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Tam CC, Benotsch EG, Li X, Zhou Y, Shen Z. Prescription Opioid Misuse, Pain Interference, Resilience, and Anxiety Among Chinese People Living with HIV: A Moderated Mediation Model. AIDS Behav 2023; 27:3508-3514. [PMID: 37074629 DOI: 10.1007/s10461-023-04066-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2023] [Indexed: 04/20/2023]
Abstract
Prescription opioid misuse (POM) is a concern in people living with HIV (PLWH). Pain interference is a robust factor, and its influences would occur through anxiety and resilience. Limited POM studies attend to Chinese PLWH. This study examined POM and its underlying psychological mechanism using data of PLWH with pain (n = 116) from a cohort study in Guangxi. The PROCESS macro was employed to examine a hypothesized moderated mediation model among pain interference, resilience, anxiety, and POM. Results showed 10.3% PLWH engaged in past-three-month POM. After controlling for demographics, HIV-related clinical outcomes, and pain severity, anxiety mediated the association between pain interference and POM (β = 0.46, 95% CI = 0.01 to 10.49), and the mediation was moderated by resilience (moderated mediation index = - 0.02, 95% CI = - 0.784 to - 0.001). Chinese PLWH seem to misuse opioids to cope with pain-related anxiety. Resilience appears to offer protection.
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Affiliation(s)
- Cheuk Chi Tam
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, South Carolina SmartState Center for Healthcare Quality, University of South Carolina, Discovery I, Suite 413, 915 Greene Street, 29208, Columbia, SC, USA.
| | - Eric G Benotsch
- Department of Psychology, Virginia Commonwealth University, 23284, Richmond, VA, PO Box 842018, USA
| | - Xiaoming Li
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, South Carolina SmartState Center for Healthcare Quality, University of South Carolina, Discovery I, Suite 413, 915 Greene Street, 29208, Columbia, SC, USA
| | - Yuejiao Zhou
- Guangxi Zhuang Autonomous Region Center for Diseases Control and Prevention, Nanning, China
| | - Zhiyong Shen
- Guangxi Zhuang Autonomous Region Center for Diseases Control and Prevention, Nanning, China
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Yeh JC, Uebelacker LA, Pinkston MM, Anderson BJ, Busch AM, Abrantes AM, Baker JV, Stein MD. Strategies Used to Manage Chronic Pain in HIV-Disease: Comparing Persons Prescribed Opioids Versus Persons not Receiving Opioids. AIDS Behav 2023; 27:3239-3247. [PMID: 36947302 PMCID: PMC10810036 DOI: 10.1007/s10461-023-04044-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/23/2023]
Abstract
Chronic pain is common in people living with HIV (PLWH), causes substantial disability and is associated with limitations in daily activities. Opioids are commonly prescribed for pain treatment among PLWH, but evidence of sustained efficacy is mixed. There is little information available on how PLWH who have chronic pain use multimodal strategies in pain management. The current cross-sectional study examined background characteristics, self-reported pain, and the use of other pain treatments among 187 PLWH with chronic pain and depressive symptoms who were and were not prescribed opioids. Approximately 20.9% of participants reported using prescription opioids at the time of the study interview. These individuals were significantly more likely to report having engaged in physical therapy or stretching, strengthening or aerobic exercises in the previous 3 months, recent benzodiazepine use, and receiving disability payments. There were no significant differences in pain characteristics (pain-related interference, average pain severity, and worst pain severity) between the two groups. Those not prescribed opioids were more likely to report better concurrent physical functioning and general health, and fewer physical role limitations, but higher depression symptom severity. Our findings suggest that many PLWH with chronic pain and depressive symptoms express high levels of pain with deficits in physical function or quality of life despite their use of opioids. The high rate of co-use of opioids and benzodiazepines (30.8%) is a concern because it may increase risk of overdose. An integrated care approach that includes a variety of effective non-pharmacologic treatment strategies such as physical therapy may be beneficial in reducing the reliance on opioids for pain management.
