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Samet JH, Tsui JI, Cheng DM, Liebschutz JM, Lira MC, Walley AY, Colasanti JA, Forman LS, Root C, Shanahan CW, Sullivan MM, Bridden CL, Abrams C, Harris C, Outlaw K, Armstrong WS, del Rio C. Improving the Delivery of Chronic Opioid Therapy Among People Living With Human Immunodeficiency Virus: A Cluster Randomized Clinical Trial. Clin Infect Dis 2021; 73:e2052-e2058. [PMID: 32697847 PMCID: PMC8492355 DOI: 10.1093/cid/ciaa1025] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/16/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Chronic pain is prevalent among people living with human immunodeficiency virus (PLWH); managing pain with chronic opioid therapy (COT) is common. Human immunodeficiency virus (HIV) providers often diverge from prescribing guidelines. METHODS This 2-arm, unblinded, cluster-randomized clinical trial assessed whether the Targeting Effective Analgesia in Clinics for HIV (TEACH) intervention improves guideline-concordant care compared to usual care for PLWH on COT. The trial was implemented from 2015 to 2018 with 12-month follow-up at safety-net hospital-based HIV clinics in Boston and Atlanta. We enrolled 41 providers and their 187 patients on COT. Prescribers were randomized 1:1 to either a 12-month intervention consisting of a nurse care manager with an interactive electronic registry, opioid education, academic detailing, and access to addiction specialists or a control condition consisting of usual care. Two primary outcomes were assessed through electronic medical records: ≥2 urine drug tests and any early COT refills by 12 months. Other outcomes included possible adverse consequences. RESULTS At 12 months, the TEACH intervention arm had higher odds of ≥2 urine drug tests than the usual care arm (71% vs 20%; adjusted odds ratio [AOR], 13.38 [95% confidence interval {CI}, 5.85-30.60]; P < .0001). We did not detect a statistically significant difference in early refills (22% vs 30%; AOR, 0.55 [95% CI, .26-1.15]; P = .11), pain severity (6.30 vs 5.76; adjusted mean difference, 0.10 [95% CI, -1.56 to 1.75]; P = .91), or HIV viral load suppression (86.9% vs 82.1%; AOR, 1.21 [95% CI, .47-3.09]; P = .69). CONCLUSIONS TEACH is a promising intervention to improve adherence to COT guidelines without evident adverse consequences.
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Affiliation(s)
- Jeffrey H Samet
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts, USA
- Clinical Addiction Research and Education Unit, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Judith I Tsui
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Debbie M Cheng
- Clinical Addiction Research and Education Unit, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Jane M Liebschutz
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Marlene C Lira
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts, USA
| | - Alexander Y Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts, USA
- Clinical Addiction Research and Education Unit, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jonathan A Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Leah S Forman
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Christin Root
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Christopher W Shanahan
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
- Clinical Addiction Research and Education Unit, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Margaret M Sullivan
- Clinical Addiction Research and Education Unit, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Carly L Bridden
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts, USA
| | - Catherine Abrams
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Catherine Harris
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Kishna Outlaw
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Wendy S Armstrong
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Carlos del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
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Chichetto NE, Polanka BM, So-Armah KA, Sung M, Stewart JC, Koethe JR, Edelman EJ, Tindle HA, Freiberg MS. Contribution of Behavioral Health Factors to Non-AIDS-Related Comorbidities: an Updated Review. Curr HIV/AIDS Rep 2020; 17:354-372. [PMID: 32314325 PMCID: PMC7363585 DOI: 10.1007/s11904-020-00498-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW We summarize recent literature on the contribution of substance use and depression to non-AIDS-related comorbidities. Discussion of recent randomized clinical trials and implementation research to curtail risk attributed to each behavioral health issue is provided. RECENT FINDINGS Smoking, unhealthy alcohol use, opioid use, and depression are common among PWH and individually contribute to increased risk for non-AIDS-related comorbidities. The concurrence of these conditions is notable, yet understudied, and provides opportunity for linked-screening and potential treatment of more than one behavioral health factor. Current results from randomized clinical trials are inconsistent. Investigating interventions to reduce the impact of these behavioral health conditions with a focus on implementation into clinical care is important. Non-AIDS-defining cancers, cardiovascular disease, liver disease, and diabetes are leading causes of morbidity in people with HIV. Behavioral health factors including substance use and mental health issues, often co-occurring, likely contribute to the excess risk of non-AIDS-related comorbidities.
