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Stein MD, Godersky ME, Kim TW, Walley AY, Heeren TC, Winter MR, Magane KM, Saitz R. 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. AIDS Care 2024; 36:414-424. [PMID: 37909062 PMCID: PMC10922286 DOI: 10.1080/09540121.2023.2275047] [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] [Received: 08/12/2023] [Accepted: 10/17/2023] [Indexed: 11/02/2023]
Abstract
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.
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Affiliation(s)
- Michael D. Stein
- Department of Health Law, Policy and Management, Boston University School of Public Health. 715 Albany Street, Boston, MA, USA 02118
| | - Margo E. Godersky
- SORCE, Department of Surgery, University of Washington Medical Center, 1107 NE 45th Street, Suite 502 Seattle, WA, USA 98105
- Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Ave, 4th Floor, Boston, MA, USA 02118
| | - Theresa W. Kim
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Grayken Center for Addiction, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Ave., Boston, MA, USA 02118
| | - Alexander Y. Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Grayken Center for Addiction, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Ave., Boston, MA, USA 02118
| | - Timothy C. Heeren
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health 85 East Newton Street, 9th Floor, Boston, MA, USA 02118
| | - Michael R. Winter
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health 85 East Newton Street, 9th Floor, Boston, MA, USA 02118
| | - Kara M. Magane
- Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Ave, 4th Floor, Boston, MA, USA 02118
| | - Richard Saitz
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Grayken Center for Addiction, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Ave., Boston, MA, USA 02118
- Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Ave, 4th Floor, Boston, MA, USA 02118
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Hu Y, Liu J, Zhuang R, Zhang C, Lin F, Wang J, Peng S, Zhang W. Progress in Pathological and Therapeutic Research of HIV-Related Neuropathic Pain. Cell Mol Neurobiol 2023; 43:3343-3373. [PMID: 37470889 DOI: 10.1007/s10571-023-01389-7] [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] [Received: 02/23/2023] [Accepted: 07/10/2023] [Indexed: 07/21/2023]
Abstract
HIV-related neuropathic pain (HRNP) is a neurodegeneration that gradually develops during the long-term course of acquired immune deficiency syndrome (AIDS) and manifests as abnormal sock/sleeve-like symmetrical pain and nociceptive hyperalgesia in the extremities, which seriously reduces patient quality of life. To date, the pathogenesis of HRNP is not completely clear. There is a lack of effective clinical treatment for HRNP and it is becoming a challenge and hot spot for medical research. In this study, we conducted a systematic review of the progress of HRNP research in recent years including (1) the etiology, classification and clinical symptoms of HRNP, (2) the establishment of HRNP pathological models, (3) the pathological mechanisms underlying HRNP from three aspects: molecules, signaling pathways and cells, (4) the therapeutic strategies for HRNP, and (5) the limitations of recent HRNP research and the future research directions and prospects of HRNP. This detailed review provides new and systematic insight into the pathological mechanism of HRNP, which establishes a theoretical basis for the future exploitation of novel target drugs. HIV infection, antiretroviral therapy and opioid abuse contribute to the etiology of HRNP with symmetrical pain in both hands and feet, allodynia and hyperalgesia. The pathogenesis involves changes in cytokine expression, activation of signaling pathways and neuronal cell states. The therapy for HRNP should be patient-centered, integrating pharmacologic and nonpharmacologic treatments into multimodal intervention.
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Affiliation(s)
- YanLing Hu
- Zhejiang Provincial Key Laboratory of Silkworm Bioreactor and Biomedicine, College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, Zhejiang, China
| | - JinHong Liu
- Zhejiang Provincial Key Laboratory of Silkworm Bioreactor and Biomedicine, College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, Zhejiang, China
| | - Renjie Zhuang
- Zhejiang Provincial Key Laboratory of Silkworm Bioreactor and Biomedicine, College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, Zhejiang, China
| | - Chen Zhang
- Department of Biological Sciences, University of Denver, Denver, CO, 80210, USA
| | - Fei Lin
- Zhejiang Provincial Key Laboratory of Silkworm Bioreactor and Biomedicine, College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, Zhejiang, China
| | - Jun Wang
- Department of Orthopedics, Rongjun Hospital, Jiaxing, Zhejiang, China
| | - Sha Peng
- Zhejiang Provincial Key Laboratory of Silkworm Bioreactor and Biomedicine, College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, Zhejiang, China
| | - Wenping Zhang
- Zhejiang Provincial Key Laboratory of Silkworm Bioreactor and Biomedicine, College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, Zhejiang, China.
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3
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Liu X, Tang SJ. Pathogenic mechanisms of human immunodeficiency virus (HIV)-associated pain. Mol Psychiatry 2023; 28:3613-3624. [PMID: 37857809 DOI: 10.1038/s41380-023-02294-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 09/25/2023] [Accepted: 10/05/2023] [Indexed: 10/21/2023]
Abstract
Chronic pain is a prevalent neurological complication among individuals living with human immunodeficiency virus (PLHIV) in the post-combination antiretroviral therapy (cART) era. These individuals experience malfunction in various cellular and molecular pathways involved in pain transmission and modulation, including the neuropathology of the peripheral sensory neurons and neurodegeneration and neuroinflammation in the spinal dorsal horn. However, the underlying etiologies and mechanisms leading to pain pathogenesis are complex and not fully understood. In this review, we aim to summarize recent progress in this field. Specifically, we will begin by examining neuropathology in the pain pathways identified in PLHIV and discussing potential causes, including those directly related to HIV-1 infection and comorbidities, such as antiretroviral drug use. We will also explore findings from animal models that may provide insights into the molecular and cellular processes contributing to neuropathology and chronic pain associated with HIV infection. Emerging evidence suggests that viral proteins and/or antiretroviral drugs trigger a complex pathological cascade involving neurons, glia, and potentially non-neural cells, and that interactions between these cells play a critical role in the pathogenesis of HIV-associated pain.
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Affiliation(s)
- Xin Liu
- Stony Brook University Pain and Analgesia Research Center (SPARC), Stony Brook University, Stony Brook, 11794, NY, USA
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, 11794, NY, USA
| | - Shao-Jun Tang
- Stony Brook University Pain and Analgesia Research Center (SPARC), Stony Brook University, Stony Brook, 11794, NY, USA.
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, 11794, NY, USA.
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Carroll JJ, Cushman PA, Lira MC, Colasanti JA, Del Rio C, Lasser KE, Parker V, Roy PJ, Samet JH, Liebschutz JM. Evidence-Based Interventions to Improve Opioid Prescribing in Primary Care: a Qualitative Assessment of Implementation in Two Studies. J Gen Intern Med 2023; 38:1794-1801. [PMID: 36396881 PMCID: PMC10271994 DOI: 10.1007/s11606-022-07909-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/27/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND The TOPCARE and TEACH randomized controlled trials demonstrated the efficacy of a multi-faceted intervention to promote guideline-adherent long-term opioid therapy (LTOT) in primary care settings. Intervention components included a full-time Nurse Care Manager (NCM), an electronic registry, and academic detailing sessions. OBJECTIVE This study sought to identify barriers, facilitators, and other issues germane to the wider implementation of this intervention. DESIGN We conducted a nested, qualitative study at 4 primary care clinics (TOPCARE) and 2 HIV primary care clinics (TEACH), where the trials had been conducted. APPROACH We purposively sampled primary care physicians and advanced practice providers (hereafter: PCPs) who had received the intervention. Semi-structured interviews explored perceptions of the intervention to identify unanticipated barriers to and facilitators of implementation. Interview transcripts were analyzed through iterative deductive and inductive coding exercises. KEY RESULTS We interviewed 32 intervention participants, 30 physicians and 2 advanced practice providers, who were majority White (66%) and female (63%). Acceptability of the intervention was high, with most PCPs valuing didactic and team-based intervention elements, especially co-management of LTOT patients with the NCM. Adoption of new prescribing practices was facilitated by proximity to expertise, available behavioral health care, and the NCM's support. Most participants were enthusiastic about the intervention, though a minority voiced concerns about the appropriateness in their particular clinical environments, threats to the patient-provider relationship, or long-term sustainability. CONCLUSION TOPCARE/TEACH participants found the intervention generally acceptable, appropriate, and easy to adopt in a variety of primary care environments, though some challenges were identified. Careful attention to the practical challenges of implementation and the professional relationships affected by the intervention may facilitate implementation and sustainability.