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Affiliation(s)
- Jih-Cheng Yeh
- Department of Health Law, Policy, and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA.
| | - Lisa A Uebelacker
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
- Department of Family Medicine, Alpert Medical School of Brown University, Providence, RI, USA
- Butler Hospital, 345 Blackstone Blvd, Providence, RI, 02906, USA
| | - Megan M Pinkston
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
- Lifespan Physicians Group, The Miriam Hospital, Providence, RI, USA
| | | | - Andrew M Busch
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota - Twin Cities, Minneapolis, MN, USA
| | - Ana M Abrantes
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
- Butler Hospital, 345 Blackstone Blvd, Providence, RI, 02906, USA
| | - Jason V Baker
- Department of Medicine, University of Minnesota - Twin Cities, Minneapolis, MN, USA
- Division of Infectious Diseases, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Michael D Stein
- Department of Health Law, Policy, and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA
- Butler Hospital, 345 Blackstone Blvd, Providence, RI, 02906, USA
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Uebelacker LA, Pinkston MM, Busch AM, Baker JV, Anderson B, Caviness CM, Herman DS, Weisberg RB, Abrantes AM, Stein MD. HIV-PASS (Pain and Sadness Support): Randomized Controlled Trial of a Behavioral Health Intervention for Interference Due to Pain in People Living With HIV, Chronic Pain, and Depression. Psychosom Med 2023; 85:250-259. [PMID: 36799731 PMCID: PMC10073275 DOI: 10.1097/psy.0000000000001172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVE This study aimed to determine whether HIV-Pain and Sadness Support (HIV-PASS), a collaborative behavioral health intervention based on behavioral activation, is associated with decreased pain-related interference with daily activities, depression, and other outcomes in people living with HIV. METHODS We conducted a three-site clinical trial ( n = 187) in which we randomly assigned participants to receive either HIV-PASS or health education control condition. In both conditions, participants received seven intervention sessions, comprising an initial in-person joint meeting with the participant, their HIV primary care provider and a behavioral health specialist, and six, primarily telephone-based, meetings with the behavioral health specialist and participant. The intervention period lasted 3 months, and follow-up assessments were conducted for an additional 9 months. RESULTS Compared with health education, HIV-PASS was associated with significantly lower pain-related interference with daily activities at the end of month 3 (our primary outcome; b = -1.31, 95% confidence interval = -2.28 to -0.34). We did not observe other differences between groups at 3 months in secondary outcomes that included worst or average pain in the past week, depression symptoms, anxiety, and perceived overall mental and physical health. There were no differences between groups on any outcomes at 12 months after enrollment. CONCLUSIONS A targeted intervention can have positive effects on pain interference. At the end of intervention, effects we found were in a clinically significant range. However, effects diminished once the intervention period ended. TRIAL REGISTRATION ClinicalTrials.gov NCT02766751.