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Affiliation(s)
- Natalie E Chichetto
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Brittanny M Polanka
- Department of Psychology, Indiana University-Purdue University Indianapolis (IUPUI), Indianapolis, IN, USA
| | - Kaku A So-Armah
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Minhee Sung
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jesse C Stewart
- Department of Psychology, Indiana University-Purdue University Indianapolis (IUPUI), Indianapolis, IN, USA
| | - John R Koethe
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, USA
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Hilary A Tindle
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Centers, Nashville, TN, USA
| | - Matthew S Freiberg
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Centers, Nashville, TN, USA
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High-dose prescribed opioids are associated with increased risk of heroin use among United States military veterans. Pain 2020; 160:2126-2135. [PMID: 31145217 DOI: 10.1097/j.pain.0000000000001606] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Despite evidence linking increased risk of opioid use disorder with specific opioid-prescribing patterns, the relationship between these patterns and heroin use is less understood. This study aimed to determine whether dose and duration of opioid prescriptions predict subsequent heroin use in United States veterans. We analyzed data from 2002 to 2012 from the Veterans Aging Cohort Study, a prospective cohort study. We used inverse probability of censoring weighted Cox regression to examine the relationship between self-reported past year heroin use and 2 primary predictors: (1) prior receipt of a high-dose opioid prescription (≥90 mg morphine equivalent daily dose), and (2) prior receipt of a long-term opioid prescription (≥90 days). Heroin use was ascertained using most recent value of time-updated self-reported past year heroin use. Models were adjusted for HIV and hepatitis C virus infection status, sociodemographics, pain interference, posttraumatic stress disorder, depression, and use of marijuana, cocaine, methamphetamines, and unhealthy alcohol use. In the final model, prior receipt of a high-dose opioid prescription was associated with past year heroin use (adjusted hazard ratio use = 2.54, 95% confidence interval: 1.26-5.10), whereas long-term opioid receipt was not (adjusted hazard ratio = 1.09, 95% confidence interval: 0.75-1.57). Patients receiving high-dose opioid prescriptions should be monitored for heroin use. These findings support current national guidelines recommending against prescribing high-dose opioids for treating pain.
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Edelman EJ, Li Y, Barry D, Braden JB, Crystal S, Kerns RD, Gaither JR, Gordon KS, Manhapra A, Merlin JS, Moore BA, Oldfield BJ, Park LS, Rentsch CT, Skanderson M, Williams EC, Justice AC, Tate JP, Becker WC, Marshall BD. Trajectories of Self-Reported Opioid Use Among Patients With HIV Engaged in Care: Results From a National Cohort Study. J Acquir Immune Defic Syndr 2020; 84:26-36. [PMID: 32267658 PMCID: PMC7147724 DOI: 10.1097/qai.0000000000002310] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
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 self-reported 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 8 US Veterans Health Administration (VA) sites. METHODS Between 2002 and 2018, we assessed past year opioid use frequency based on self-reported "prescription painkillers" and/or heroin use at baseline and follow-up. We used group-based 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 3702 PWH, we identified 4 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, 1 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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Affiliation(s)
- E. Jennifer Edelman
- Yale School of Medicine, New Haven, CT
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT
| | - Yu Li
- Brown University School of Public Health, Providence, RI
| | | | - Jennifer Brennan Braden
- University of Washington School of Medicine, Seattle, WA
- Valley Medical Center Psychiatry and Counseling, Behavioral Health Integration Program
| | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Rutgers University, Rutgers, NJ
| | - Robert D. Kerns
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | | | - Kirsha S. Gordon
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Ajay Manhapra
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | | | - Brent A. Moore
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | | | | | - Christopher T. Rentsch
- VA Connecticut Healthcare System, West Haven, CT
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Emily C. Williams
- VA Puget Sound Health Services Research and Development and Department of Health Services, University of Washington, Seattle, WA
| | - Amy C. Justice
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Janet P. Tate
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - William C. Becker
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
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Opioid-Related Diagnoses and Concurrent Claims for HIV, HBV, or HCV among Medicare Beneficiaries, United States, 2015. J Clin Med 2019; 8:jcm8111768. [PMID: 31652928 PMCID: PMC6912616 DOI: 10.3390/jcm8111768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/17/2019] [Accepted: 10/21/2019] [Indexed: 01/10/2023] Open
Abstract
Unsterile opioid injection increases risk for infection transmission, including HIV, hepatitis B virus (HBV), or hepatitis C virus (HCV). We assess prevalence of and risk factors associated with opioid overdose and infections with HIV, HBV, or HCV among Medicare beneficiaries with opioid-related fee-for-service claims during 2015. We conducted a cross-sectional analysis to estimate claims for opioid use and overdose and HIV, HBV, or HCV infections, using data from US Medicare fee-for-service claims. Beneficiaries with opioid-related claims had increased odds for HIV (2.3; 95% confidence interval (CI), 2.3–2.4), acute HBV (6.7; 95% CI, 6.3–7.1), chronic HBV (5.0; 95% CI, 4.7–5.4), acute HCV (9.6; 95% CI, 9.2–10.0), and chronic HCV (8.9; 95% CI, 8.7–9.1). Beneficiaries with opioid-related claims and for HIV, HBV, or HCV infection, respectively, had a 1.1–1.9-fold odds for having a claim for opioid overdose. Independent risk factors for opioid overdose and each selected infection outcome included age, sex, race/ethnicity, region, and residence in a high-vulnerability county. Having opioid-related claims and selected demographic attributes were independent, significant risk factors for having HIV, HBV, or HCV claims among US Medicare beneficiaries. These results might help guide interventions intended to reduce incidences of HIV, HCV, and HBV infections among beneficiaries with opioid-related claims.
