant medications and various treatment patterns (eg, last dose strength and dose adjustments) were assessed in the postindex 6-month period. Persistence was measured as the duration of BTDS from initiation to the 1st >28-day refill gap in the postindex 6-month period. Descriptive statistical and survival analysis was used to assess the predictors of BTDS persistence. RESULTS During the study period, 10,457 patients newly treated with BTDS were identified. Patients' mean (± SD) age was 54.5 (± 15.2) years; 69.9% were women, and the mean (± SD) CCI was 1 (± 1.4). Utilizing a hierarchical approach, patients were separated into different cohorts based on the initial analgesic prescription identified during postindex period with 91.7%, 34.7%, and 59.0% of the patients using opioids, NSAIDs and adjuvant analgesics, respectively. Multivariate regression analyses showed that patients with prior opioid and adjuvant analgesic use were 21% and 5% less likely to discontinue BTDS (P < 0.05), respectively, as compared to patients not using these agents. Patients with concomitant use of adjuvant analgesics were 15% less likely to discontinue therapy (P < 0.05) as compared to patients without concomitant use of these agents. Long-term BTDS persistence was also observed in patients who had a dose change or a last dose strength >5 mcg/hour. Sensitivity analyses for those with 30-day prior opioid use and patients with ≥ 2 claims of BTDS confirmed these findings. CONCLUSIONS Prior and concomitant use of adjuvant analgesics, prior use of opioids, and dose adjustments were associated with significantly longer persistence among patients initiating BTDS. The results suggest that patients are less likely to discontinue BTDS early if practitioners account for prior treatment history and dose titration.
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Affiliation(s)
- Joseph V Pergolizzi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A.; Temple University School of Medicine, Philadelphia, Pennsylvania, U.S.A.; Naples Anesthesia and Pain Associates, Naples, Florida, U.S.A
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60
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Chang SL, Connaghan KP, Wei Y, Li MD. NeuroHIV and use of addictive substances. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2014; 118:403-40. [PMID: 25175871 DOI: 10.1016/b978-0-12-801284-0.00013-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In the past three decades, substance abuse has been identified as a key comorbidity of human immunodeficiency virus-1 (HIV-1) infection. Many studies have found that the use and abuse of addictive substances hastens the progression of HIV-1 infection and HIV-associated neurocognitive disorders. Advances in highly active antiretroviral therapy (HAART) in the mid-1990s have been successful in limiting the HIV-1 viral load and maintaining a relatively healthy immune response, allowing the life expectancy of patients infected with HIV to approach that of the general population. However, even with HAART, HIV-1 viral proteins are still expressed and eradication of the virus, particularly in the brain, the key reservoir organ, does not occur. In the post-HAART era, the clinical challenge in the treatment of HIV infection is inflammation of the central nervous system (CNS) and its subsequent neurological disorders. To date, various explicit and implicit connections have been identified between the neuronal circuitry involved in immune responses and brain regions affected by and implicated in substance abuse. This chapter discusses past and current medical uses of prototypical substances of abuse, including morphine, alcohol, cocaine, methamphetamine, marijuana, and nicotine, and the evidence that systemic infections, particularly HIV-1 infection, cause neurological dysfunction as a result of inflammation in the CNS, which can increase the risk of substance abuse.
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Affiliation(s)
- Sulie L Chang
- Institute of NeuroImmune Pharmacology, Seton Hall University, South Orange, New Jersey, USA; Department of Biological Sciences, Seton Hall University, South Orange, New Jersey, USA.
| | - Kaitlyn P Connaghan
- Institute of NeuroImmune Pharmacology, Seton Hall University, South Orange, New Jersey, USA
| | - Yufeng Wei
- Institute of NeuroImmune Pharmacology, Seton Hall University, South Orange, New Jersey, USA
| | - Ming D Li
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, Virginia, USA
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Edelman EJ, Gordon KS, Glover J, McNicholl IR, Fiellin DA, Justice AC. The next therapeutic challenge in HIV: polypharmacy. Drugs Aging 2013; 30:613-28. [PMID: 23740523 PMCID: PMC3715685 DOI: 10.1007/s40266-013-0093-9] [Citation(s) in RCA: 167] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
With the adoption of combination antiretroviral therapy (ART), most HIV-infected individuals in care are on five or more medications and at risk of harm from polypharmacy, a risk that likely increases with number of medications, age, and physiologic frailty. Established harms of polypharmacy include decreased medication adherence and increased serious adverse drug events, including organ system injury, hospitalization, geriatric syndromes (falls, fractures, and cognitive decline) and mortality. The literature on polypharmacy among those with HIV infection is limited, and the literature on polypharmacy among non-HIV patients requires adaptation to the special issues facing those on chronic ART. First, those aging with HIV infection often initiate ART in their 3rd or 4th decade of life and are expected to remain on ART for the rest of their lives. Second, those with HIV may be at higher risk for age-associated comorbid disease, further increasing their risk of polypharmacy. Third, those with HIV may have an enhanced susceptibility to harm from polypharmacy due to decreased organ system reserve, chronic inflammation, and ongoing immune dysfunction. Finally, because ART is life-extending, nonadherence to ART is particularly concerning. After reviewing the relevant literature, we propose an adapted framework with which to address polypharmacy among those on lifelong ART and suggest areas for future work.