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Affiliation(s)
- Lisa A Uebelacker
- From the Departments of Psychiatry and Human Behavior (Uebelacker, Pinkston, Caviness, Herman, Abrantes) and Family Medicine (Uebelacker, Weisberg), Alpert Medical School of Brown University; Behavioral Medicine and Addictions Research (Uebelacker, Anderson, Caviness, Herman, Abrantes, Stein), Butler Hospital; Department of Medicine (Pinkston), Alpert Medical School of Brown University; Lifespan Physicians Group (Pinkston), The Miriam Hospital, Providence, Rhode Island; Department of Medicine (Busch, Baker), Hennepin Healthcare; Department of Medicine (Busch, Baker), University of Minnesota, Minneapolis, Minnesota; VA Boston Healthcare System (Weisberg); Department of Psychiatry (Weisberg), Boston University School of Medicine; and Department of Health Law, Policy and Management(Stein), Boston University School of Public Health, Boston, Massachusetts
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Kim TW, Samet JH, Lodi S, Kimmel SD, Forman LS, Lira MC, Liebschutz JM, Williams EC, Walley AY. Functional Impairment and Cognitive Symptoms Among People with HIV Infection on Chronic Opioid Therapy for Pain: The Impact of Gabapentin and Other Sedating Medications. AIDS Behav 2022; 26:3889-3896. [PMID: 35737281 PMCID: PMC11055610 DOI: 10.1007/s10461-022-03716-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2022] [Indexed: 11/01/2022]
Abstract
Gabapentin is associated with dizziness, falls, and somnolence yet commonly prescribed to people with HIV (PWH) treated with chronic opioid therapy (COT). Physical function and cognition are understudied when prescribed together. Among PWH on COT, we evaluated whether co-prescribed gabapentin is associated with (a) functional impairment; (b) trouble thinking clearly; and (c) difficulty controlling drowsiness using logistic regression models adjusted for prescribed opioid dose, other (non-gabapentin) sedating medication, substance use disorder, and mental/physical health indicators in a cross-sectional study. Among 166 participants, 40% were prescribed gabapentin, 41% reported functional impairment, 41% trouble thinking clearly, and 38% difficulty controlling drowsiness. Gabapentin co-prescribed with COT was significantly associated with trouble thinking clearly but not with functional impairment or difficulty controlling drowsiness. Clinicians should be cognizant of potential problems with thinking clearly when co-prescribing gabapentin and opioid medication.
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Affiliation(s)
- Theresa W Kim
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.
| | - Jeffrey H Samet
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Sara Lodi
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Simeon D Kimmel
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Leah S Forman
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, USA
| | - Marlene C Lira
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Jane M Liebschutz
- Division of General Internal Medicine, Department of Medicine, Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Emily C Williams
- Department of Health Services, University of Washington, Seattle, WA, USA
- Veterans Health Administration Health Services Research and Development, Center of Innovation for Veteran-Centered Value-Drive Care, Seattle, WA, USA
| | - Alexander Y Walley
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
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Derry-Vick HM, Johnston CD, Brennan-Ing M, Burchett CO, Glesby N, Zhu YS, Siegler EL, Glesby MJ. Pain Is Associated With Depressive Symptoms, Inflammation, and Poorer Physical Function in Older Adults With HIV. Psychosom Med 2022; 84:957-965. [PMID: 35980785 PMCID: PMC9553263 DOI: 10.1097/psy.0000000000001119] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 03/11/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE People living with HIV (PLWH) frequently experience pain, which often co-occurs with psychological symptoms and may impact functional outcomes. We investigated cross-sectional associations between pain, depressive symptoms, and inflammation, and then explored whether pain was related to poorer physical function among older PLWH. METHODS We examined data from PLWH aged 54 to 78 years ( n = 162) recruited from a single outpatient program for a larger study on HIV and aging. Participants reported depressive symptoms (10-item Center for Epidemiological Studies Depression Scale) and then attended a biomedical visit in which they reported past-month pain (Medical Outcomes Study-HIV pain subscale), completed physical function assessments, and provided blood samples (assayed for interleukin 6, interferon-γ, tumor necrosis factor α, and C-reactive protein). Links between pain, depressive symptoms, inflammation, and physical function were tested using linear regression models. RESULTS PLWH with greater depressive symptoms experienced more pain than did those with fewer depressive symptoms ( B = 1.31, SE = 0.28, p < .001), adjusting for age, sex, race, body mass index, smoking, disease burden, time since HIV diagnosis, and medication use. Higher composite cytokine levels were associated with worse pain ( B = 5.70, SE = 2.54, p = .027 in adjusted model). Poorer physical function indicators, including slower gait speed, weaker grip strength, recent falls, and prefrail or frail status, were observed among those with worse pain. Exploratory mediation analyses suggested that pain may partially explain links between depressive symptoms and several physical function outcomes. CONCLUSIONS Pain is a potential pathway linking depressive symptoms and inflammation to age-related health vulnerabilities among older PLWH; longitudinal investigation of this pattern is warranted. PLWH presenting with pain may benefit from multidisciplinary resources, including behavioral health and geriatric medicine approaches.
