Opioid-Prescribing Practices and Provider Confidence Recognizing Opioid Analgesic Abuse in HIV Primary Care Settings

Drug-related physician continuing medical education requirements, 2010-2020

INTRODUCTION

The crisis of drug-related harm in the United States continues to worsen. While prescription-related overdoses have fallen dramatically, they are still far above pre-2010 levels. Physicians can reduce the risk of overdose and other drug-related harms by improving opioid prescribing practices and ensuring that patients are able to easily access medications for substance use disorder treatment. Most physicians received little or no training in those subjects in medical school. It is possible that continuing medical education can improve physician knowledge of appropriate prescribing and substance use disorder treatment and patient outcomes.

METHODS

Descriptive legal review. Laws in all 50 states and the District of Columbia were searched for provisions that require all or most physicians to receive either one-time or continuing medical education regarding controlled substance prescribing, pain management, or substance use disorder treatment.

RESULTS

There has been a rapid increase in the number of states with relevant requirements, from three states at the end of 2010 to 42 at the end of 2020. The frequency and duration of required education varied substantially across states. In all states, the number of hours required in relevant topics is a small fraction of overall required continuing education, an average of 1 h per year. Despite recent shifts in the substances driving overdose, most requirements remain focused on opioids.

CONCLUSION

While most states have now adopted continuing education requirements regarding controlled substance prescribing, pain management, or substance use disorder treatment, these requirements comprise a small component of the required post-training education requirements. Research is needed to determine whether this training translates into reductions in drug-related harm.

Confidence in providing methadone maintenance treatment of primary care providers in Vietnam

BACKGROUND

Delivering methadone treatment in community health facilities by primary care providers is a task-shifting strategy to expand access to drug use treatment, especially in rural mountainous areas. This study aims to investigate factors related to confidence in providing methadone treatment among primary care providers in Vietnam to inform good practice development.

METHODS

We conducted a cross-sectional survey with 276 primary care providers who were physicians, physician assistants, nurses, pharmacists or dispensing staff from 67 communes in a mountainous province in Northern Vietnam. Using self-report scales, we measured providers' confidence in providing methadone treatment, beliefs in harm reduction, perceived work-related support, perceived stigma and risk in working with drug-using patients, and empathy towards this population. We used multiple linear regression analyses to explore factors associated with providers' confidence in providing methadone treatment in the whole sample and to compare two groups of providers who did and did not have experience providing methadone. Potential associated factors were measured at facility and provider levels.

RESULT

114 (41.3%) participants had previously experience in providing methadone treatment. Providers with methadone treatment experiences had higher confidence in and more accurate knowledge of methadone treatment, perceived less stigma of working with drug-using patients, and reported more work-related support than those without experiences. Higher medical education is associated with lower confidence in providing methadone treatment among providers without methadone experiences, but higher confidence among providers with methadone experiences. Better methadone knowledge was associated with greater confidence in providing methadone treatment among inexperienced providers but not among those with experiences. Receiving work-related support was associated with greater confidence in providing treatment in both groups, regardless of their past methadone experiences.

CONCLUSION

In rural provinces where methadone treatment has been expanded to primary care clinics, interventions to improve primary care providers' confidence should benefit professionals with diverse experiences in providing methadone treatment. Continued training and support at work for providers is essential to ensuring quality in decentralized methadone treatment.

Self-medication of pain and discomfort with alcohol and other substances by people with HIV infection and substance use disorder: preliminary findings from a secondary analysis

There is a limited literature regarding factors associated with self-medication of pain and discomfort using alcohol, non-prescription substances or overuse of prescription medications among people living with Human Immunodeficiency Virus (HIV). This cross-sectional analysis used data from the Boston ARCH Cohort among participants with HIV infection and a history of alcohol or other substance use. Among 248 participants, 37% were female, 50% Black, 25% Latinx; 36% reported fair to poor health and 89% had CD4 cell counts >200/mm3. Half reported self-medication and of those, 8.8% reported doing so only with alcohol, 48.8% only with other substances and 42.4% with both alcohol and other substances. Those reporting self-medication were significantly (p < .05) younger (mean 47 vs 50 years), less employed (11% vs 21%), and less likely to have HIV viral suppression (60% vs. 80%). Depression, anxiety, and HIV symptoms were associated with significantly greater odds of self-medicating, as were substance dependence, recent injection substance use, heavy alcohol use, cocaine use, opioid use, sedative use, and cannabis use. Self-medication, highly prevalent and associated with worse mental health symptoms, greater substance use, and lesser HIV disease control, should be explored by HIV clinicians caring for people who use substances.

Stimulant use and opioid-related harm in patients on long-term opioids for chronic pain

BACKGROUND

There is lack of clarity regarding the impact of and optimal clinical response to stimulant use among people prescribed long-term opioid therapy (LTOT) for pain.

OBJECTIVE

To determine if a positive urine drug test (UDT) for stimulants was associated with subsequent opioid-related harm or discontinuation of LTOT.

DESIGN

Retrospective cohort study.

PATIENTS

People living with and without HIV living in a major metropolitan area with public insurance, prescribed LTOT for chronic, non-cancer pain (n=600).

MAIN MEASURES

UDT results from January 2012 to June 2019 were evaluated against 1) opioid-related emergency department (ED) visits (oversedation, constipation, infections associated with injecting opioids, and opioid seeking) or death in each 90-day period following a UDT, using logistic regression, and 2) LTOT discontinuation.

RESULTS

There were no opioid overdose deaths within 90 days following a stimulant-positive UDT. A stimulant-positive UDT was not statistically significantly associated with opioid-related ED visits within 90 days (adjusted odds ratio [aOR] 1.39; 95% CI=0.88-2.21). Stimulant-positive UDT was independently associated with subsequent discontinuation of LTOT within 90 days (aOR 2.96; 95% CI=2.13 - 4.12). Living with HIV was independently associated with decreased odds of LTOT discontinuation (aOR 0.65; 95% CI 0.43 - 0.99).

CONCLUSIONS

Despite no association between a stimulant-positive UDT and subsequent opioid-related harm, there was an association with subsequent LTOT discontinuation, with heterogeneity across clinical groups. Detection of stimulant use should result in a discussion of substance use and risk, rather than reflex LTOT discontinuation.

Opioid misuse among people with HIV: results from the National Survey on Drug Use and Health (NSDUH) 2015-2019

Aim: Pain is a major challenge in the management of HIV/AIDS. This research analyzed the prevalence of substance use and opioid misuse among people with HIV (PWH) and those without (PWoH) in the USA. Methods: Using data from the 2015-2019 National Survey on Drug Use and Health, the study assessed misuse of pain relievers and opioids in 279,025 individuals. Results: PWH were about 1.88-times more likely to misuse pain relievers and 1.85-times to misuse opioids than PWoH, with a notable rise in hydrocodone and tramadol misuse. Conclusion: The data highlights an imperative for interventions targeting substance misuse among PWH, addressing the complex nexus of HIV, chronic pain and opioid use.