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Lira MC, Tsui JI, Liebschutz JM, Colasanti J, Root C, Cheng DM, Walley AY, Sullivan M, Shanahan C, O’Connor K, Abrams C, Forman LS, Chaisson C, Bridden C, Podolsky MC, Outlaw K, Harris CE, Armstrong WS, del Rio C, Samet JH. 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. HIV Res Clin Pract 2019; 20:48-63. [PMID: 31303143 PMCID: PMC6693587 DOI: 10.1080/15284336.2019.1627509] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 04/26/2019] [Accepted: 05/30/2019] [Indexed: 12/12/2022]
Abstract
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 to 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). Conclusions: 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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Affiliation(s)
- Marlene C. Lira
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
| | - Judith I. Tsui
- Section of General Internal Medicine, Department of Medicine, University of Washington and Harborview Medical Center
| | - Jane M. Liebschutz
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jonathan Colasanti
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Christin Root
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Debbie M. Cheng
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Alexander Y. Walley
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Meg Sullivan
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Christopher Shanahan
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Kristen O’Connor
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
| | - Catherine Abrams
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Leah S. Forman
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA
| | - Christine Chaisson
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA
| | - Carly Bridden
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
| | - Melissa C. Podolsky
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
| | - Kishna Outlaw
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Catherine E. Harris
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Wendy S. Armstrong
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Carlos del Rio
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jeffrey H. Samet
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
- Department of Medicine, Boston University School of Medicine, Boston, MA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA
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7
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Laycock H, Crawford V, Rice AS, Cox S. Lessons learnt from establishing a high dose opioid review clinic for people living with HIV. Pain Manag 2018; 9:37-44. [PMID: 30501569 DOI: 10.2217/pmt-2018-0041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
People living with HIV represent a unique aging population, living with a chronic condition associated with significant pain. A number take high dose, long-term opioids to manage moderate to severe chronic pain, presenting specific risks. This article highlights the size and impact of this problem and outlines the service objectives and set up of a specialist clinic to manage people living with HIV on high dose opioids, alongside its successes and learning points.
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Affiliation(s)
- Helen Laycock
- Clinical Lecturer in Pain Medicine, Department of Surgery & Cancer, Imperial College London, London, UK
| | - Vanessa Crawford
- Honorary Consultant Psychiatrist, HIV Pain Management Clinic, Chelsea & Westminster Hospital NHS Foundation Trust, London, UK
| | - Andrew Sc Rice
- Professor of Pain Research, Department of Surgery & Cancer, Imperial College London, London, UK.,Consultant in Pain Medicine, Department of Pain Medicine, Chelsea & Westminster Hospital NHS Foundation Trust, London, UK
| | - Sarah Cox
- Consultant in Palliative Medicine, Department of Palliative Care, Chelsea & Westminster Hospital NHS Foundation Trust, London, UK
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8
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Gaither JR, Gordon K, Crystal S, Edelman EJ, Kerns RD, Justice AC, Fiellin DA, Becker WC. Racial disparities in discontinuation of long-term opioid therapy following illicit drug use among black and white patients. Drug Alcohol Depend 2018; 192:371-376. [PMID: 30122319 PMCID: PMC7106601 DOI: 10.1016/j.drugalcdep.2018.05.033] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 05/09/2018] [Accepted: 05/12/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Among patients prescribed long-term opioid therapy (LTOT) for chronic pain, no study has yet examined how clinicians respond to evidence of illicit drug use and whether the decision to discontinue opioids is influenced by a patient's race. METHODS Among outpatients of black and white race initiating LTOT through the VA between 2000 and 2010, we reviewed electronic medical records to determine whether opioids were discontinued within 60 days of a positive urine drug test. Logistic regression was used to examine differences by race. RESULTS Among 15,366 patients of black (48.1%) or white (51.9%) race initiating LTOT from 2000 to 2010, 20.5% (25.5% of blacks vs. 15.8% of whites, P <. 001) received a urine drug test within the first 6 months of treatment; 13.8% tested positive for cannabis and 17.4% for cocaine. LTOT was discontinued in 11.4% of patients who tested positive for cannabis and in 13.1% of those who tested positive for cocaine. Among patients testing positive for cannabis, blacks were 2.1 times more likely than whites to have LTOT discontinued (adjusted odds ratio [AOR] 2.06, 95% confidence interval [CI] 1.04-4.08). Among patients testing positive for cocaine, blacks were 3.3 times more likely than whites to have LTOT discontinued (AOR 3.30, CI 1.28-8.53). CONCLUSIONS Among patients testing positive for illicit drug use while receiving LTOT, clinicians are substantially more likely to discontinue opioids when the patient is black. A more universal approach to administering and responding to urine drug testing is urgently needed.