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Check DK, Bagett CD, Kim K, Roberts AW, Roberts MC, Robinson T, Oeffinger KC, Dinan MA. Predictors of Chronic Opioid Use: A Population-level Analysis of North Carolina Cancer Survivors Using Multi-Payer Claims. J Natl Cancer Inst 2021; 113:1581-1589. [PMID: 33881543 PMCID: PMC8562975 DOI: 10.1093/jnci/djab082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/22/2021] [Accepted: 04/13/2021] [Indexed: 11/13/2022] Open
Abstract
Background No population-based studies have examined chronic opioid use among cancer survivors who are diverse with respect to diagnosis, age group, and insurance status. Methods We conducted a retrospective cohort study using North Carolina cancer registry data linked with claims from public and private insurance (2006-2016). We included adults with nonmetastatic cancer who had no prior chronic opioid use (n = 38 366). We used modified Poisson regression to assess the adjusted relative risk of chronic opioid use in survivorship (>90-day continuous supply of opioids in the 13-24 months following diagnosis) associated with patient characteristics. Results Only 3.0% of cancer survivors in our cohort used opioids chronically in survivorship. Predictors included younger age (adjusted risk ratio [aRR] 50-59 vs 60-69 = 1.23, 95% confidence interval [CI] = 1.05 to 1.43), baseline depression (aRR = 1.22, 95% CI = 1.06 to 1.41) or substance use (aRR = 1.43, 95% CI = 1.15 to 1.78) and Medicaid (aRR vs private = 1.93, 95% CI = 1.56 to 2.40). Survivors who used opioids intermittently (vs not at all) before diagnosis were twice as likely to use opioids chronically in survivorship (aRR = 2.62, 95% CI = 2.28 to 3.02). Those who used opioids chronically (vs intermittently or not at all) during active treatment had a nearly 17-fold increased likelihood of chronic use in survivorship (aRR = 16.65, 95% CI = 14.30 to 19.40). Conclusions Younger and low-income survivors, those with baseline depression or substance use, and those who require chronic opioid therapy during treatment are at increased risk for chronic opioid use in survivorship. Our findings point to opportunities to improve assessment of psychosocial histories and to engage patients in shared decision-making around long-term pain management, when chronic opioid therapy is required during treatment.
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Affiliation(s)
| | | | - KyungSu Kim
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Megan C Roberts
- University of North Carolina at Chapel Hill, Chapel Hill, NC
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Pullen S, Marconi VC, Del Rio C, Head C, Nimmo M, O'Neil J, Ziebart M. From Silos to Solidarity: Case Study of a Patient-Centered, Integrative Approach to Opioid Tapering and Chronic Pain Mitigation in a Multidisciplinary AIDS Clinic. JOURNAL OF AIDS AND HIV TREATMENT 2021; 3:4-11. [PMID: 34263265 PMCID: PMC8277158 DOI: 10.33696/aids.3.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background: People with HIV (PWH) are at a disproportionate risk for experiencing both chronic pain and opioid use disorder (OUD). Prescription opioid tapering is typically addressed within the “silo model” of medical care, whereby attention is focused solely on opioid addiction rather than also addressing chronic pain management, and limited communication occurs between patient and providers. Objective: This descriptive case study examined an integrative, collaborative care model consisting of Provider, Physical Therapist (PT), and Patient aimed at decreasing chronic pain and opioid use within a multidisciplinary HIV/AIDS clinic. Method: A physical-therapy based model of chronic pain mitigation and physician-driven opioid tapering was implemented. The Provider, PT, and Patient worked collaboratively to address physiological pain, pain coping skills and opioid tapering. A patient case example was used to illustrate the implementation of the model for a future, larger study in the same patient population. Results: This model was feasible in this case example in terms of clinic workflow and acceptability to both the Patient and Providers in this clinic. After the intervention, the Patient’s pain was fully eliminated, and he had ceased all opioid use. Conclusion: Results of this case study suggest that utilizing an integrative, patient-centered approach to both chronic pain management and opioid tapering may be feasible within the context of a multidisciplinary HIV/AIDS clinic. Generalizability is limited by case study model; however, this gives insight into the value of a collaborative alternative compared to a “silo” model of opioid tapering and chronic pain management in preparation for a larger study.