Engagement in HIV care and viral suppression following changes in long-term opioid therapy for treatment for chronic pain

Chronic pain is common among persons living with HIV and changes in opioid prescribing practices may complicate HIV care management. Using medical record data from a retrospective cohort study conducted January 1, 2012 to June 30, 2019 for 300 publicly insured HIV-positive primary care patients prescribed opioids for chronic non-cancer pain in San Francisco, we examined associations between opioid dose changes and both time to disengagement from HIV care and experiencing virologic failure using logistic regression. Discontinuation of prescribed opioids was associated with increased odds of disengagement in care at 3, 6, and 9 months after discontinuation. There were no associations with virologic failure. Providers and policy makers must weigh impacts on HIV care when implementing necessary changes in opioid prescribing.

Practices, attitudes, and confidence related to tobacco treatment interventions in HIV clinics: a multisite cross-sectional survey

Tobacco use disorder (TUD) is a major threat to health among people with HIV (PWH), but it is often untreated. Among HIV clinicians and staff, we sought to characterize practices, attitudes, and confidence addressing TUD among PWH to identify potential opportunities to enhance provision of care. Cross-sectional deidentified, web-based surveys were administered from November 4, 2020 through December 15, 2020 in HIV clinics in three health systems in the United States Northeast. Surveys assessed provider characteristics and experience, reported practices addressing tobacco use, and knowledge and attitudes regarding medications for TUD. Chi-square tests or Fisher's exact tests were used to examine differences in responses between clinicians and staff who were prescribers versus nonprescribers and to examine factors associated with frequency of prescribing TUD medications. Among 118 survey respondents (56% prescribers), only 50% reported receiving prior training on brief smoking cessation interventions. Examining reported practices identified gaps in the delivery of TUD care, including counseling patients on the impact of smoking on HIV, knowledge of clinical practice guidelines, and implementation of assessment and brief interventions for smoking. Among prescribers, first-line medications for TUD were infrequently prescribed and concerns about medication side effects and interaction with antiretroviral treatments were associated with low frequency of prescribing. HIV clinicians and staff reported addressable gaps in their knowledge, understanding, and practices related to tobacco treatment. Additional work is needed to identify ways to ensure adequate training for providers to enhance the delivery of TUD treatment in HIV clinic settings.

Community Capacity Building for HIV and Addiction Service Integration: An Intervention Trial in Vietnam

Scientific findings and policy guidelines recommend integrating HIV and drug addiction prevention and care into community-based settings. Systematic capacity-building efforts are warranted to provide technical support for community health workers and improve their confidence in the integrated service provision. An intervention trial was conducted between 2018 and 2019 with 120 community health workers (CHW) from 60 communes in Vietnam’s four provinces. The 60 intervention CHW received in-person training to enhance their HIV/addiction-related service knowledge and skills. Online support groups were established between trained CHW and local HIV and addiction specialists. The intervention outcomes were assessed using mixed-effects regression models with the data collected at baseline and every 3 months for 1 year. Adjusted analyses showed that intervention CHW reported a significant increase in the interaction with other treatment providers than the control group at 6 months and remained at the 12-month follow-up. The difference in the improvement of confidence in HIV/addiction-related service delivery between the intervention and control groups was significant at 6-month but became insignificant at the 12-month. Male CHW were more confident in providing services than female CHW at baseline, and gender differences in the changing patterns were observed over time. This capacity-building intervention demonstrated promising outcomes on CHW inter-agency collaborations and confidence in service delivery. Gender divides in healthcare professionals should be attended to in future studies.

Opioid use disorder treatment in rural settings: The primary care perspective

Despite the efficacy of medications for treating opioid use disorder (OUD), they are underutilized, especially in rural areas. Our objectives were to determine the association between primary care practitioners (PCPs) rurality and concerns for patient substance use, and to identify factors associated with PCP comfort treating OUD, focusing on barriers to treatment. We developed a web-based survey completed by 116 adult-serving PCPs located in Vermont's rural and non-rural counties between April-August 2020. The instrument included PCP-identified concerns for substance use among patients, barriers to treating patients with OUD, and current level of comfort treating patients with OUD. On a scale from 0 to 10, rural PCPs reported higher concern for heroin (mean difference; Mdiff = 1.38, 95% CI: 0.13 to 2.63), fentanyl (Mdiff = 1.52, 95% CI: 0.29 to 2.74), and methamphetamine (Mdiff = 1.61, 95% CI: 0.33 to 2.90) use among patients compared to non-rural PCPs, and practitioners in both settings expressed high concern regarding their patients' use of tobacco (7.6 out of 10) and alcohol (7.0 out of 10). There was no difference in reported comfort in treating patients with OUD among rural vs. non-rural PCPs (Mdiff = 0.65, 95%CI: 0.17 to 1.46; P = 0.119), controlling for higher comfort among male PCPs and those waivered to prescribe buprenorphine (Ps < 0.05). Lack of training/experience and medication diversion were PCP-identified barriers associated with less comfort treating OUD patients, while time constraints was associated with more comfort (Ps < 0.05). Taken together, these data highlight important areas for dissemination of evidence-based training, support, and resources to expand OUD treatment capacity in rural communities.

A SMARTTT approach to Treating Tobacco use disorder in persons with HIV (SMARTTT): Rationale and design for a hybrid type 1 effectiveness-implementation study

BACKGROUND

Tobacco use disorder is a leading threat to the health of persons with HIV (PWH) on antiretroviral treatment and identifying optimal treatment approaches to promote abstinence is critical. We describe the rationale, aims, and design for a new study, "A SMART Approach to Treating Tobacco Use Disorder in Persons with HIV (SMARTTT)," a sequential multiple assignment randomized trial.

METHODS

In HIV clinics within three health systems in the northeastern United States, PWH with tobacco use disorder are randomized to nicotine replacement therapy (NRT) with or without contingency management (NRT vs. NRT + CM). Participants with response (defined as exhaled carbon monoxide (eCO)-confirmed smoking abstinence at week 12), continue the same treatment for another 12 weeks. Participants with non-response, are re-randomized to either switch medications from NRT to varenicline or intensify treatment to a higher CM reward schedule. Interventions are delivered by clinical pharmacists embedded in HIV clinics. The primary outcome is eCO-confirmed smoking abstinence; secondary outcomes include CD4 cell count, HIV viral load suppression, and the Veterans Aging Cohort Study (VACS) Index 2.0 score (a validated measure of morbidity and mortality based on laboratory data). Consistent with a hybrid type 1 effectiveness-implementation design and grounded in implementation science frameworks, we will conduct an implementation-focused process evaluation in parallel. Study protocol adaptations related to the COVID-19 pandemic have been made.

CONCLUSIONS

SMARTTT is expected to generate novel findings regarding the impact, cost, and implementation of an adaptive clinical pharmacist-delivered intervention involving medications and CM to promote smoking abstinence among PWH. ClinicalTrials.govidentifier:NCT04490057.