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Affiliation(s)
- Julie R. Gaither
- Yale Center for Medical Informatics, Yale School of Medicine, Yale University, 333 Cedar St., New Haven, CT 06510, USA,VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, USA,Yale School of Public Health, Yale University, 60 College St., New Haven, CT 06510, USA,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, 135 College St., Suite 200, New Haven, CT 06510, USA
| | - Kirsha Gordon
- VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, USA
| | - Stephen Crystal
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 112 Paterson St., New Brunswick, NJ 08901, USA
| | - E. Jennifer Edelman
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, 135 College St., Suite 200, New Haven, CT 06510, USA,Department of Internal Medicine, Yale School of Medicine, Yale University, 330 Cedar St., Boardman 110, P.O. Box 208056, New Haven, CT 06520, USA
| | - Robert D. Kerns
- Yale Center for Medical Informatics, Yale School of Medicine, Yale University, 333 Cedar St., New Haven, CT 06510, USA,Department of Psychiatry, Yale School of Medicine, 300 George St. #901, New Haven, CT 06511, USA
| | - Amy C. Justice
- VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, USA,Yale School of Public Health, Yale University, 60 College St., New Haven, CT 06510, USA,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, 135 College St., Suite 200, New Haven, CT 06510, USA,Department of Internal Medicine, Yale School of Medicine, Yale University, 330 Cedar St., Boardman 110, P.O. Box 208056, New Haven, CT 06520, USA
| | - David A. Fiellin
- Yale Center for Medical Informatics, Yale School of Medicine, Yale University, 333 Cedar St., New Haven, CT 06510, USA,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, 135 College St., Suite 200, New Haven, CT 06510, USA,Department of Internal Medicine, Yale School of Medicine, Yale University, 330 Cedar St., Boardman 110, P.O. Box 208056, New Haven, CT 06520, USA
| | - William C. Becker
- VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, USA,Department of Internal Medicine, Yale School of Medicine, Yale University, 330 Cedar St., Boardman 110, P.O. Box 208056, New Haven, CT 06520, USA
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9
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The Effect of Substance Use Disorders on the Association Between Guideline-concordant Long-term Opioid Therapy and All-cause Mortality. J Addict Med 2017; 10:418-428. [PMID: 27610580 DOI: 10.1097/adm.0000000000000255] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Patients with substance use disorders (SUDs) prescribed long-term opioid therapy (LtOT) are at risk for overdose and mortality. Prior research has shown that receipt of LtOT in accordance with clinical practice guidelines has the potential to mitigate these outcomes. Our objective was to determine whether the presence of a SUD modifies the association between guideline-concordant care and 1-year all-cause mortality among patients receiving LtOT for pain. METHODS Among HIV+ and HIV- patients initiating LtOT (≥90 days opioids) between 2000 and 2010 as part of the Veterans Aging Cohort Study, we used time-updated Cox regression and propensity-score matching to examine-stratified by SUD status-the association between 1-year all-cause mortality and 3 quality indicators derived from national opioid-prescribing guidelines. Specifically, we examined whether patients received psychotherapeutic cointerventions (≥2 outpatient mental health visits), benzodiazepine coprescriptions (≥7 days), and SUD treatment (≥1 inpatient day or outpatient visit). These indicators were among those found in a previous study to have a strong association with mortality. RESULTS Among 17,044 patients initiating LtOT, there were 1048 (6.1%) deaths during 1 year of follow-up. Receipt of psychotherapeutic cointerventions was associated with lower mortality in the overall sample and was more protective in patients with SUDs (adjusted hazard ratio [AHR] 0.43, 95% confidence interval [CI] 0.33-0.56 vs AHR 0.65, 95% CI 0.53-0.81; P for interaction = 0.002). Benzodiazepine coprescribing was associated with higher mortality in the overall sample (AHR 1.41, 95% CI 1.22-1.63), but we found no interaction by SUD status (P for interaction = 0.11). Among patients with SUDs, receipt of SUD treatment was associated with lower mortality (AHR 0.43, 95% CI 0.33-0.57). CONCLUSIONS For clinicians prescribing LtOT to patients with untreated SUDs, engaging patients with psychotherapeutic and SUD treatment services may reduce mortality. Clinicians should also avoid, when possible, prescribing opioids with benzodiazepines.