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Affiliation(s)
- Jennifer J Carroll
- Department of Sociology and Anthropology, North Carolina State University, Raleigh, NC, USA.
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA.
| | - Phoebe A Cushman
- Department of Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Marlene C Lira
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Jonathan A Colasanti
- Division of Infectious Diseases, Emory University, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
| | - Carlos Del Rio
- Division of Infectious Diseases, Emory University, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
| | - Karen E Lasser
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Victoria Parker
- Department of Management, Peter. T. Paul College of Business & Economics, University of New Hampshire, Durham, NH, USA
| | - Payel J Roy
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jeffrey H Samet
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Jane M Liebschutz
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Hayashi K, Yi H, Zhu X, Liu S, Gu J, Takahashi K, Kashiwagi Y, Pardo M, Kanda H, Li H, Levitt RC, Hao S. Role of Tumor Necrosis Factor Receptor 1-Reactive Oxygen Species-Caspase 11 Pathway in Neuropathic Pain Mediated by HIV gp120 With Morphine in Rats. Anesth Analg 2023; 136:789-801. [PMID: 36662639 DOI: 10.1213/ane.0000000000006335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Recent clinical research suggests that repeated use of opioid pain medications can increase neuropathic pain in people living with human immunodeficiency virus (HIV; PLWH). Therefore, it is significant to elucidate the exact mechanisms of HIV-related chronic pain. HIV infection and chronic morphine induce proinflammatory factors, such as tumor necrosis factor (TNF)α acting through tumor necrosis factor receptor I (TNFRI). HIV coat proteins and/or chronic morphine increase mitochondrial superoxide in the spinal cord dorsal horn (SCDH). Recently, emerging cytoplasmic caspase-11 is defined as a noncanonical inflammasome and can be activated by reactive oxygen species (ROS). Here, we tested our hypothesis that HIV coat glycoprotein gp120 with chronic morphine activates a TNFRI-mtROS-caspase-11 pathway in rats, which increases neuroinflammation and neuropathic pain. METHODS Neuropathic pain was induced by repeated administration of recombinant gp120 with morphine (gp120/M) in rats. Mechanical allodynia was assessed using von Frey filaments, and thermal latency using hotplate test. Protein expression of spinal TNFRI and cleaved caspase-11 was examined using western blots. The image of spinal mitochondrial superoxide was examined using MitoSox Red (mitochondrial superoxide indicator) image assay. Immunohistochemistry was used to examine the location of TNFRI and caspase-11 in the SCDH. Intrathecal administration of antisense oligodeoxynucleotide (AS-ODN) against TNFRI, caspase-11 siRNA, or a scavenger of mitochondrial superoxide was given for antinociceptive effects. Statistical tests were done using analysis of variance (1- or 2-way), or 2-tailed t test. RESULTS Intrathecal gp120/M induced mechanical allodynia and thermal hyperalgesia lasting for 3 weeks ( P < .001). Gp120/M increased the expression of spinal TNFRI, mitochondrial superoxide, and cleaved caspase-11. Immunohistochemistry showed that TNFRI and caspase-11 were mainly expressed in the neurons of the SCDH. Intrathecal administration of antisense oligonucleotides against TNFRI, Mito-Tempol (a scavenger of mitochondrial superoxide), or caspase-11 siRNA reduced mechanical allodynia and thermal hyperalgesia in the gp120/M neuropathic pain model. Spinal knockdown of TNFRI reduced MitoSox profile cell number in the SCDH; intrathecal Mito-T decreased spinal caspase-11 expression in gp120/M rats. In the cultured B35 neurons treated with TNFα, pretreatment with Mito-Tempol reduced active caspase-11 in the neurons. CONCLUSIONS These results suggest that spinal TNFRI-mtROS-caspase 11 signal pathway plays a critical role in the HIV-associated neuropathic pain state, providing a novel approach to treating chronic pain in PLWH with opioids.
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Affiliation(s)
- Kentaro Hayashi
- From the Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
- Department of Anesthesiology, Asahikawa Medical University, Ashikawa, Japan
| | - Hyun Yi
- From the Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
| | - Xun Zhu
- From the Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
- Department of Anesthesiology, the 6th Affiliated Hospital of Guangzhou Medical University, Qingyuan, China
| | - Shue Liu
- From the Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
| | - Jun Gu
- From the Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
| | - Keiya Takahashi
- From the Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
- Department of Anesthesiology, Asahikawa Medical University, Ashikawa, Japan
| | - Yuta Kashiwagi
- From the Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
| | - Marta Pardo
- From the Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
| | - Hirotsugu Kanda
- Department of Anesthesiology, Asahikawa Medical University, Ashikawa, Japan
| | - Heng Li
- Department of Anesthesiology, the 6th Affiliated Hospital of Guangzhou Medical University, Qingyuan, China
| | - Roy C Levitt
- From the Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
- John T. MacDonald Foundation, Department of Human Genetics, University of Miami Miller School of Medicine, Miami, Florida
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, Florida
| | - Shuanglin Hao
- From the Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
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6
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Huang J, Lin F, Hu Y, Bloe CB, Wang D, Zhang W. From Initiation to Maintenance: HIV-1 Gp120-induced Neuropathic Pain Exhibits Different Molecular Mechanisms in the Mouse Spinal Cord Via Bioinformatics Analysis Based on RNA Sequencing. J Neuroimmune Pharmacol 2022; 17:553-575. [PMID: 35059976 DOI: 10.1007/s11481-021-10044-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 12/09/2021] [Indexed: 01/13/2023]
Abstract
Human immunodeficiency virus (HIV), which causes acquired immunodeficiency syndrome (AIDS), remains one of the most diverse crucial health and development challenges around the world. People infected with HIV constitute a large patient population, and a significant number of them experience neuropathic pain. To study the key mechanisms that mediate HIV-induced neuropathic pain (HNP), we established an HNP mouse model via intrathecal injection of the HIV-1 envelope glycoprotein gp120. The L3~L5 spinal cord was isolated on postoperative days 1/12 (POD1/12), 1 (POD1), and 14 (POD14) for RNA sequencing to investigate the gene expression profiles of the initiation, transition, and maintenance stages of HNP. A total of 1682, 430, and 413 differentially expressed genes were obtained in POD1/12, POD1, and POD14, respectively, and their similarity was low. Bioinformatics analysis confirmed that POD1/12, POD1, and POD14 exhibited different biological processes and signaling pathways. Inflammation, oxidative damage, apoptosis, and inflammation-related signaling pathways were enriched on POD1/12. Inflammation, chemokine activity, and downstream signaling regulated by proinflammatory cytokines, such as the MTOR signaling pathway, were enriched on POD1, while downregulation of ion channel activity, mitochondrial damage, endocytosis, MAPK and neurotrophic signaling pathways developed on POD14. Additionally, we screened key genes and candidate genes, which were verified at the transcriptional and translational levels. Our results suggest that the initiation and maintenance of HNP are regulated by different molecular mechanisms. Therefore, our research may yield a fresh and deeper understanding of the mechanisms underlying HNP, providing accurate molecular targets for HNP therapy.