Improving the Delivery of Chronic Opioid Therapy Among People Living With Human Immunodeficiency Virus: A Cluster Randomized Clinical Trial

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.

Readiness to Provide Medications for Addiction Treatment in HIV Clinics: A Multisite Mixed-Methods Formative Evaluation

BACKGROUND

We sought to characterize readiness, barriers to, and facilitators of providing medications for addiction treatment (MAT) in HIV clinics.

SETTING

Four HIV clinics in the northeastern United States.

METHODS

Mixed-methods formative evaluation conducted June 2017-February 2019. Surveys assessed readiness [visual analog scale, less ready (0-<7) vs. more ready (≥7-10)]; evidence and context ratings for MAT provision; and preferred addiction treatment model. A subset (n = 37) participated in focus groups.

RESULTS

Among 71 survey respondents (48% prescribers), the proportion more ready to provide addiction treatment medications varied across substances [tobacco (76%), opioid (61%), and alcohol (49%) treatment medications (P values < 0.05)]. Evidence subscale scores were higher for those more ready to provide tobacco [median (interquartile range) = 4.0 (4.0, 5.0) vs. 4.0 (3.0, 4.0), P = 0.008] treatment medications, but not significantly different for opioid [5.0 (4.0, 5.0) vs. 4.0 (4.0, 5.0), P = 0.11] and alcohol [4.0 (3.0, 5.0) vs. 4.0 (3.0, 4.0), P = 0.42] treatment medications. Median context subscale scores ranged from 3.3 to 4.0 and generally did not vary by readiness status (P values > 0.05). Most favored integrating MAT into HIV care but preferred models differed across substances. Barriers to MAT included identification of treatment-eligible patients, variable experiences with MAT and perceived medication complexity, perceived need for robust behavioral services, and inconsistent availability of on-site specialists. Facilitators included knowledge of adverse health consequences of opioid and tobacco use, local champions, focus on quality improvement, and multidisciplinary teamwork.

CONCLUSIONS

Efforts to implement MAT in HIV clinics should address both gaps in perspectives regarding the evidence for MAT and contextual factors and may require substance-specific models.

Common and Challenging Behaviors Among Individuals on Long-term Opioid Therapy

OBJECTIVE

Long-term opioid therapy (LTOT) is commonly prescribed for chronic pain, despite risks such as opioid use disorder (OUD) and overdose. Caring for patients on LTOT can be difficult, given lack of evidence about assessment of challenging behaviors among patients on LTOT. To develop this evidence, a critical first step is to systematically identify the common and challenging behaviors that primary care providers encounter among patients on LTOT, and also to highlight to diverse range of behaviors encountered.

METHOD

We conducted a Delphi study in 42 chronic pain experts to determine consensus on how to address the top common and challenging behaviors. This paper reports on the first round of the study, which elicited a range of behaviors. We conducted thematic analysis of the behaviors and also used the Diagnostic and Statistical Manual (DSM)-5 criteria for OUD as a priori codes.

RESULTS

In all, 124 unique behaviors were identified by participants and coded into 4 thematic categories: concerning behaviors that map onto DSM-5 criteria for OUD, and those that do not which were: behaviors that suggest deception, signs of diversion, and nonadherence to treatment plan. Those behaviors that fell outside of OUD criteria we identified as "gray zone" behaviors.

CONCLUSIONS

While some of these challenging behaviors fall under the criteria for an OUD, many fall outside of this framework, making diagnosis and treatment difficult, and consensus on how to deal with these "gray zone" behaviors is vital. Future research should explore how these "gray zone" behaviors can best be assessed and managed in a primary care setting.

Hazardous alcohol use is associated with greater pain interference and prescription opioid misuse among persons living with HIV and chronic pain

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.

Chronic High Risk Prescription Opioid Use Among Persons With HIV

Persons with HIV (PWH) are a population at risk for adverse sequelae of opioid use. Yet, few studies have examined correlates of chronic high risk opioid use and its impact on HIV outcomes. Trends in prescribing patterns and identification of factors that impact the use of opioid prescriptions among PWH are crucial to determine prevention and treatment interventions. This study examined electronic medical records (EMR) of patients receiving HIV care to characterize prescribing patterns and identify risk factors for chronic high risk prescription opioid use and the impact on HIV outcomes among PWH in primary care from July 1, 2016-December 31, 2017. EMR were analyzed from 8,882 patients who were predominantly male and ethnically and racially diverse with half being 50 years of age or older. The majority of the 8,744 prescriptions (98% oral and 2% transdermal preparations) given to 1,040 (12%) patients were oxycodone (71%), 8% were morphine, 7% tramadol, 4% hydrocodone, 4% codeine, 2% fentanyl, and 4% were other opioids. The number of monthly prescriptions decreased about 14% during the study period. Bivariate analyses indicated that most demographic and clinical variables were associated with receipt of any opioid prescription. After controlling for patient socio-demographic characteristics and clinical factors, the odds of receipt of any prescription were higher among patients with pain diagnoses and opioid use and mental health disorders. In addition, the odds of receipt of high average daily morphine equivalent dose (MED) prescriptions were higher for patients with pain diagnoses. Lastly, patients with substance use disorders (SUD) had an increased likelihood of detectable viral load compared to patients with no SUD, after adjusting for known covariates. Our findings show that despite opioid prescribing guidelines and monitoring systems, additional efforts are needed to prevent chronic high risk prescriptions in patients with comorbid conditions, including pain-related, mental health and substance use disorders. Evidence about the risk for chronic high risk use based on prescribing patterns could better inform pain management and opioid prescribing practices for patients receiving HIV care.

Working with HIV clinics to adopt addiction treatment using implementation facilitation (WHAT-IF?): Rationale and design for a hybrid type 3 effectiveness-implementation study

BACKGROUND

Tobacco, alcohol and opioid misuse are associated with substantial morbidity and mortality among people with HIV (PWH). Despite existence of evidence-based counseling and medications for addiction, these treatments are infrequently offered in HIV clinics. The Working with HIV clinics to adopt Addiction Treatment using Implementation Facilitation (WHAT-IF?) study was conducted to address this implementation challenge. The study's goals were to conduct a formative evaluation of barriers to and facilitators of implementing addiction treatment for PWH followed by an evaluation of the impact of Implementation Facilitation (IF) on promoting adoption of addiction treatments and clinical outcomes.

METHODS

The study was conducted at four HIV clinics in the northeast United States, using a hybrid type 3 effectiveness-implementation stepped wedge design and guided by the Promoting Action on Research Implementation in Health Services Research (PARiHS) framework. A mixed-methods approach was used to identify evidence, context, and facilitation-related barriers to and facilitators of integration of addiction treatments into HIV clinics and to help tailor IF for each clinic. An evaluation was then conducted of the impact of IF on implementation outcomes, including provision of addiction treatment (primary outcome), organizational and clinician and staff readiness to adopt addiction treatment, and changes in organizational models of care used to deliver addiction treatment. The evaluation also included IF's impact on effectiveness outcomes, specifically HIV-related outcomes among patients eligible for addiction treatment.