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10
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Brief Report: Longitudinal Opioid Use Among HIV-Infected Patients, 2000 to 2014. J Acquir Immune Defic Syndr 2017; 75:77-80. [PMID: 28198711 DOI: 10.1097/qai.0000000000001321] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Longitudinal opioid prescription use is unknown among HIV-infected patients. Group-based trajectory modeling followed by multinomial logistic regression was used to identify distinct trajectories and their association with baseline characteristics among 1239 HIV-infected UNC CFAR HIV Clinical Cohort participants, 2000-2014. Three trajectories were identified: (1) 72% never/sporadic opioid use (referent group), (2) 11% episodic use (associated with female sex, depression, drug-related diagnoses, antiretroviral therapy use, and undetectable HIV RNA), and (3) 16% chronic use (associated with older age, female sex, and mental health diagnoses). Overall, opioid prescription decreased substantially with longer time in HIV care among both episodic and chronic users.
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Starrels JL, Peyser D, Haughton L, Fox A, Merlin JS, Arnsten JH, Cunningham CO. When human immunodeficiency virus (HIV) treatment goals conflict with guideline-based opioid prescribing: A qualitative study of HIV treatment providers. Subst Abus 2017; 37:148-53. [PMID: 26860130 DOI: 10.1080/08897077.2015.1129391] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-infected patients have a high prevalence of chronic pain and opioid use, making HIV care a critical setting for improving the safety of opioid prescribing. Little is known about HIV treatment providers' perspectives about opioid prescribing to patients with chronic pain. METHODS The authors administered a questionnaire and conducted semistructured telephone interviews with 18 HIV treatment providers (infectious disease specialists, general internists, family medicine physicians, nurse practitioners, and physician assistants) in Bronx, NY. Open-ended interview questions focused on providers' experiences, beliefs, and attitudes about opioid prescribing and about the use of guideline-based opioid prescribing practices (conservative prescribing, and monitoring for and responding to misuse). Transcripts were thematically analyzed using a modified grounded theory approach. RESULTS Eighteen HIV treatment providers included 13 physicians, four nurse practitioners, and one physician assistant. They were 62% female, 56% white, and practiced as HIV treatment providers for a mean of 14.6 years. Most reported always or almost always using opioid treatment agreements (56%) and urine drug testing (61%) with their patients on long-term opioid therapy. HIV treatment providers tended to view opioid prescribing for chronic pain within the "HIV paradigm," a set of priorities and principles defined by three key themes: (1) primacy of HIV goals, (2) familiarity with substance use, and (3) the clinician as ally. The HIV paradigm sometimes supported, and sometimes conflicted with, guideline-based opioid prescribing practices. For HIV treatment providers, perceived alignment with the HIV paradigm determined whether and how guideline-based opioid prescribing practices were adopted. For example, the primacy of HIV goals superseded conservative opioid prescribing when providers prescribed opioids with the goal of retaining patients in HIV care. CONCLUSION These findings highlight unique factors in HIV care that influence adoption of guideline-based opioid prescribing practices. These factors should be considered in future research and initiatives to address opioid prescribing in HIV care.