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Affiliation(s)
| | | | | | - Ian R. McNicholl
- />UCSF Positive Health Program at San Francisco General Hospital, University of California, San Francisco, CA USA
| | - David A. Fiellin
- />Yale University Schools of Medicine and Public Health, New Haven, CT USA
| | - Amy C. Justice
- />Yale University Schools of Medicine and Public Health, New Haven, CT USA
- />VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516 USA
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Receipt of opioid analgesics by HIV-infected and uninfected patients. J Gen Intern Med 2013; 28:82-90. [PMID: 22895747 PMCID: PMC3539026 DOI: 10.1007/s11606-012-2189-z] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Revised: 07/02/2012] [Accepted: 07/23/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND Opioids are increasingly prescribed, but there are limited data on opioid receipt by HIV status. OBJECTIVES To describe patterns of opioid receipt by HIV status and the relationship between HIV status and receiving any, high-dose, and long-term opioids. DESIGN Cross-sectional analysis of the Veterans Aging Cohort Study. PARTICIPANTS HIV-infected (HIV+) patients receiving Veterans Health Administration care, and uninfected matched controls. MAIN MEASURES Pain-related diagnoses were determined using ICD-9 codes. Any opioid receipt was defined as at least one opioid prescription; high-dose was defined as an average daily dose ≥ 120 mg of morphine equivalents; long-term opioids was defined as ≥ 90 consecutive days, allowing a 30 day refill gap. Multivariable models were used to assess the relationship between HIV infection and the three outcomes. KEY RESULTS Among the HIV+ (n = 23,651) and uninfected (n = 55,097) patients, 31 % of HIV+ and 28 % of uninfected (p < 0.001) received opioids. Among patients receiving opioids, HIV+ patients were more likely to have an acute pain diagnosis (7 % vs. 4 %), but less likely to have a chronic pain diagnosis (53 % vs. 69 %). HIV+ patients received a higher mean daily morphine equivalent dose than uninfected patients (41 mg vs. 37 mg, p = 0.001) and were more likely to receive high-dose opioids (6 % vs. 5 %, p < 0.001). HIV+ patients received fewer days of opioids than uninfected patients (median 44 vs. 60, p < 0.001), and were less likely to receive long-term opioids (31 % vs. 34 %, p < 0.001). In multivariable analysis, HIV+ status was associated with receipt of any opioids (AOR 1.40, 95 % CI 1.35, 1.46) and high-dose opioids (AOR 1.22, 95 % CI 1.07, 1.39), but not long-term opioids (AOR 0.94, 95 % CI 0.88, 1.01). CONCLUSIONS Patients with HIV infection are more likely to be prescribed opioids than uninfected individuals, and there is a variable association with pain diagnoses. Efforts to standardize approaches to pain management may be warranted in this highly complex and vulnerable patient population.
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Abstract
Substance use disorders are a large public health problem in the United States. Over the past decade, there has been a trend of increased prescription drug misuse, morbidity, and mortality related to prescription opioids. For providers who treat pain, this has led to clinical dilemmas as the newly appreciated risks must be balanced with the benefits of treatment, particularly in patients with known substance use disorders. Acute, chronic, and palliative each present distinct issues in pain treatment. A best practices model of pain treatment, including risk stratification and integrative treatment, may provide the best prospect for safe and effective treatment.
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Affiliation(s)
- Daniel Krashin
- Anesthesiology and Pain Medicine, University of Washington Medical Center, Box 354692, 1959 NE Pacific, Seattle, WA 98195, USA.
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Robinson-Papp J, Elliott K, Simpson DM, Morgello S. Problematic prescription opioid use in an HIV-infected cohort: the importance of universal toxicology testing. J Acquir Immune Defic Syndr 2012; 61:187-93. [PMID: 22820804 PMCID: PMC3458135 DOI: 10.1097/qai.0b013e3182683c98] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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