CONCLUSIONS

Results will generate important information regarding the impact of IF as a reproducible strategy to promote addiction treatment in HIV clinics.

Determinants of healthcare providers' confidence in their clinical skills to deliver quality obstetric and newborn care in Uganda and Zambia

Background

Poor quality obstetric and newborn care persists in sub-Saharan Africa and weak provider competence is an important contributor. To be competent, providers need to be both knowledgeable and confident in their ability to perform necessary clinical actions. Confidence or self-efficacy has not been extensively studied but may be related to individuals’ knowledge, ability to practice their skills, and other modifiable factors. In this study, we investigated how knowledge and scope of practice are associated with provider confidence in delivering obstetric and newborn health services in Uganda and Zambia.

Methods

This study was a secondary analysis of data from an obstetric and newborn care program implementation evaluation. Provider knowledge, scope of practice (completion of a series of obstetric tasks in the past 3 months) and confidence in delivering obstetric and newborn care were measured post intervention in intervention and comparison districts in Uganda and Zambia. We used multiple linear regression models to investigate the extent to which exposure to a wider range of clinical tasks associated with confidence, adjusting for facility and provider characteristics.

Results

Of the 574 providers included in the study, 69% were female, 24% were nurses, and 6% were doctors. The mean confidence score was 71%. Providers’ mean knowledge score was 56% and they reported performing 57% of basic obstetric tasks in the past 3 months. In the adjusted model, providers who completed more than 69% of the obstetric tasks reported a 13-percentage point (95% CI 0.08, 0.17) higher confidence than providers who performed less than 50% of the tasks. Female providers and nurses were considerably less confident than males and doctors. Provider knowledge was moderately associated with provider confidence.

Conclusions

Our study showed that scope of practice (the range of clinical tasks routinely performed by providers) is an important determinant of confidence. Ensuring that providers are exposed to a variety of services is crucial to support improvement in provider confidence and competence. Policies to improve provider confidence and pre-service training should also address differences by gender and by cadres.

Trajectories of Self-Reported Opioid Use Among Patients With HIV Engaged in Care: Results From a National Cohort Study

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.

Chronic Opioid Therapy in People Living With Human Immunodeficiency Virus: Patients' Perspectives on Risks, Monitoring, and Guidelines

Background

Chronic opioid therapy (COT) is common in people living with human immunodeficiency virus (PLHIV), but is not well studied. We assessed opioid risk behaviors, perceptions of risk, opioid monitoring, and associated Current Opioid Misuse Measure (COMM) scores of PLHIV on COT.

Methods

COT was defined as ≥3 opioid prescriptions ≥21 days apart in the past 6 months. Demographics, substance use, COMM score, and perceptions of and satisfaction with COT monitoring were assessed among PLHIV on COT from 2 HIV clinics.

Results

Among participants (N = 165) on COT, 66% were male and 72% were black, with a median age of 55 (standard deviation, 8) years. Alcohol and drug use disorders were present in 17% and 19%, respectively. In 43%, the COMM score, a measure of potential opioid misuse, was high. Thirty percent had an opioid treatment agreement, 66% a urine drug test (UDT), and 12% a pill count. Ninety percent acknowledged opioids' addictive potential. Median (interquartile range) satisfaction levels (1-10 [10 = highest]) were 10 (7-10) for opioid treatment agreements, 9.5 (6-10) for pill counts, and 10 (8-10) for UDT. No association was found between higher COMM score and receipt of or satisfaction with COT monitoring.

Conclusions

Among PLHIV on COT, opioid misuse and awareness of the addictive potential of COT are common, yet COT monitoring practices were not guideline concordant. Patients who received monitoring practices reported high satisfaction. Patient attitudes suggest high acceptance of guideline concordant care for PLHIV on COT when it occurs.

Predictors of Medication Utilization for Opioid Use Disorder Among Medicaid-Insured HIV Patients in New York

BACKGROUND AND OBJECTIVES

This paper investigates the prevalence and predictors for opioid use disorder (OUD) pharmacotherapy utilization for Medicaid-insured patients with human immunodeficiency virus (HIV) in New York.

METHODS

We identified patients with HIV and OUD in 2014 in the New York State Medicaid claims data (n = 5621). The claims were used to identify individual client medication for addiction treatment (MAT) utilization, demographic information, and other medical and psychiatric health conditions. The logistic regression analyses were performed to explore the potential predictors of MAT service utilization among people with HIV and OUD.

RESULTS

Of 5621 identified patients with HIV and OUD, 3647 (65%) received some type of MAT. Eighty-seven percent of treated patients received methadone while 10% received buprenorphine and 3% utilized both the therapies.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

A substantial number of patients with HIV and OUD did not receive MAT. Findings suggest that there are opportunities to improve OUD care for patients with HIV and OUD, particularly among the younger generation, blacks, individuals living outside of New York City, and among those with serious psychiatric conditions. This initial study suggests that an additional research is needed to better understand how the gap in care affects this population. (Am J Addict 2020;29:151-154).

Preferences for implementation of HIV pre-exposure prophylaxis (PrEP): Results from a survey of primary care providers

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PrEP implementation in primary care has been slow.

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Primary care providers equally favor training all vs. having a PrEP specialist.

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Efforts to promote knowledge of clinical guidelines may enhance PrEP implementation.

Primary care physicians (PCPs) are critical for promoting HIV prevention by prescribing pre-exposure prophylaxis (PrEP). Yet, there are limited data regarding PCP’s preferred approaches for PrEP implementation. In 2015, we conducted an online survey of PCPs’ PrEP prescribing and implementation. Participants were general internists recruited from a national professional organization. We examined provider and practice characteristics and perceived implementation barriers and facilitators associated with preferred models for PrEP implementation. Among 240 participants, the majority (85%) favored integrating PrEP into primary care, either by training all providers (“all trained”) (42%) or having an onsite PrEP specialist (“on-site specialist”) (43%). Only 15% preferred referring patients out of the practice to a specialist (“refer out”). Compared to those who preferred to “refer out,” participants who preferred the “all trained” model were more likely to spend most of their time delivering direct patient care and to practice in the Northeast. Compared to participants who preferred the “refer out” or on-site specialist” models, PCPs preferring the all trained model were less likely to perceive lack of clinic PrEP guidelines/protocols as a barrier to PrEP. Most PCPs favored integrating PrEP into primary care by either training all providers or having an on-site specialist. Time devoted to clinical care and geography may influence preferences for PrEP implementation. Establishing clinic-specific PrEP protocols may promote on-site PrEP implementation. Future studies should focus on evaluating the effectiveness of different PrEP implementation models on PrEP delivery.