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Affiliation(s)
- Jian Huang
- Zhejiang Provincial Key Laboratory of Silkworm Bioreactor and Biomedicine, College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, Zhejiang, China
| | - Fei Lin
- Zhejiang Provincial Key Laboratory of Silkworm Bioreactor and Biomedicine, College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, Zhejiang, China
| | - Yanling Hu
- Zhejiang Provincial Key Laboratory of Silkworm Bioreactor and Biomedicine, College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, Zhejiang, China
| | - Chris Bloe Bloe
- Zhejiang Provincial Key Laboratory of Silkworm Bioreactor and Biomedicine, College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, Zhejiang, China
| | - Dan Wang
- Zhejiang Provincial Key Laboratory of Silkworm Bioreactor and Biomedicine, College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, Zhejiang, China
| | - Wenping Zhang
- Zhejiang Provincial Key Laboratory of Silkworm Bioreactor and Biomedicine, College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, Zhejiang, China.
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Slawek DE. People living with HIV and the emerging field of chronic pain-what is known about epidemiology, etiology, and management. Curr HIV/AIDS Rep 2021; 18:436-442. [PMID: 34046859 DOI: 10.1007/s11904-021-00563-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Chronic pain is common in people living with HIV (PLWH). It causes significant disability and poor HIV outcomes. Despite this, little is understood about its etiology and management. RECENT FINDINGS Recent studies suggest that chronic pain in PLWH is caused by inflammation that persists despite viral load suppression. This coupled with central sensitization and psychosocial factors leads to chronic pain that is difficult to manage. PLWH with chronic pain often feel that their pain is incompletely treated, and yet there are few evidence-based options for the management of chronic pain in PLWH. Recent studies suggest that an approach pairing pharmacotherapy and nonpharmacologic therapy may address the complex nature of chronic in PLWH. Chronic pain in PLWH is common yet poorly understood. Further research is needed in order to better understand the etiology of chronic pain and its optimal management.
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Affiliation(s)
- Deepika E Slawek
- Department of Medicine, Montefiore Health System & Albert Einstein College of Medicine, Bronx, NY, USA.
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8
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Kamba PF, Mulangwa J, Kageni P, Balikuna S, Kengo A, Mutamba BB, Sewankambo N, Adome RO, Byakika-Kibwika P. Predictors of controlled prescription drug non-medical and lifetime use among patients accessing public mental health services in Uganda: a cross-sectional study. BMJ Open 2021; 11:e037602. [PMID: 33771822 PMCID: PMC8006833 DOI: 10.1136/bmjopen-2020-037602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES We determined the prevalence of controlled prescription drug (CPD) non-medical and lifetime use and their predictors among patients at three public psychiatric clinics in Uganda to identify missed care opportunities, enhanced screening priorities, and drug control needs. METHODS A cross-sectional survey of 1275 patients was performed from November to December 2018. Interviewer-administered semi-structured questionnaires, desk review guide and urine drug assays were employed. Questionnaire recorded CPD non-medical and illicit drug use history from patients' files, CPD lifetime use and risk factors. Desk review guide recorded recently prescribed drugs in patients' files to corroborate with urine assays. Predictors were analysed by multivariate logistic regression. RESULTS From desk review, 145 (11.4%) patients had history of CPD non-medical use and 36 (2.8%) had used illicit drugs. Of 988 patients who provided urine, 166 (16.8%) self-medicated CPDs, particularly benzodiazepines while 12 (1.2%) used illicit drugs. Of those with drug-positive urine, 123 (69.1%) had no documented history of CPD non-medical and illicit drug use. Being an inpatient (OR=10.90, p<0.001) was independently associated with CPD non-medical use. Additionally, being an inpatient (OR=8.29, p<0.001) and tobacco consumption (OR=1.85, p=0.041) were associated with CPD non-medical and illicit drug use combined. Among participants, 119 (9.3%) reported CPD lifetime use, and this was independently associated with education level (OR=2.71, p<0.001) and history of treatment for substance abuse (OR=2.08, p=0.018). CONCLUSIONS CPD non-medical use is common among Uganda's psychiatric patients, and more prevalent than illicit drug use. Rapid diagnostic assays may be needed in psychiatric care in resource limited settings. It is necessary to assess how CPD non-medical use impacts mental care outcomes and patient safety. High risk groups like inpatients and tobacco consumers should be prioritised in psychiatric screening.
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Affiliation(s)
- Pakoyo Fadhiru Kamba
- Department of Pharmacy, College of Health Sciences, Makerere University, Kampala, Uganda
| | - John Mulangwa
- Department of Pharmacy, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Peter Kageni
- Department of Pharmacy, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sulah Balikuna
- Department of Pharmacy, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Allan Kengo
- Department of Pharmacology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Brian Byamah Mutamba
- Department of Psychiatry, Butabika National Referral Mental Hospital, Kampala, Uganda
| | - Nelson Sewankambo
- Department of Internal Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Richard Odoi Adome
- Department of Pharmacy, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Pauline Byakika-Kibwika
- Department of Internal Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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9
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Cody SL, Hobson JM, Gilstrap SR, Gloston GF, Riggs KR, Justin Thomas S, Goodin BR. Insomnia severity and depressive symptoms in people living with HIV and chronic pain: associations with opioid use. AIDS Care 2021; 34:679-688. [PMID: 33625927 DOI: 10.1080/09540121.2021.1889953] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Chronic pain commonly occurs in people living with HIV (PLWH). Many PLWH in the United States obtain opioids for chronic pain management. Whether insomnia severity and depressive symptoms are exacerbated by chronic pain and opioid use in PLWH remains to be determined. This study examined insomnia severity and depressive symptoms in 85 PLWH with chronic pain and 35 PLWH without chronic pain. Among PLWH with chronic pain, reported opioid use was examined in relation to insomnia severity and depressive symptoms. PLWH with chronic pain reported significantly greater insomnia severity (p = .033) and depressive symptoms (p = .025) than PLWH without chronic pain. Among PLWH with chronic pain who reported opioid use (n = 36), insomnia severity was greater compared to those who denied opioid use (n = 49), even after controlling for pain severity and number of comorbidities (p = .026). Greater pain severity was significantly associated with greater insomnia severity (p < .001) and depressive symptoms (p = .048) among PLWH with chronic pain who reported opioid use. These associations were not significant among those PLWH with chronic pain who denied opioid use. Findings suggest that PLWH with chronic pain are likely to experience poor sleep and depressed mood. Furthermore, poor sleep was associated with opioid use among PLWH with chronic pain.