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Affiliation(s)
- Joanna L Starrels
- a Albert Einstein College of Medicine and Montefiore Medical Center , Bronx, New York , USA
| | - Deena Peyser
- b Center for Alcohol Studies , Rutgers University , New York , New York , USA
| | - Lorlette Haughton
- a Albert Einstein College of Medicine and Montefiore Medical Center , Bronx, New York , USA
| | - Aaron Fox
- a Albert Einstein College of Medicine and Montefiore Medical Center , Bronx, New York , USA
| | - Jessica S Merlin
- c School of Medicine, University of Alabama at Birmingham , Birmingham , Alabama , USA
| | - Julia H Arnsten
- a Albert Einstein College of Medicine and Montefiore Medical Center , Bronx, New York , USA
| | - Chinazo O Cunningham
- a Albert Einstein College of Medicine and Montefiore Medical Center , Bronx, New York , USA
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Banerjee G, Edelman EJ, Barry DT, Becker WC, Cerdá M, Crystal S, Gaither JR, Gordon AJ, Gordon KS, Kerns RD, Martins SS, Fiellin DA, Marshall BDL. Non-medical use of prescription opioids is associated with heroin initiation among US veterans: a prospective cohort study. Addiction 2016; 111:2021-2031. [PMID: 27552496 PMCID: PMC5056813 DOI: 10.1111/add.13491] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 03/30/2016] [Accepted: 06/09/2016] [Indexed: 01/05/2023]
Abstract
AIMS To estimate the influence of non-medical use of prescription opioids (NMUPO) on heroin initiation among US veterans receiving medical care. DESIGN Using a multivariable Cox regression model, we analyzed data from a prospective, multi-site, observational study of HIV-infected and an age/race/site-matched control group of HIV-uninfected veterans in care in the United States. Approximately annual behavioral assessments were conducted and contained self-reported measures of NMUPO and heroin use. SETTING Veterans Health Administration (VHA) infectious disease and primary care clinics in Atlanta, Baltimore, New York, Houston, Los Angeles, Pittsburgh and Washington, DC. PARTICIPANTS A total of 3396 HIV-infected and uninfected patients enrolled into the Veterans Aging Cohort Study who reported no life-time NMUPO or heroin use, had no opioid use disorder diagnoses at baseline and who were followed between 2002 and 2012. MEASUREMENTS The primary outcome measure was self-reported incident heroin use and the primary exposure of interest was new-onset NMUPO. Our final model was adjusted for socio-demographics, pain interference, prior diagnoses of post-traumatic stress disorder and/or depression and self-reported other substance use. FINDINGS Using a multivariable Cox regression model, we found that non-medical use of prescription opioids NMUPO was associated positively and independently with heroin initiation [adjusted hazard ratio (AHR) = 5.43, 95% confidence interval (CI) = 4.01, 7.35]. CONCLUSIONS New-onset non-medical use of prescription opioids (NMUPO) is a strong risk factor for heroin initiation among HIV-infected and uninfected veterans in the United States who reported no previous history of NMUPO or illicit opioid use.
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Affiliation(s)
- Geetanjoli Banerjee
- Department of Epidemiology, Brown School of Public Health, Providence, RI, USA
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
- Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Declan T Barry
- Yale University School of Medicine, New Haven, CT, USA
- APT Foundation Pain Treatment Services, New Haven, CT, USA
| | - William C Becker
- Pain Research, Informatics, Multi-morbidities and Education (PRIME) Center, VA, Connecticut Healthcare System, West Haven, CT, USA
| | - Magdalena Cerdá
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA
| | - Stephen Crystal
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, NJ, USA
| | - Julie R Gaither
- Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA
- Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT, USA
| | - Adam J Gordon
- Center for Health Equity Research and Promotion (CHERP) & Mental Illness Research Education and Clinical Center (MIRECC), VA Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Robert D Kerns
- Pain Research, Informatics, Multi-morbidities and Education (PRIME) Center, VA, Connecticut Healthcare System, West Haven, CT, USA
- Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT, USA
| | - Silvia S Martins
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - David A Fiellin
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
- Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA
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Edelman EJ, Gordon KS, Tate JP, Becker WC, Bryant K, Crothers K, Gaither JR, Gibert CL, Gordon AJ, Marshall B, Rodriguez-Barradas MC, Samet JH, Skanderson M, Justice AC, Fiellin DA. The impact of prescribed opioids on CD4 cell count recovery among HIV-infected patients newly initiating antiretroviral therapy. HIV Med 2016; 17:728-739. [PMID: 27186715 PMCID: PMC5053822 DOI: 10.1111/hiv.12377] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2015] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Certain prescribed opioids have immunosuppressive properties, yet their impact on clinically relevant outcomes, including antiretroviral therapy (ART) response among HIV-infected patients, remains understudied. METHODS Using the Veterans Aging Cohort Study data, we conducted a longitudinal analysis of 4358 HIV-infected patients initiating ART between 2002 and 2010 and then followed them for 24 months. The primary independent variable was prescribed opioid duration, categorized using pharmacy data as none prescribed, short-term (< 90 days) and long-term (≥ 90 days). Outcomes included CD4 cell count over time. Analyses adjusted for demographics, comorbid conditions, ART type and year of initiation, and overall disease severity [ascertained with the Veterans Aging Cohort Study (VACS) Index]. Sensitivity analyses examined whether effects varied according to baseline CD4 cell count, achievement of viral load suppression, and opioid properties (i.e. dose and known immunosuppressive properties). RESULTS Compared to those with none, patients with short-term opioids had a similar increase in CD4 cell count (mean rise per year: 74 vs. 68 cells/μL; P = 0.11), as did those with long-term prescribed opioids (mean rise per year: 74 vs. 75 cells/μL; P = 0.98). In sensitivity analysis, compared with no opioids, the effects of short-term prescribed opioids were statistically significant among those with a baseline CD4 cell count ≥ 500 cells/μL (mean rise per year: 52 cells/μL for no opioids vs. 20 cells/μL for short-term opioids; P = 0.04); findings were otherwise unchanged. CONCLUSIONS Despite immunosuppressive properties intrinsic to opioids, prescribed opioids appeared to have no effect on CD4 cell counts over 24 months among HIV-infected patients initiating ART.