Provider opioid prescribing practices and the belief that opioids keep people living with HIV engaged in care: a cross-sectional study

We describe HIV providers' opioid prescribing practices and assess whether belief that chronic opioid therapy (COT) keeps people living with HIV (PLWH) engaged in care is associated with differences in these practices among providers from two HIV clinics. We conducted logistic regression to evaluate the association between the belief that COT keeps PLWH engaged in care and at least one component of guideline-recommended care (i.e., urine drug tests, treatment agreements, and/or prescription monitoring program use). The sample included 41 providers with a median age of 42 years, 63% female, 37% non-white. Routine adherence to guideline-recommended practices was: 34% urine drug tests, 27% treatment agreements, and 17% prescription monitoring program. Over half [54%] agreed that COT keeps PLWH engaged in care. There was no significant association between belief that COT keeps PLWH engaged in care and routinely providing any recommended COT care component (aOR 2.38; 95% CI 0.65-8.73). Most HIV providers do not routinely follow guidelines for opioid prescribing. We observed a positive association between belief that COT keeps PLWH engaged in care and following any guideline-recommended prescribing practices, although the result was not statistically significant. Interventions are needed to improve guideline-concordant care for COT by HIV providers.

HIV Physicians and Chronic Opioid Therapy: It's Time to Raise the Bar

Clinical practice that utilizes chronic opioid therapy has been recognized as one major cause of the opioid crisis. Among patients living with HIV, the risks associated with chronic opioid therapy may be complicated by factors such as co-occurring mental health diagnoses, substance use, and economic marginalization. Improving opioid prescribing practices in HIV clinics requires attention to these and other characteristics common to HIV care. In the context of a randomized controlled trial testing an intervention to improve opioid prescribing practices in HIV outpatient clinics, we interviewed physicians about their perspectives on chronic opioid therapy. Overwhelmingly, physicians voiced ambivalence about their own knowledge and comfort with prescription opioids. They raised concerns about the impact of opioid prescribing on patient-provider relationships and the increasing workload associated with prescribing and monitoring patients. In this report, we explore these concerns and propose several strategies for improving clinical care in which chronic opioid therapy is addressed.

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

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.

"No more falling through the cracks": A qualitative study to inform measurement of integration of care of HIV and opioid use disorder

INTRODUCTION

Integration of HIV- and opioid use disorder (OUD)-related care is associated with improved patient outcomes. Our goal was to develop a novel instrument for measuring quality of integration of HIV and OUD-related care that would be applicable across diverse care settings.

METHODS

Grounded in community-based participatory research principles, we conducted a qualitative study from August through November 2017 to inform modification of the Behavioral Health Integration in Medical Care (BHIMC) instrument, a validated measure of quality of integration of behavioral health in primary care. We conducted semi-structured interviews of patients (n = 22), focus groups with clinical staff (n = 24), and semi-structured interviews of clinic leadership (n = 5) in two urban centers in Connecticut.

RESULTS

We identified three themes that characterize optimal integration of HIV- and OUD-related care: (1) importance of mitigating mismatches in resources and knowledge, particularly resources to address social risks and knowledge gaps about evidence-based treatments for OUD; (2) need for patient-centered policies and inter-organization communication, and (3) importance of meeting people where they are, geographically and at their stage of change. These themes highlighted aspects of integrated care for HIV and OUD not captured in the original BHIMC.

CONCLUSIONS

Patients, clinical staff, and organization leadership perceive that addressing social risks, communication across agencies, and meeting patients in their psychosocial and structural context are important for optimizing integration of HIV and OUD-related care. Our proposed, novel instrument is a step towards measuring and improving service delivery locally and nationally for this vulnerable population.

Opioid misuse and perceived smoking-pain relationships among HIV+ individuals with pain: Exploring negative affect responses to pain

Persons living with HIV/AIDS (PLWHA) report high rates of clinically significant pain that is associated with several negative outcomes, including higher CD4 T-cell count, poor medication adherence, and substance use and misuse. Importantly, PLWHA also report elevated rates of both opioid and tobacco use, and these elevated rates have often been associated with increased pain experience. Although research suggests that negative affective responses to pain may be uniquely associated with substance misuse among individuals in the general population, little work has examined these relations among PLWHA. The current study examined negative emotions in response to pain as a predictor of current opioid misuse, future opioid misuse, and perceived smoking-pain relationships among 66 (M_age = 51.26, SD = 8.00, 60.6% male) HIV+ adults with co-occurring pain. Results indicated that negative emotions in response to pain uniquely predicted each of the substance use outcomes, with clinically significant effect sizes that may be characterized as medium in magnitude. Overall, these findings suggest that negative affective responses to pain may play a role in prescription opioid misuse and smoking among PLWHA. These findings may inform the development of tailored interventions for PLWHA smokers who are prescribed opioid pain medications.

Lessons learnt from establishing a high dose opioid review clinic for people living with HIV

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.

Williams AC. Psychosocial factors associated with persistent pain in people with HIV: a systematic review with meta-analysis

Chronic pain remains a prevalent and disabling problem for people living with HIV in the current antiretroviral treatment era. Psychosocial treatments may have promise for managing the impact of this pain. However, research is needed to identify psychosocial processes to target through such treatments. The current systematic review and meta-analysis examined the evidence for psychosocial factors associated with pain, disability, and quality of life in people living with HIV and persistent pain. Observational and experimental studies reporting on the association between one or more psychosocial factors and one or more pain-related variables in an adult sample of people living with HIV and pain were eligible. Two reviewers independently conducted eligibility screening, data extraction, and quality assessment. Forty-six studies were included in the review and 37 of these provided data for meta-analyses (12,493 participants). "Some" or "moderate" evidence supported an association between pain outcomes in people with HIV and the following psychosocial factors: depression, psychological distress, posttraumatic stress, drug abuse, sleep disturbance, reduced antiretroviral adherence, health care use, missed HIV clinic visits, unemployment, and protective psychological factors. Surprisingly, few studies examined protective psychological factors or social processes, such as stigma. There were few high-quality studies. These findings can inform future research and psychosocial treatment development in this area. Greater theoretical and empirical focus is needed to examine the role of protective factors and social processes on pain outcomes in this context. The review protocol was registered with PROSPERO (CRD42016036329).

Duration of opioid prescriptions predicts incident nonmedical use of prescription opioids among U.S. veterans receiving medical care

BACKGROUND/AIMS

Although nonmedical use of prescription opioids (NMUPO) is a public health problem, few studies have examined the new-onset NMUPO in clinical populations. We estimated NMUPO incidence among veterans in medical care who had received prescription opioid medication and examined correlates of new-onset NMUPO.

DESIGN

Prospective cohort study.

SETTING

Veterans Health Administration primary care and infectious disease clinics in Atlanta, Baltimore, Bronx, Houston, Los Angeles, Manhattan, Pittsburgh, and Washington, DC.