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Affiliation(s)
- Shameka L Cody
- Capstone College of Nursing, The University of Alabama, Tuscaloosa, AL, USA
| | - Joanna M Hobson
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Shannon R Gilstrap
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gabrielle F Gloston
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kevin R Riggs
- Division of Preventive Medicine, University of Alabama in Birmingham School of Medicine, Birmingham, AL, USA
| | - S Justin Thomas
- Department of Psychiatry & Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Burel R Goodin
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA.,Center for Addiction & Pain Prevention & Intervention (CAPPI), University of Alabama at Birmingham, Birmingham, AL, USA
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Ventuneac A, Hecht G, Forcht E, Duah BA, Tarar S, Langenbach B, Gates J, Cain D, Rendina HJ, Aberg JA, Perlman DC. Chronic High Risk Prescription Opioid Use Among Persons With HIV. FRONTIERS IN SOCIOLOGY 2021; 6:645992. [PMID: 34095287 PMCID: PMC8176351 DOI: 10.3389/fsoc.2021.645992] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 04/26/2021] [Indexed: 05/07/2023]
Abstract
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.
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Affiliation(s)
- Ana Ventuneac
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, NY, NY, United States
- *Correspondence: Ana Ventuneac,
| | - Gavriella Hecht
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, NY, NY, United States
| | - Emily Forcht
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, NY, NY, United States
| | - Bianca A. Duah
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, NY, NY, United States
| | - Shafaq Tarar
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, NY, NY, United States
| | - Blanche Langenbach
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, NY, NY, United States
| | - Jay Gates
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, NY, NY, United States
| | - Demetria Cain
- Department of Psychology, Hunter College, City University of New York, NY, NY, United States
| | - H. Jonathon Rendina
- Department of Psychology, Hunter College, City University of New York, NY, NY, United States
- Health Psychology and Clinical Science PhD Program, The Graduate Center, City University of New York, NY, NY, United States
| | - Judith A. Aberg
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, NY, NY, United States
| | - David C. Perlman
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, NY, NY, United States
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11
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Hermes DJ, Jacobs IR, Key MC, League AF, Yadav-Samudrala BJ, Xu C, McLane VD, Nass SR, Jiang W, Meeker RB, Ignatowska-Jankowska BM, Lichtman AH, Li Z, Wu Z, Yuan H, Knapp PE, Hauser KF, Fitting S. Escalating morphine dosing in HIV-1 Tat transgenic mice with sustained Tat exposure reveals an allostatic shift in neuroinflammatory regulation accompanied by increased neuroprotective non-endocannabinoid lipid signaling molecules and amino acids. J Neuroinflammation 2020; 17:345. [PMID: 33208151 PMCID: PMC7672881 DOI: 10.1186/s12974-020-01971-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/29/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus type-1 (HIV-1) and opiates cause long-term inflammatory insult to the central nervous system (CNS) and worsen disease progression and HIV-1-related neuropathology. The combination of these proinflammatory factors reflects a devastating problem as opioids have high abuse liability and continue to be prescribed for certain patients experiencing HIV-1-related pain. METHODS Here, we examined the impact of chronic (3-month) HIV-1 transactivator of transcription (Tat) exposure to short-term (8-day), escalating morphine in HIV-1 Tat transgenic mice that express the HIV-1 Tat protein in a GFAP promoter-regulated, doxycycline (DOX)-inducible manner. In addition to assessing morphine-induced tolerance in nociceptive responses organized at spinal (i.e., tail-flick) and supraspinal (i.e., hot-plate) levels, we evaluated neuroinflammation via positron emission tomography (PET) imaging using the [18F]-PBR111 ligand, immunohistochemistry, and cytokine analyses. Further, we examined endocannabinoid (eCB) levels, related non-eCB lipids, and amino acids via mass spectrometry. RESULTS: Tat-expressing [Tat(+)] transgenic mice displayed antinociceptive tolerance in the tail withdrawal and hot-plate assays compared to control mice lacking Tat [Tat(-)]. This tolerance was accompanied by morphine-dependent increases in Iba-1 ± 3-nitrotryosine immunoreactive microglia, and alterations in pro- and anti-inflammatory cytokines, and chemokines in the spinal cord and striatum, while increases in neuroinflammation were absent by PET imaging of [18F]-PBR111 uptake. Tat and morphine exposure differentially affected eCB levels, non-eCB lipids, and specific amino acids in a region-dependent manner. In the striatum, non-eCB lipids were significantly increased by short-term, escalating morphine exposure, including peroxisome proliferator activator receptor alpha (PPAR-α) ligands N-oleoyl ethanolamide (OEA) and N-palmitoyl ethanolamide (PEA), as well as the amino acids phenylalanine and proline. In the spinal cord, Tat exposure increased amino acids leucine and valine, while morphine decreased levels of tyrosine and valine but did not affect eCBs or non-eCB lipids. CONCLUSION Overall results demonstrate that 3 months of Tat exposure increased morphine tolerance and potentially innate immune tolerance evidenced by reductions in specific cytokines (e.g., IL-1α, IL-12p40) and microglial reactivity. In contrast, short-term, escalating morphine exposure acted as a secondary stressor revealing an allostatic shift in CNS baseline inflammatory responsiveness from sustained Tat exposure.
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Affiliation(s)
- Douglas J Hermes
- Department of Psychology & Neuroscience, University of North Carolina, Chapel Hill, NC, USA
| | - Ian R Jacobs
- Department of Psychology & Neuroscience, University of North Carolina, Chapel Hill, NC, USA
| | - Megan C Key
- Department of Psychology & Neuroscience, University of North Carolina, Chapel Hill, NC, USA
| | - Alexis F League
- Department of Psychology & Neuroscience, University of North Carolina, Chapel Hill, NC, USA
| | | | - Changqing Xu
- Department of Psychology & Neuroscience, University of North Carolina, Chapel Hill, NC, USA
| | - Virginia D McLane
- Department of Pharmacology & Toxicology, Virginia Commonwealth University, Richmond, VA, USA
| | - Sara R Nass
- Department of Pharmacology & Toxicology, Virginia Commonwealth University, Richmond, VA, USA
| | - Wei Jiang
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, USA
- Division of Infectious Diseases, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Rick B Meeker
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | | | - Aron H Lichtman
- Department of Pharmacology & Toxicology, Virginia Commonwealth University, Richmond, VA, USA
| | - Zibo Li
- Department of Radiology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Zhanhong Wu
- Department of Radiology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Hong Yuan
- Department of Radiology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Pamela E Knapp
- Department of Pharmacology & Toxicology, Virginia Commonwealth University, Richmond, VA, USA
- Department of Anatomy & Neurobiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Kurt F Hauser
- Department of Pharmacology & Toxicology, Virginia Commonwealth University, Richmond, VA, USA
- Department of Anatomy & Neurobiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Sylvia Fitting
- Department of Psychology & Neuroscience, University of North Carolina, Chapel Hill, NC, USA.