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Affiliation(s)
- E J Edelman
- Yale University School of Medicine, New Haven, CT, USA.
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT, USA.
| | - K S Gordon
- VA Connecticut Health Care System, West Haven, CT, USA
| | - J P Tate
- Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Health Care System, West Haven, CT, USA
| | - W C Becker
- Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Health Care System, West Haven, CT, USA
| | - K Bryant
- National Institute on Alcohol Abuse and Alcoholism, HIV/AIDS Program, Bethesda, MD, USA
| | - K Crothers
- University of Washington, Seattle, WA, USA
| | - J R Gaither
- Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Health Care System, West Haven, CT, USA
- Yale University School of Public Health, New Haven, CT, USA
| | - C L Gibert
- DC Veterans Affairs Medical Center and George Washington University, Washington, DC, USA
| | - A J Gordon
- Veterans Affairs Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, PA, USA
| | - Bdl Marshall
- Brown University School of Public Health, Providence, RI, USA
| | - M C Rodriguez-Barradas
- Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - J H Samet
- Boston University Schools of Medicine and Public Health, Boston, MA, USA
| | - M Skanderson
- VA Connecticut Health Care System, West Haven, CT, USA
| | - A C Justice
- Yale University School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT, USA
- VA Connecticut Health Care System, West Haven, CT, USA
| | - D A Fiellin
- Yale University School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT, USA
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Gaither JR, Goulet JL, Becker WC, Crystal S, Edelman EJ, Gordon K, Kerns RD, Rimland D, Skanderson M, Justice AC, Fiellin DA. The Association Between Receipt of Guideline-Concordant Long-Term Opioid Therapy and All-Cause Mortality. J Gen Intern Med 2016; 31:492-501. [PMID: 26847447 PMCID: PMC4835362 DOI: 10.1007/s11606-015-3571-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE For patients receiving long-term opioid therapy (LtOT), the impact of guideline-concordant care on important clinical outcomes--notably mortality--is largely unknown, even among patients with a high comorbidity and mortality burden (e.g., HIV-infected patients). Our objective was to determine the association between receipt of guideline-concordant LtOT and 1-year all-cause mortality. METHODS Among HIV-infected and uninfected patients initiating LtOT between 2000 and 2010 through the Department of Veterans Affairs, we used Cox regression with time-updated covariates and propensity-score matched analyses to examine the association between receipt of guideline-concordant care and 1-year all-cause mortality. RESULTS Of 17,044 patients initiating LtOT between 2000 and 2010, 1048 patients (6%) died during 1 year of follow-up. Patients receiving psychotherapeutic co-interventions (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.51-0.75; P < 0.001) or physical rehabilitative therapies (HR 0.81; 95% CI 0.67-0.98; P = 0.03) had a decreased risk of all-cause mortality compared to patients not receiving these services, whereas patients prescribed benzodiazepines concurrent with opioids had a higher risk of mortality (HR 1.39; 95% CI 1.12-1.66; P < 0.001). Among patients with a current substance use disorder (SUD), those receiving SUD treatment had a lower risk of mortality than untreated patients (HR 0.47; 95% CI 0.32-0.68; P = < 0.001). No association was found between all-cause mortality and primary care visits (HR 1.12; 95% CI 0.90-1.26; P = 0.32) or urine drug testing (HR 0.96; 95% CI 0.78-1.17; P = 0.67). CONCLUSIONS Providers should use caution in initiating LtOT in conjunction with benzodiazepines and untreated SUDs. Patients receiving LtOT may benefit from multi-modal treatment that addresses chronic pain and its associated comorbidities across multiple disciplines.