PARTICIPANTS

Patients enrolled in the Veterans Aging Cohort Study wave 3 (2005-2007) who received prescription opioids in the previous year and without lifetime NMUPO were followed at waves 4 and 5 (2008-2011).

MEASUREMENTS

Cox proportional hazards regression was used to examine the relationship between duration of prescription opioid receipt and incident NMUPO, adjusting for demographics, alcohol and tobacco use, substance use disorders, psychiatric and medical diagnoses, and medication-related characteristics.

FINDINGS

Among eligible participants (n = 815), the median age was 52 (IQR = 47-58) and 498 (59.8%) were Black; 122 (15.0%) reported new-onset NMUPO, for an incidence rate of 5.0 per 100 person-years. In a multivariable Cox model, compared to <30 days, receipt of prescription opioids for 30-180 days (adjusted hazard ratio [AHR] = 1.65 95% CI: 1.06, 2.58) or >180 days (AHR = 1.99, 95% CI: 1.21, 3.29) was associated with incident NMUPO.

CONCLUSIONS

Duration of prescription opioid receipt is a risk factor for incident NMUPO among veterans receiving medical care. Providers who prescribe opioids should monitor for NMUPO, especially among those with a longer duration of opioid therapy.

Communication between pharmacists and primary care physicians in the midst of a U.S. opioid crisis

BACKGROUND

Effective communication between prescribers of opioids and community pharmacists can contribute to maximizing appropriate pain management and reducing opioid misuse and diversion. While much of the education and training available on reducing opioid misuse and diversion stresses the importance of interprofessional communication between prescribers and pharmacists, few studies have been explored those communication patterns directly.

OBJECTIVE

The objectives of this manuscript are to present and explore key emergent themes from a qualitative study around the nature, frequency, and content of communication between primary care physicians (PCPs) and pharmacists focusing on opioids.

METHODS

Interviews were conducted with 48 PCPs and 60 community pharmacists across four states in the U.S.: Washington, Idaho, Kentucky and Arkansas.

RESULTS

Convergent results from both samples indicated that the content of communication usually centers on questions of dosing, timing of the prescription, and/or evidence of potential misuse/diversion. When communication was focused on relaying information about a patient and/or clarifying questions around the prescription, it appeared positive for both parties. Results also indicated that close physical proximity between PCPs and dispensing pharmacists contributed to more positive and useful communication, especially when the clinics and pharmacies were part of the same healthcare system. Many pharmacists reported hesitancy in "questioning" a physician's judgement, which appeared related to commonly held beliefs of both pharmacists and physicians about the respective roles of each in providing patient care. Pharmacists reported difficulty in reaching PCPs for discussion, while PCPs reported it was easy to reach pharmacists.

CONCLUSIONS

Physician and pharmacist communication around opioids can be mutually beneficial. When prescribers and pharmacists are co-located, higher levels of trust and teamwork are reported, which in turn seems to be related to more open and positive communication. Additional research is needed to identify interventions to increase mutually-valued communication that improves the quality of decision-making around opioids.

2017 HIVMA of IDSA Clinical Practice Guideline for the Management of Chronic Pain in Patients Living With HIV

Pain has always been an important part of human immunodeficiency virus (HIV) disease and its experience for patients. In this guideline, we review the types of chronic pain commonly seen among persons living with HIV (PLWH) and review the limited evidence base for treatment of chronic noncancer pain in this population. We also review the management of chronic pain in special populations of PLWH, including persons with substance use and mental health disorders. Finally, a general review of possible pharmacokinetic interactions is included to assist the HIV clinician in the treatment of chronic pain in this population.It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The Infectious Diseases Society of American considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Challenges Facing a Rural Opioid Epidemic: Treatment and Prevention of HIV and Hepatitis C

PURPOSE OF REVIEW

This article reviews recent epidemiologic trends in HIV and hepatitis C virus (HCV) and strategies for treatment and prevention of these infections as they relate to the opioid epidemic.

RECENT FINDINGS

Among people who inject drugs (PWID) in the United States (US), HIV diagnoses are decreasing, while HCV is increasing. Care for HIV and HCV relies heavily on specialist infrastructure, which is lacking in rural areas. Antiretrovirals for HIV and direct-acting antivirals for HCV are effective among PWID, yet multiple barriers make it difficult for rural injectors to access these treatments. Similarly, access to syringe service programs, medication-assisted therapy for opioid addiction, and pre-exposure prophylaxis for HIV are all limited in rural areas. Previous research on HIV and HCV among PWID has focused on urban or international populations, yet the US opioid epidemic is moving away from metropolitan centers. Increasing rurality of opioid injection brings unique challenges in treatment and prevention. Research into the care of HIV, HCV, and opioid use disorder among rural populations is urgently needed.

A qualitative exploration of chronic pain and opioid treatment among HIV patients with drug use disorders

OBJECTIVE

The study explored high-risk participants' experiences with pain management regarding clinical access to and use of prescription opioids.

DESIGN

Qualitative semistructured interviews and focus groups.

SETTING

Data were collected August 2014 to May 2015 at an urban community-based research facility in Baltimore City, MD.

PARTICIPANTS

HIV participants with chronic pain and a history of illicit drug use.

METHODS

Qualitative coding and analysis used an iterative, inductive, and thematic approach and coders achieved inter-coder consistency.

RESULTS

The authors identified two major themes. First, participants had positive and negative interactions with healthcare providers regarding chronic pain treatment. Participants perceived that providers lacked empathy for their pain and/or were not adequately managing their pain. These interactions resulted in participants seeking new providers or mistrusting the medical system. Further, providers' surveillance of participants' pain treatment regimen contributed to distress surrounding pain management. The second theme centered on participants' pain management experiences with prescribed opioid analgesics. Participants felt they were receiving dosages and classes of analgesics that did not sufficiently address their pain, and consequently modified their dosages or rationed prescription opioids. Other participants were reluctant to take analgesics due to their history of illicit drug use. Some participants relapsed to illicit drug use when they felt their prescription opioids did not adequately address their pain needs.

CONCLUSIONS

Participant struggles with receiving and managing prescribed opioid analgesics suggest a need for: therapies beyond these medications; guidelines for providers specific to this population; and harm reduction trainings for providers.

Prescription Opioid Use is Associated with Virologic Failure in People Living with HIV

Prescription opioid misuse is a rising epidemic in the U.S., and people living with HIV are at increased risk. We assessed the association between prescription opioid use and virologic failure in HIV+ patients in the South Texas HIV Cohort. We found prescription opioid use was significantly associated with virologic failure, after adjustment for age, race, gender, insurance status, years living with HIV, reported HIV risk factor, chronic hepatitis C virus infection, current substance abuse, and care engagement. These findings suggest that opioid analgesic use may have negative consequences beyond misuse in people living with HIV.