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12
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Shi Y, Yuan S, Tang SJ. Reactive Oxygen Species (ROS) are Critical for Morphine Exacerbation of HIV-1 gp120-Induced Pain. J Neuroimmune Pharmacol 2020; 16:581-591. [PMID: 32827051 DOI: 10.1007/s11481-020-09951-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 08/17/2020] [Indexed: 02/07/2023]
Abstract
Many HIV patients develop chronic pain and use opioid-derived medicine as primary analgesics. Emerging clinical evidence suggests that chronic use of opioid analgesics paradoxically heightens pain states in patients. This side effect of opioid analgesics has a significant negative impact on clinical practice, but the underlying pathogenic mechanism remains elusive. Using a mouse model of HIV-associated pain, we simulated the development of morphine exacerbation on pain and investigated potential underlying cellular and molecular pathways. We found that repeated morphine treatment promoted astrocyte activation in the spinal dorsal horn (SDH) and up-regulation of pro-inflammatory cytokines IL-1β and TNF-α. Furthermore, we observed that morphine administration potentiated mitochondrial reactive oxygen species (ROS) in the SDH of the HIV pain model, especially on astrocytes. Systemic application of the ROS scavenger phenyl-N-t-butyl nitrone (PBN) not only blocked the enhancement of gp120-induced hyperalgesia by morphine but also astrocytic activation and cytokine up-regulation. These findings suggest a critical role of ROS in mediating the exacerbation of gp120-induced pain by morphine. Graphical abstract.
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Affiliation(s)
- Yuqiang Shi
- Department of Neuroscience and Cell Biology, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Subo Yuan
- Department of Neuroscience and Cell Biology, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Shao-Jun Tang
- Department of Neuroscience and Cell Biology, University of Texas Medical Branch, Galveston, TX, 77555, USA.
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13
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Shi Y, Yuan S, Tang SJ. Morphine and HIV-1 gp120 cooperatively promote pathogenesis in the spinal pain neural circuit. Mol Pain 2020; 15:1744806919868380. [PMID: 31368399 PMCID: PMC6676262 DOI: 10.1177/1744806919868380] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Opioids are common analgesics for pain relief in HIV patients. Ironically, emerging clinical data indicate that repeated use of opioid analgesics in fact leads to a heightened chronic pain state. To understand the underlying pathogenic mechanism, we generated a mouse model to study the interactive effect of morphine and HIV-1 gp120 on pain pathogenesis. We simulated chronic pain in the model by showing that repeated morphine administrations potentiated HIV-1 intrathecal gp120-induced pain. Several spinal cellular and molecular pathologies that are implicated in the development of HIV-associated pain are exacerbated by morphine, including astroglial activation, pro-inflammatory cytokine expression and Wnt5a signaling. We further demonstrated that inhibition of Wnt5a not only reversed the glial activation and cytokine upregulation but also the exacerbation of gp120-induced pain. These studies establish a mouse model for the opioid exacerbation of HIV-associated pain and reveal potential cellular and molecular mechanisms by which morphine enhances the pain.
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Affiliation(s)
- Yuqiang Shi
- 1 Department of Neuroscience and Cell Biology, University of Texas Medical Branch, Galveston, TX, USA
| | - Subo Yuan
- 1 Department of Neuroscience and Cell Biology, University of Texas Medical Branch, Galveston, TX, USA
| | - Shao-Jun Tang
- 1 Department of Neuroscience and Cell Biology, University of Texas Medical Branch, Galveston, TX, USA
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14
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Huang J, Bloe CB, Zhou X, Wu S, Zhang W. The Role of the Spinal Wnt Signaling Pathway in HIV-Related Neuropathic Pain. Cell Mol Neurobiol 2020; 40:1075-1085. [PMID: 32100186 DOI: 10.1007/s10571-020-00805-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 01/28/2020] [Indexed: 12/29/2022]
Abstract
Human immunodeficiency virus (HIV)-related neuropathic pain includes HIV-induced neuropathic pain (HNP) and antiretroviral therapy-induced neuropathic pain (ART-NP). A significant amount of evidence from the past few years has shown that the development of HIV-related neuropathic pain is closely related to the activation of the Wnt signaling pathway in the spinal cord. This review summarizes the function of the spinal Wnt signaling pathway in HIV-induced neuropathic pain, focusing on the role of the spinal Wnt signaling pathway in HNP, and provides a theoretical basis for further studies and the exploration of new target drugs.
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Affiliation(s)
- Jian Huang
- Zhejiang Provincial Key Laboratory of Silkworm Bioreactor and Biomedicine, College of Life Science and Medicine, Zhejiang Sci-Tech University, Hangzhou, 310018, China
| | - Chris Bloe Bloe
- Zhejiang Provincial Key Laboratory of Silkworm Bioreactor and Biomedicine, College of Life Science and Medicine, Zhejiang Sci-Tech University, Hangzhou, 310018, China
| | - Xinxin Zhou
- Zhejiang Provincial Key Laboratory of Silkworm Bioreactor and Biomedicine, College of Life Science and Medicine, Zhejiang Sci-Tech University, Hangzhou, 310018, China
| | - Shengjun Wu
- Clinical Laboratory of Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China.
| | - Wenping Zhang
- Zhejiang Provincial Key Laboratory of Silkworm Bioreactor and Biomedicine, College of Life Science and Medicine, Zhejiang Sci-Tech University, Hangzhou, 310018, China.
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15
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Colasanti J, Lira MC, Cheng DM, Liebschutz JM, Tsui JI, Forman LS, Sullivan M, Walley AY, Bridden C, Root C, Podolsky M, Abrams C, Outlaw K, Harris CE, Armstrong WS, Samet JH, Del Rio C. Chronic Opioid Therapy in People Living With Human Immunodeficiency Virus: Patients' Perspectives on Risks, Monitoring, and Guidelines. Clin Infect Dis 2020; 68:291-297. [PMID: 29860411 DOI: 10.1093/cid/ciy452] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 05/29/2018] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Jonathan Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Marlene C Lira
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Massachusetts
| | - Debbie M Cheng
- Department of Biostatistics, Boston University School of Public Health, Massachusetts
| | - Jane M Liebschutz
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Judith I Tsui
- Section of General Internal Medicine, Department of Medicine, University of Washington and Harborview Medical Center, Seattle
| | - Leah S Forman
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Massachusetts
| | - Meg Sullivan
- Section of Infectious Disease, Department of Medicine, Boston University School of Medicine, Massachusetts
| | - Alexander Y Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Massachusetts
| | - Carly Bridden
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Massachusetts
| | - Christin Root
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Melissa Podolsky
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Massachusetts
| | - Catherine Abrams
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kishna Outlaw
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Catherine E Harris
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Wendy S Armstrong
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jeffrey H Samet
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Massachusetts
| | - Carlos Del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
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16
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Pöyhiä RTI, Mwalumuli EO, Mtega AC, Vegula JJ. Sustainability of Palliative Care in a Rural Hospital in Tanzania: A Longitudinal and Prospective 4-Year Study. J Palliat Care 2020; 35:192-198. [PMID: 31973645 DOI: 10.1177/0825859719892083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Palliative care has been developed in recent years in many sub-Saharan countries in Africa due to activities of African Association for Palliative Care. Palliative care units have been established also in most hospitals in Tanzania. Yet very little is known about their functions. Long-term studies about the sustainability of palliative care have not been carried out. METHODS The attitudes of 101 members of hospital staff and persons in charge of palliative care services of Ilembula District Designated Hospital (IDDH), Tanzania, were assessed using a modified and prevalidated questionnaire annually in 2014 to 2017. The inquiries were executed on randomly allocated days. Also, the patient and economy registries were analyzed. Additional qualitative data were obtained in personal interviews and during observational visits twice a year at the IDDH. RESULTS Ilembula District Designated Hospital has a true multiprofessional palliative care team, which provides services in the hospital, in the villages, and at homes. The activities are based on careful 5-year planning and budgeting. Up to 17 villages have been included in the services. Ninety-five percent of the patients were HIV infected. Short-acting morphine oral solution was the only available strong opioid. The hospital staff evaluated palliative care as good or excellent; 50% of the staff would need more support in the end-of-life care. CONCLUSIONS A sustainable palliative care service can be built in a Tanzanian rural hospital if an advanced planning and budgeting are made. In Tanzania, the biggest group of palliative care patients are still HIV-infected individuals. There is a lack of opioids in the country.