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Affiliation(s)
- S Pullen
- Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - V C Marconi
- Emory University School of Medicine, Department of Medicine, Division of Infectious Diseases, Atlanta, GA, United States.,Emory University Rollins School of Public Health, Department of Global Health, Atlanta, GA, United States
| | - C Del Rio
- Emory University School of Medicine, Department of Medicine, Division of Infectious Diseases, Atlanta, GA, United States.,Emory University Rollins School of Public Health, Department of Global Health, Atlanta, GA, United States
| | - C Head
- Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - M Nimmo
- Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - J O'Neil
- Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - M Ziebart
- Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, United States
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Ngo B, Liebschutz JM, Cheng DM, Colasanti JA, Merlin JS, Armstrong WS, Forman LS, Lira MC, Samet JH, Del Rio C, Tsui JI. Hazardous alcohol use is associated with greater pain interference and prescription opioid misuse among persons living with HIV and chronic pain. BMC Public Health 2021; 21:564. [PMID: 33752634 PMCID: PMC7986380 DOI: 10.1186/s12889-021-10566-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Alcohol use is common among persons living with HIV (PLWH), who often experience chronic pain, yet its impact on pain and opioid misuse is not fully characterized. METHODS We assessed associations between hazardous alcohol use and pain interference, defined as the self-reported impact of pain on daily living, pain severity, and risk for opioid misuse among PLWH who were on long-term opioid therapy (LTOT). A cohort was recruited as part of the "Targeting Effective Analgesia in Clinics for HIV" (TEACH) study, a randomized controlled trial to improve LTOT in HIV clinics. The Alcohol Use Disorders Test (AUDIT), Brief Pain Inventory (BPI) and the Current Opioid Misuse Measure (COMM) were administered at both baseline and 12-months. Linear mixed and generalized estimating equation models, incorporating data from both time points, evaluated associations between hazardous alcohol use (AUDIT ≥8) and: pain interference (0-10), pain severity (0-10), and opioid misuse risk (COMM ≥13), adjusting for age, gender, depressive symptoms, use of non-alcohol substances, time-point, and study-arm. RESULTS The sample was comprised of 166 participants, of which 31 (19%) reported hazardous alcohol use. The majority were male (65%), black (72%), and the mean age was 54 (range: 29-77). Hazardous alcohol use was significantly associated with higher pain interference (adjusted mean difference [AMD]: 1.02; 95% CI: 0.08, 1.96) and higher odds of opioid misuse risk (AOR: 3.73, 95% CI: 1.88-7.39), but not pain severity (AMD: 0.47, 95% CI: - 0.35, 1.29). CONCLUSIONS Hazardous alcohol use was associated with greater functional impairment in daily living from their pain and higher odds for prescription opioid misuse in this study of PLWH on LTOT. Providers should be attentive to alcohol use among PLWH who are prescribed opioids given associations with pain and opioid misuse. TRIAL REGISTRATION ClinicalTrials.gov NCT02564341 (Intervention, September 30, 2015) and NCT02525731 (Patient Cohort, August 17, 2015). Both prospectively registered.
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Affiliation(s)
- Belle Ngo
- University of Washington School of Medicine, Seattle, WA, USA
| | - Jane M Liebschutz
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Debbie M Cheng
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jonathan A Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jessica S Merlin
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Wendy S Armstrong
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Leah S Forman
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Marlene C Lira
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jeffrey H Samet
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Carlos Del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Judith I Tsui
- University of Washington School of Medicine, Seattle, WA, USA.
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