Managing Concerning Behaviors in Patients Prescribed Opioids for Chronic Pain: A Delphi Study

BACKGROUND

Current guideline-recommended monitoring of patients prescribed long-term opioid therapy (LTOT) for chronic pain will likely result in increased identification of behaviors of concern for misuse and addiction, but there is a dearth of empiric evidence about how these behaviors should be managed.

OBJECTIVE

To establish expert consensus about treatment approaches for common and challenging concerning behaviors that arise among patients on LTOT.

DESIGN

We used a Delphi approach, which allows for generation of consensus.

PARTICIPANTS

Participants were clinical experts in chronic pain and opioid prescribing recruited from professional societies and other expert groups.

MAIN MEASURES

The Delphi process was conducted online, and consisted of an initial brainstorming round to identify common and challenging behaviors, a second round to identify management strategies for each behavior, and two rounds to establish consensus and explore disagreement/uncertainty.

KEY RESULTS

Forty-two participants completed round 1, 22 completed round 2, 30 completed round 3, and 28 completed round 4. Half of round 1 participants were female (52%), and the majority were white (83%). Most (71%) were physicians, and most participants practiced in academic primary (40%) or specialty care (19%).The most frequently cited common and challenging behaviors were missing appointments, taking opioids for symptoms other than pain, using more opioid medication than prescribed, asking for an increase in opioid dose, aggressive behavior, and alcohol and other substance use. Across behaviors, participants agreed that patient education and information gathering were important approaches. Participants also agreed that stopping opioids is not important initially, but if initial approaches do not work, tapering opioids and stopping opioids immediately may become important approaches.

CONCLUSIONS

This study presents clinical expert consensus on how to manage concerning behaviors among patients on LTOT. Future research is needed to investigate how implementing these management strategies would impact patient outcomes, practice and policy.

Provider confidence in opioid prescribing and chronic pain management: results of the Opioid Therapy Provider Survey

Introduction

Many providers report lack of confidence in managing patients with chronic pain. Thus, the primary aim of this study was to investigate the associations of provider confidence in managing chronic pain with their practice behaviors and demographics.

Materials and methods

The primary outcome measure was the results of the Opioid Therapy Provider Survey, which was administered to clinicians attending a pain-focused continuing medical education conference. Nonparametric correlations were assessed using Spearman’s rho.

Results

Of the respondents, 55.0% were women, 92.8% were white, and 56.5% were physicians. Primary care providers accounted for 56.5% of the total respondents. The majority of respondents (60.8%) did not feel confident managing patients with chronic pain. Provider confidence in managing chronic pain was positively correlated with 1) following an opioid therapy protocol (P=0.001), 2) the perceived ability to identify patients at risk for opioid misuse (P=0.006), and 3) using a consistent practice-based approach to improve their comfort level with prescribing opioids (P<0.001). Provider confidence was negatively correlated with the perception that treating pain patients was a “problem in my practice” (P=0.005).

Conclusion

In this study, the majority of providers did not feel confident managing chronic pain. However, provider confidence was associated with a protocolized and consistent practice-based approach toward managing opioids and the perceived ability to identify patients at risk for opioid misuse. Future studies should investigate whether provider confidence is associated with measurable competence in managing chronic pain and explore approaches to enhance appropriate levels of confidence in caring for patients with chronic pain.

Patient-Provider Engagement and Chronic Pain in Drug-Using, Primarily African American Persons Living with HIV/AIDS

Among disadvantaged persons living with HIV/AIDS (PLHIV), patient-provider engagement, which has been defined as patient-provider relationships that promote the use of health care services and are characterized by active listening and supportive decision making, has been associated with antiretroviral therapy (ART) maintenance and viral suppression. However, chronic pain, depression, and substance use, all of which are prevalent in this population, can reduce the quality of patient-provider engagement. We hypothesized a model in which chronic pain, depression, and substance use would be associated with poorer patient-provider engagement, which would be positively associated with adherence, with the latter associated positively with viral suppression. We analyzed data from the BEACON study, which included surveys from 383 PLHIV who were primarily African American, on ART, and had histories of drug use. Due to six missing cases on the chronic pain variable, we used data from 377 respondents in a structural equation model. Chronic pain and depressive symptoms were significantly associated with poorer patient-provider engagement, while substance use was associated with better engagement. Patient-provider engagement in turn was associated with better ART adherence, which was associated with higher viral suppression. Results suggest the role of chronic pain in poor patient-physician engagement in this population, which has potential implications for quality of HIV patient care and health outcomes. Findings suggest the need for attention to patient-provider engagement in PLHIV.

Pain is Associated with Missed Clinic Visits Among HIV-Positive Women

Pain is highly prevalent among HIV-positive individuals, with women representing a large subset of those with pain. However, little is known about the relationship between pain and retention in HIV medical care. Among a cohort of HIV-positive women of color, we evaluated the association between pain and retention in care, as measured by missed clinic visits. The Health Resources and Services Administration's Women of Color Initiative was a multi-site observational cohort study evaluating demonstration projects to engage HIV-positive women in medical care. From November 2010 to July 2013, 921 women were enrolled in the study across nine U.S. sites; baseline interviews collected data on socio-demographic, clinical, and risk behavior characteristics. Pain was assessed at baseline based on number of days in pain over the last 30 days and was categorized as no pain (0 days), infrequent pain (1-13 days), and frequent pain (14-30 days), with 14 days being the median. Missed visits over the one-year follow-up period, evaluated by chart abstraction, were dichotomized as ≤1 missed visit versus >1 missed visit. We conducted multivariate logistic regression to assess the association between pain at baseline and missed visits, adjusting for pertinent covariates. Among our sample (N = 862), 52.2 % of women reported no pain, 23.7 % reported infrequent pain and 24.1 % reported frequent pain. Forty-five percent had >1 missed visit during the one-year follow-up period. Overall, we did not find a significant association between pain and missed visits (aOR 2.30; 95 % CI 1.00-5.25). However, in planned stratified analyses, among women reporting current substance use at baseline, reporting frequent pain was associated with a higher odds of missed visits as compared with reporting no pain (aOR 15.14; 95 % CI 1.78-128.88). In our overall sample, pain was not significantly associated with missed visits. However, frequent pain was associated with missed visits among HIV-positive women of color who reported substance use at baseline. A better understanding of the relationship between pain and missed visits could guide efforts to improve retention in care in this population.

Primary Care Physicians' Willingness to Prescribe HIV Pre-exposure Prophylaxis for People who Inject Drugs

Pre-exposure prophylaxis for HIV (PrEP) is recommended for people who inject drugs (PWID). Despite their central role in disease prevention, willingness to prescribe PrEP to PWID among primary care physicians (PCPs) is largely understudied. We conducted an online survey (April-May 2015) of members of a society for academic general internists regarding PrEP. Among 250 respondents, 74% (n = 185) of PCPs reported high willingness to prescribe PrEP to PWID. PCPs were more likely to report high willingness to prescribe PrEP to all other HIV risk groups (p's < 0.03 for all pair comparisons). Compared with PCPs delivering care to more HIV-infected clinic patients, PCPs delivering care to fewer HIV-infected patients were more likely to report low willingness to prescribe PrEP to PWID (Odds Ratio [95% CI] = 6.38 [1.48-27.47]). PCP and practice characteristics were not otherwise associated with low willingness to prescribe PrEP to PWID. Interventions to improve PCPs' willingness to prescribe PrEP to PWID are needed.