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Affiliation(s)
- Reino Torsti Ilmari Pöyhiä
- Department of Oncology, Division of Palliative Care, University of Turku, Turku, Finland.,Kauniala Hospital, Kauniainen, Finland
| | - Emmanuel Owden Mwalumuli
- Departments of Palliative Care and Aministration, Ilembula District Designated Hospital, Ilembula, Tanzania
| | - Aida Charles Mtega
- Departments of Palliative Care and Aministration, Ilembula District Designated Hospital, Ilembula, Tanzania
| | - Jackson John Vegula
- Departments of Palliative Care and Aministration, Ilembula District Designated Hospital, Ilembula, Tanzania
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17
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Schatman ME, Vasciannie A, Kulich RJ. Opioid moderatism and the imperative of rapprochement in pain medicine. J Pain Res 2019; 12:649-657. [PMID: 30863137 PMCID: PMC6388760 DOI: 10.2147/jpr.s198849] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Michael E Schatman
- Research and Network Development, Boston PainCare, Waltham, MA, USA,
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA,
| | - Alexis Vasciannie
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA
- Department of Biological Sciences, Northeastern University, Boston, MA, USA
| | - Ronald J Kulich
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA
- Department of Anesthesia Critical Care and Pain Medicine, Harvard Medical School/Massachusetts General Hospital, Boston, MA, USA
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18
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Laycock H, Crawford V, Rice AS, Cox S. Lessons learnt from establishing a high dose opioid review clinic for people living with HIV. Pain Manag 2018; 9:37-44. [PMID: 30501569 DOI: 10.2217/pmt-2018-0041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
People living with HIV represent a unique aging population, living with a chronic condition associated with significant pain. A number take high dose, long-term opioids to manage moderate to severe chronic pain, presenting specific risks. This article highlights the size and impact of this problem and outlines the service objectives and set up of a specialist clinic to manage people living with HIV on high dose opioids, alongside its successes and learning points.
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Affiliation(s)
- Helen Laycock
- Clinical Lecturer in Pain Medicine, Department of Surgery & Cancer, Imperial College London, London, UK
| | - Vanessa Crawford
- Honorary Consultant Psychiatrist, HIV Pain Management Clinic, Chelsea & Westminster Hospital NHS Foundation Trust, London, UK
| | - Andrew Sc Rice
- Professor of Pain Research, Department of Surgery & Cancer, Imperial College London, London, UK.,Consultant in Pain Medicine, Department of Pain Medicine, Chelsea & Westminster Hospital NHS Foundation Trust, London, UK
| | - Sarah Cox
- Consultant in Palliative Medicine, Department of Palliative Care, Chelsea & Westminster Hospital NHS Foundation Trust, London, UK
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19
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Bruce RD, Merlin J, Lum PJ, Ahmed E, Alexander C, Corbett AH, Foley K, Leonard K, Treisman GJ, Selwyn P. 2017 HIVMA of IDSA Clinical Practice Guideline for the Management of Chronic Pain in Patients Living With HIV. Clin Infect Dis 2018; 65:e1-e37. [PMID: 29020263 DOI: 10.1093/cid/cix636] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/19/2017] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- R Douglas Bruce
- Department of Medicine, Cornell Scott-Hill Health Center and Yale University, New Haven, Connecticut
| | - Jessica Merlin
- Divisions of Infectious Diseases and Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham
| | - Paula J Lum
- Division of HIV, Infectious Disease, and Global Medicine, University of California San Francisco
| | - Ebtesam Ahmed
- St. Johns University College of Pharmacy and Health Sciences, Metropolitan Jewish Health System Institute for Innovation in Palliative Care, New York
| | - Carla Alexander
- University of Maryland School of Medicine, Institute of Human Virology, Baltimore
| | - Amanda H Corbett
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Kathleen Foley
- Attending Neurologist Emeritus, Memorial Sloan Kettering Cancer Center, New York
| | - Kate Leonard
- Division of Neuroscience and Clinical Pharmacology, Cornell University, New York, New York
| | | | - Peter Selwyn
- Department of Family and Social Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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20
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Cunningham CO. Opioids and HIV Infection: From Pain Management to Addiction Treatment. TOPICS IN ANTIVIRAL MEDICINE 2018; 25:143-146. [PMID: 29689538 PMCID: PMC5935219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
HIV-infected persons are more likely to have chronic pain, receive opioid analgesic treatment, receive higher doses of opioids, and to have substance use disorders and mental illness compared with the general population, putting them at increased risk for opioid use disorder. Management of opioid use in HIV-infected individuals can be complex, and the limited data on opioid treatment in this population are conflicting with regard to its effect on HIV outcomes. Buprenorphine treatment for opioid use disorder improves HIV outcomes and other outcomes. This article summarizes a presentation by Chinazo O. Cunningham, MD, MS at the IAS-USA continuing education program, Improving the Management of HIV Disease, held in Atlanta, Georgia, in March 2017.
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21
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The Effect of Substance Use Disorders on the Association Between Guideline-concordant Long-term Opioid Therapy and All-cause Mortality. J Addict Med 2017; 10:418-428. [PMID: 27610580 DOI: 10.1097/adm.0000000000000255] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Patients with substance use disorders (SUDs) prescribed long-term opioid therapy (LtOT) are at risk for overdose and mortality. Prior research has shown that receipt of LtOT in accordance with clinical practice guidelines has the potential to mitigate these outcomes. Our objective was to determine whether the presence of a SUD modifies the association between guideline-concordant care and 1-year all-cause mortality among patients receiving LtOT for pain. METHODS Among HIV+ and HIV- patients initiating LtOT (≥90 days opioids) between 2000 and 2010 as part of the Veterans Aging Cohort Study, we used time-updated Cox regression and propensity-score matching to examine-stratified by SUD status-the association between 1-year all-cause mortality and 3 quality indicators derived from national opioid-prescribing guidelines. Specifically, we examined whether patients received psychotherapeutic cointerventions (≥2 outpatient mental health visits), benzodiazepine coprescriptions (≥7 days), and SUD treatment (≥1 inpatient day or outpatient visit). These indicators were among those found in a previous study to have a strong association with mortality. RESULTS Among 17,044 patients initiating LtOT, there were 1048 (6.1%) deaths during 1 year of follow-up. Receipt of psychotherapeutic cointerventions was associated with lower mortality in the overall sample and was more protective in patients with SUDs (adjusted hazard ratio [AHR] 0.43, 95% confidence interval [CI] 0.33-0.56 vs AHR 0.65, 95% CI 0.53-0.81; P for interaction = 0.002). Benzodiazepine coprescribing was associated with higher mortality in the overall sample (AHR 1.41, 95% CI 1.22-1.63), but we found no interaction by SUD status (P for interaction = 0.11). Among patients with SUDs, receipt of SUD treatment was associated with lower mortality (AHR 0.43, 95% CI 0.33-0.57). CONCLUSIONS For clinicians prescribing LtOT to patients with untreated SUDs, engaging patients with psychotherapeutic and SUD treatment services may reduce mortality. Clinicians should also avoid, when possible, prescribing opioids with benzodiazepines.