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Affiliation(s)
- Julie R Gaither
- Yale School of Public Health, Yale University, New Haven, CT, USA. .,VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA. .,Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, CT, USA. .,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA.
| | - Joseph L Goulet
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.,Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - William C Becker
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.,Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Stephen Crystal
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, NJ, USA
| | - E Jennifer Edelman
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Kirsha Gordon
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA
| | - Robert D Kerns
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.,Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - David Rimland
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Atlanta VA Medical Center, Decatur, GA, USA
| | | | - Amy C Justice
- Yale School of Public Health, Yale University, New Haven, CT, USA.,VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.,Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - David A Fiellin
- Yale School of Public Health, Yale University, New Haven, CT, USA.,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
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Livorsi D, Comer AR, Matthias MS, Perencevich EN, Bair MJ. Barriers to guideline-concordant antibiotic use among inpatient physicians: A case vignette qualitative study. J Hosp Med 2016; 11:174-80. [PMID: 26443327 PMCID: PMC4779411 DOI: 10.1002/jhm.2495] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 09/11/2015] [Accepted: 09/15/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Greater adherence to antibiotic-prescribing guidelines may promote more judicious antibiotic use, which could benefit individual patients and society at large. OBJECTIVE To assess physician knowledge and acceptance of antibiotic-prescribing guidelines through the use of case vignettes. DESIGN We conducted semistructured interviews with 30 inpatient physicians. Participants were asked to respond to 3 hypothetical case vignettes: (1) a skin and soft tissue infection (SSTI), (2) suspected hospital-acquired pneumonia (HAP), and (3) asymptomatic bacteriuria (ASB). All participants received feedback according to guidelines from the Infectious Diseases Society of America (IDSA) and were asked to discuss their level of comfort with following these guidelines. SETTING Two acute care teaching hospitals for adult patients. INTERVENTION None. MEASUREMENTS Data from transcribed interviews were analyzed using emergent thematic analysis. RESULTS Participants were receptive to guidelines and believed they were useful. However, participants' responses to the case vignettes demonstrated that IDSA guideline recommendations were not routinely followed for SSTI, HAP, and ASB. We identified 3 barriers to guideline-concordant care: (1) physicians' lack of awareness of specific guideline recommendations; (2) tension between adhering to guidelines and the desire to individualize patient care; and (3) skepticism of certain guideline recommendations. CONCLUSIONS Case vignettes may be useful tools to assess physician knowledge and acceptance of antibiotic-prescribing guidelines. Using case vignettes, we identified 3 barriers to following IDSA guidelines. Efforts to improve guideline-concordant antibiotic prescribing should focus on reducing such barriers at the local level.
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Affiliation(s)
- Daniel Livorsi
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Iowa City VA Health Care System, Iowa City, Iowa
| | - Amber R Comer
- Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
| | - Marianne S Matthias
- VA Health Services Research and Development Service Center for Health Information and Communication, Richard Roudebush VA Medical Center, Indianapolis, Indiana
- Regenstrief Institute, Indiana University School of Medicine, Indianapolis, Indiana
| | - Eli N Perencevich
- Iowa City VA Health Care System, Iowa City, Iowa
- Division of General Internal Medicine and Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Matthew J Bair
- VA Health Services Research and Development Service Center for Health Information and Communication, Richard Roudebush VA Medical Center, Indianapolis, Indiana
- Regenstrief Institute, Indiana University School of Medicine, Indianapolis, Indiana
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Merlin JS, Tamhane A, Starrels JL, Kertesz S, Saag M, Cropsey K. Factors Associated with Prescription of Opioids and Co-prescription of Sedating Medications in Individuals with HIV. AIDS Behav 2016; 20:687-98. [PMID: 26487298 DOI: 10.1007/s10461-015-1178-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Opioids are often prescribed for chronic pain, and opioid risks such as overdose and death are heightened when opioids are co-prescribed with other sedating medications. We investigated factors associated with chronic opioid prescription, alone and in combination with benzodiazepines and muscle relaxants, in a clinical cohort of individuals with HIV. We used multivariable logistic regression models to determine participant clinical and demographic characteristics that are associated with chronic prescription of opioids or chronic co-prescription of opioids with sedating medications. Among 1474 participants, chronic prescription of opioids occurred in 253 individuals (17.2 %), and chronic co-prescription occurred in 90 individuals (6.1 %). Age >50, public insurance as compared to private insurance, and symptoms of depression and anxiety were significantly associated with chronic opioid prescription and chronic co-prescription. Our findings raise concern that opioid prescription and co-prescription of sedating medications occurs disproportionately in patients for whom use is riskier.
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Affiliation(s)
- Jessica S Merlin
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, BBRB 222, 1530 3rd Ave S, Birmingham, AL, 35294-2170, USA.
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Ashutosh Tamhane
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, BBRB 222, 1530 3rd Ave S, Birmingham, AL, 35294-2170, USA
| | - Joanna L Starrels
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Stefan Kertesz
- Birmingham VA Medical Center, Birmingham, AL, USA
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael Saag
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, BBRB 222, 1530 3rd Ave S, Birmingham, AL, 35294-2170, USA
| | - Karen Cropsey
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, USA
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