Primary Care-Based Models for the Treatment of Opioid Use Disorder: A Scoping Review

Greater integration of medication-assisted treatment (MAT) for opioid use disorder (OUD) in U.S. primary care settings would expand access to treatment for this condition. Models for integrating MAT into primary care vary in structure. This article summarizes findings of a technical report for the Agency for Healthcare Research and Quality describing MAT models of care for OUD, based on a literature review and interviews with key informants in the field. The report describes 12 representative models of care for integrating MAT into primary care settings that could be considered for adaptation across diverse health care settings. Common components of existing care models include pharmacotherapy with buprenorphine or naltrexone, provider and community education, coordination and integration of OUD treatment with other medical and psychological needs, and psychosocial services and interventions. Models vary in how each component is implemented. Decisions about adopting MAT models of care should be individualized to address the unique milieu of each implementation setting.

When human immunodeficiency virus (HIV) treatment goals conflict with guideline-based opioid prescribing: A qualitative study of HIV treatment providers

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.

A Cross-Sectional Online Survey of HIV Pre-Exposure Prophylaxis Adoption Among Primary Care Physicians

BACKGROUND

Among health care providers, prescription of HIV pre-exposure prophylaxis (PrEP) has been low. Little is known specifically about primary care physicians (PCPs) with regard to PrEP awareness and adoption (i.e., prescription or referral), and factors associated with adoption.

OBJECTIVE

To assess PrEP awareness, PrEP adoption, and factors associated with adoption among PCPs.

DESIGN

Cross-sectional online survey conducted in April and May 2015.

RESPONDENTS

Members of a national professional organization for academic primary care physicians (n = 266).

MAIN MEASURES

PrEP awareness, PrEP adoption (ever prescribed or referred a patient for PrEP [yes/no]), provider and practice characteristics, and self-rated knowledge, attitudes, and beliefs associated with adoption.

KEY RESULTS

The survey response rate was 8.6 % (266/2093). Ninety-three percent of respondents reported prior awareness of PrEP. Of these, 34.9 % reported PrEP adoption. In multivariable analysis of provider and practice characteristics, compared with non-adopters, adopters were more likely to provide care to more than 50 HIV-positive patients (vs. 0, aOR = 6.82, 95 % CI 2.06-22.52). Compared with non-adopters, adopters were also more likely to report excellent, very good, or good self-rated PrEP knowledge (15.1 %, 33.7 %, 30.2 % vs. 2.5 %, 18.1 %, 23.8 %, respectively; p < 0.001) and to perceive PrEP as extremely safe (35.1 % vs. 10.7 %; p = 0.002). Compared with non-adopters, adopters were less likely to perceive PrEP as being moderately likely to increase risk behaviors ("risk compensation") (12.8 % vs. 28.8 %, p = 0.02).

CONCLUSIONS

While most respondents were aware of PrEP, only one-third of PrEP-aware PCPs reported adoption. Adopters were more likely to have experience providing HIV care and to perceive PrEP as extremely safe, and were less likely to perceive PrEP use as leading to risk compensation. To enhance PCP adoption of PrEP, educational efforts targeting PCPs without HIV care experience should be considered, as well as training those with HIV care experience to be PrEP "clinical champions". Concerns about safety and risk compensation must also be addressed.

Physician continuing education to reduce opioid misuse, abuse, and overdose: Many opportunities, few requirements

BACKGROUND

The opioid overdose epidemic in the United States is driven in large part by inappropriate opioid prescribing. Although most American physicians receive little or no training during medical school regarding evidence-based prescribing, substance use disorders, and pain management, some states require continuing medical education (CME) on these topics. We report the results of a systematic legal analysis of such requirements, together with recommendations for improved physician training.

METHODS

To determine the presence and characteristics of CME requirements in the United States, we systematically collected, reviewed, and coded all laws that require such education as a condition of obtaining or renewing a license to practice medicine. Laws or regulations that mandate one-time or ongoing training in topics designed to reduce overdose risk were further characterized using an iterative protocol

RESULTS

Only five states require all or nearly all physicians to obtain CME on topics such as pain management and controlled substance prescribing, and fewer than half require any physicians to obtain such training.

CONCLUSIONS

While not a replacement for improved education in medical school and post-graduate clinical training, evidence-based CME can help improve provider knowledge and practice. Requiring physicians to obtain CME that accurately presents evidence regarding opioid prescribing and related topics may help reduce opioid-related morbidity and mortality. States and the federal government should also strongly consider requiring such training in medical school and residency.

The Association Between Receipt of Guideline-Concordant Long-Term Opioid Therapy and All-Cause Mortality

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.

Factors Associated with Prescription of Opioids and Co-prescription of Sedating Medications in Individuals with HIV

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.

Trends in Any and High-Dose Opioid Analgesic Receipt Among Aging Patients With and Without HIV

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.

'Two pains together': patient perspectives on psychological aspects of chronic pain while living with HIV

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.

Pathology consultation on urine compliance testing and drug abuse screening

OBJECTIVES

Compliance testing in pain management requires a distinct approach compared with classic clinical toxicology testing. Differences in the patient populations and clinical expectations require modifications to established reporting cutoffs, assay performance expectations, and critical review of how best to apply the available testing methods. Although other approaches to testing are emerging, immunoassay screening followed by mass spectrometry confirmation remains the most common testing workflow for pain management compliance and drug abuse testing.

METHODS

A case-based approach was used to illustrate the complexities inherent to and uniqueness of pain management compliance testing for both clinicians and laboratories.

RESULTS

A basic understanding of the inherent strengths and weaknesses of immunoassays and mass spectrometry provides the clinician a better understanding of how best to approach pain management compliance testing.

CONCLUSIONS

Pain management compliance testing is a textbook example of an emerging field requiring open communication between physician and performing laboratory to fully optimize patient care.

Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic addiction in the current opioid epidemic

An epidemic of drug overdose deaths has led to calls for programs and policies to limit misuse and diversion of opioid medications. Any parallel call to consider the risk of iatrogenic addiction when treating pain has been muted in comparison. We have moved beyond questions of nonmedical use, abuse, and diversion to highlight the role of prescription opioids in causing addiction even when prescribed and used appropriately. Unfortunately, current evidence is insufficient, and a rapid expansion of longitudinal research is urgently needed to guide clinicians in balancing the need for opioids with the risk of adverse consequences. Meanwhile, medical education should place greater emphasis on the abuse liability of prescription opioids, and providers should endeavor to attenuate risk when possible.