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Starrels JL, Peyser D, Haughton L, Fox A, Merlin JS, Arnsten JH, Cunningham CO. When human immunodeficiency virus (HIV) treatment goals conflict with guideline-based opioid prescribing: A qualitative study of HIV treatment providers. Subst Abus 2017; 37:148-53. [PMID: 26860130 DOI: 10.1080/08897077.2015.1129391] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-infected patients have a high prevalence of chronic pain and opioid use, making HIV care a critical setting for improving the safety of opioid prescribing. Little is known about HIV treatment providers' perspectives about opioid prescribing to patients with chronic pain. METHODS The authors administered a questionnaire and conducted semistructured telephone interviews with 18 HIV treatment providers (infectious disease specialists, general internists, family medicine physicians, nurse practitioners, and physician assistants) in Bronx, NY. Open-ended interview questions focused on providers' experiences, beliefs, and attitudes about opioid prescribing and about the use of guideline-based opioid prescribing practices (conservative prescribing, and monitoring for and responding to misuse). Transcripts were thematically analyzed using a modified grounded theory approach. RESULTS Eighteen HIV treatment providers included 13 physicians, four nurse practitioners, and one physician assistant. They were 62% female, 56% white, and practiced as HIV treatment providers for a mean of 14.6 years. Most reported always or almost always using opioid treatment agreements (56%) and urine drug testing (61%) with their patients on long-term opioid therapy. HIV treatment providers tended to view opioid prescribing for chronic pain within the "HIV paradigm," a set of priorities and principles defined by three key themes: (1) primacy of HIV goals, (2) familiarity with substance use, and (3) the clinician as ally. The HIV paradigm sometimes supported, and sometimes conflicted with, guideline-based opioid prescribing practices. For HIV treatment providers, perceived alignment with the HIV paradigm determined whether and how guideline-based opioid prescribing practices were adopted. For example, the primacy of HIV goals superseded conservative opioid prescribing when providers prescribed opioids with the goal of retaining patients in HIV care. CONCLUSION These findings highlight unique factors in HIV care that influence adoption of guideline-based opioid prescribing practices. These factors should be considered in future research and initiatives to address opioid prescribing in HIV care.
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Affiliation(s)
- Joanna L Starrels
- a Albert Einstein College of Medicine and Montefiore Medical Center , Bronx, New York , USA
| | - Deena Peyser
- b Center for Alcohol Studies , Rutgers University , New York , New York , USA
| | - Lorlette Haughton
- a Albert Einstein College of Medicine and Montefiore Medical Center , Bronx, New York , USA
| | - Aaron Fox
- a Albert Einstein College of Medicine and Montefiore Medical Center , Bronx, New York , USA
| | - Jessica S Merlin
- c School of Medicine, University of Alabama at Birmingham , Birmingham , Alabama , USA
| | - Julia H Arnsten
- a Albert Einstein College of Medicine and Montefiore Medical Center , Bronx, New York , USA
| | - Chinazo O Cunningham
- a Albert Einstein College of Medicine and Montefiore Medical Center , Bronx, New York , USA
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23
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Edelman EJ, Gordon KS, Tate JP, Becker WC, Bryant K, Crothers K, Gaither JR, Gibert CL, Gordon AJ, Marshall B, Rodriguez-Barradas MC, Samet JH, Skanderson M, Justice AC, Fiellin DA. The impact of prescribed opioids on CD4 cell count recovery among HIV-infected patients newly initiating antiretroviral therapy. HIV Med 2016; 17:728-739. [PMID: 27186715 PMCID: PMC5053822 DOI: 10.1111/hiv.12377] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2015] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Certain prescribed opioids have immunosuppressive properties, yet their impact on clinically relevant outcomes, including antiretroviral therapy (ART) response among HIV-infected patients, remains understudied. METHODS Using the Veterans Aging Cohort Study data, we conducted a longitudinal analysis of 4358 HIV-infected patients initiating ART between 2002 and 2010 and then followed them for 24 months. The primary independent variable was prescribed opioid duration, categorized using pharmacy data as none prescribed, short-term (< 90 days) and long-term (≥ 90 days). Outcomes included CD4 cell count over time. Analyses adjusted for demographics, comorbid conditions, ART type and year of initiation, and overall disease severity [ascertained with the Veterans Aging Cohort Study (VACS) Index]. Sensitivity analyses examined whether effects varied according to baseline CD4 cell count, achievement of viral load suppression, and opioid properties (i.e. dose and known immunosuppressive properties). RESULTS Compared to those with none, patients with short-term opioids had a similar increase in CD4 cell count (mean rise per year: 74 vs. 68 cells/μL; P = 0.11), as did those with long-term prescribed opioids (mean rise per year: 74 vs. 75 cells/μL; P = 0.98). In sensitivity analysis, compared with no opioids, the effects of short-term prescribed opioids were statistically significant among those with a baseline CD4 cell count ≥ 500 cells/μL (mean rise per year: 52 cells/μL for no opioids vs. 20 cells/μL for short-term opioids; P = 0.04); findings were otherwise unchanged. CONCLUSIONS Despite immunosuppressive properties intrinsic to opioids, prescribed opioids appeared to have no effect on CD4 cell counts over 24 months among HIV-infected patients initiating ART.
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Affiliation(s)
- E J Edelman
- Yale University School of Medicine, New Haven, CT, USA.
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT, USA.
| | - K S Gordon
- VA Connecticut Health Care System, West Haven, CT, USA
| | - J P Tate
- Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Health Care System, West Haven, CT, USA
| | - W C Becker
- Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Health Care System, West Haven, CT, USA
| | - K Bryant
- National Institute on Alcohol Abuse and Alcoholism, HIV/AIDS Program, Bethesda, MD, USA
| | - K Crothers
- University of Washington, Seattle, WA, USA
| | - J R Gaither
- Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Health Care System, West Haven, CT, USA
- Yale University School of Public Health, New Haven, CT, USA
| | - C L Gibert
- DC Veterans Affairs Medical Center and George Washington University, Washington, DC, USA
| | - A J Gordon
- Veterans Affairs Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, PA, USA
| | - Bdl Marshall
- Brown University School of Public Health, Providence, RI, USA
| | - M C Rodriguez-Barradas
- Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - J H Samet
- Boston University Schools of Medicine and Public Health, Boston, MA, USA
| | - M Skanderson
- VA Connecticut Health Care System, West Haven, CT, USA
| | - A C Justice
- Yale University School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT, USA
- VA Connecticut Health Care System, West Haven, CT, USA
| | - D A Fiellin
- Yale University School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT, USA
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24
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Abdel-Hamid IA, Andersson KE, Waldinger MD, Anis TH. Tramadol Abuse and Sexual Function. Sex Med Rev 2016; 4:235-246. [DOI: 10.1016/j.sxmr.2015.10.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 10/20/2015] [Accepted: 10/21/2015] [Indexed: 11/24/2022]
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25
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Gaither JR, Goulet JL, Becker WC, Crystal S, Edelman EJ, Gordon K, Kerns RD, Rimland D, Skanderson M, Justice AC, Fiellin DA. The Association Between Receipt of Guideline-Concordant Long-Term Opioid Therapy and All-Cause Mortality. J Gen Intern Med 2016; 31:492-501. [PMID: 26847447 PMCID: PMC4835362 DOI: 10.1007/s11606-015-3571-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE For patients receiving long-term opioid therapy (LtOT), the impact of guideline-concordant care on important clinical outcomes--notably mortality--is largely unknown, even among patients with a high comorbidity and mortality burden (e.g., HIV-infected patients). Our objective was to determine the association between receipt of guideline-concordant LtOT and 1-year all-cause mortality. METHODS Among HIV-infected and uninfected patients initiating LtOT between 2000 and 2010 through the Department of Veterans Affairs, we used Cox regression with time-updated covariates and propensity-score matched analyses to examine the association between receipt of guideline-concordant care and 1-year all-cause mortality. RESULTS Of 17,044 patients initiating LtOT between 2000 and 2010, 1048 patients (6%) died during 1 year of follow-up. Patients receiving psychotherapeutic co-interventions (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.51-0.75; P < 0.001) or physical rehabilitative therapies (HR 0.81; 95% CI 0.67-0.98; P = 0.03) had a decreased risk of all-cause mortality compared to patients not receiving these services, whereas patients prescribed benzodiazepines concurrent with opioids had a higher risk of mortality (HR 1.39; 95% CI 1.12-1.66; P < 0.001). Among patients with a current substance use disorder (SUD), those receiving SUD treatment had a lower risk of mortality than untreated patients (HR 0.47; 95% CI 0.32-0.68; P = < 0.001). No association was found between all-cause mortality and primary care visits (HR 1.12; 95% CI 0.90-1.26; P = 0.32) or urine drug testing (HR 0.96; 95% CI 0.78-1.17; P = 0.67). CONCLUSIONS Providers should use caution in initiating LtOT in conjunction with benzodiazepines and untreated SUDs. Patients receiving LtOT may benefit from multi-modal treatment that addresses chronic pain and its associated comorbidities across multiple disciplines.
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Affiliation(s)
- Julie R Gaither
- Yale School of Public Health, Yale University, New Haven, CT, USA. .,VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA. .,Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, CT, USA. .,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA.
| | - Joseph L Goulet
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.,Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - William C Becker
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.,Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Stephen Crystal
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, NJ, USA
| | - E Jennifer Edelman
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Kirsha Gordon
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA
| | - Robert D Kerns
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.,Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - David Rimland
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Atlanta VA Medical Center, Decatur, GA, USA
| | | | - Amy C Justice
- Yale School of Public Health, Yale University, New Haven, CT, USA.,VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.,Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - David A Fiellin
- Yale School of Public Health, Yale University, New Haven, CT, USA.,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
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26
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Merlin JS, Tamhane A, Starrels JL, Kertesz S, Saag M, Cropsey K. Factors Associated with Prescription of Opioids and Co-prescription of Sedating Medications in Individuals with HIV. AIDS Behav 2016; 20:687-98. [PMID: 26487298 DOI: 10.1007/s10461-015-1178-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Opioids are often prescribed for chronic pain, and opioid risks such as overdose and death are heightened when opioids are co-prescribed with other sedating medications. We investigated factors associated with chronic opioid prescription, alone and in combination with benzodiazepines and muscle relaxants, in a clinical cohort of individuals with HIV. We used multivariable logistic regression models to determine participant clinical and demographic characteristics that are associated with chronic prescription of opioids or chronic co-prescription of opioids with sedating medications. Among 1474 participants, chronic prescription of opioids occurred in 253 individuals (17.2 %), and chronic co-prescription occurred in 90 individuals (6.1 %). Age >50, public insurance as compared to private insurance, and symptoms of depression and anxiety were significantly associated with chronic opioid prescription and chronic co-prescription. Our findings raise concern that opioid prescription and co-prescription of sedating medications occurs disproportionately in patients for whom use is riskier.
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Affiliation(s)
- Jessica S Merlin
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, BBRB 222, 1530 3rd Ave S, Birmingham, AL, 35294-2170, USA.
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Ashutosh Tamhane
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, BBRB 222, 1530 3rd Ave S, Birmingham, AL, 35294-2170, USA
| | - Joanna L Starrels
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Stefan Kertesz
- Birmingham VA Medical Center, Birmingham, AL, USA
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael Saag
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, BBRB 222, 1530 3rd Ave S, Birmingham, AL, 35294-2170, USA
| | - Karen Cropsey
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, USA
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27
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Liu B, Liu X, Tang SJ. Interactions of Opioids and HIV Infection in the Pathogenesis of Chronic Pain. Front Microbiol 2016; 7:103. [PMID: 26903982 PMCID: PMC4748029 DOI: 10.3389/fmicb.2016.00103] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 01/19/2016] [Indexed: 12/30/2022] Open
Abstract
Over 50% of HIV-1/AIDS patients suffer chronic pain. Currently, opioids are the cornerstone medications for treating severe pain in these patients. Ironically, emerging clinical data indicates that repeated use of opiate pain medicines might in fact heighten the chronic pain states in HIV patients. Both laboratory-based and clinical studies strongly suggest that opioids exacerbate the detrimental effects of HIV-1 infection on the nervous system, both on neurons and glia. The combination of opioids and HIV-1infection may promote the damage of neurons, including those in the pain sensory and transmission pathway, by activating both caspase-dependent and caspase-independent pro-apoptotic pathways. In addition, the opiate-HIV-1 interaction may also cause widespread disturbance of glial function and elicit glial-derived pro-inflammatory responses that dysregulate neuronal function. The deregulation of neuron-glia cross-talk that occurs with the combination of HIV-1 and opioids appears to play an important role in the development of the pathological pain state. In this article, we wish to provide an overview of the potential molecular and cellular mechanisms by which opioids may interact with HIV-1 to cause neurological problems, especially in the context of HIV-associated pathological pain. Elucidating the underlying mechanisms will help researchers and clinicians to understand how chronic use of opioids for analgesia enhances HIV-associated pain. It will also assist in optimizing therapeutic approaches to prevent or minimize this significant side effect of opiate analgesics in pain management for HIV patients.
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Affiliation(s)
- Bolong Liu
- Department of Neuroscience and Cell Biology, University of Texas Medical Branch, GalvestonTX, USA; Department of Urology, Third Affiliated Hospital of Sun Yat-Sen UniversityGuangzhou, China
| | - Xin Liu
- Department of Neuroscience and Cell Biology, University of Texas Medical Branch, Galveston TX, USA
| | - Shao-Jun Tang
- Department of Neuroscience and Cell Biology, University of Texas Medical Branch, Galveston TX, USA
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28
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Uebelacker LA, Weisberg RB, Herman DS, Bailey GL, Pinkston-Camp MM, Stein MD. Chronic Pain in HIV-Infected Patients: Relationship to Depression, Substance Use, and Mental Health and Pain Treatment. PAIN MEDICINE 2015; 16:1870-81. [PMID: 26119642 DOI: 10.1111/pme.12799] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE As the advent of highly active antiretroviral therapy, HIV has become a chronic disease for most individuals in developed countries. Chronic pain is a common occurrence for HIV-infected patients and has an impact on quality of life and antiretroviral adherence. The objective of this study was to examine relationships between chronic pain and depression, substance use, mental health treatment, and pain treatment in HIV-infected patients. DESIGN Cross-sectional study. SETTING Three primary care sites where HIV+ patients receive treatment. SUBJECTS Two hundred and thirty eight HIV-infected primary care patients. METHODS We collected self-report and chart-review information on demographics, HIV clinical status, chronic pain, depression, substance use, mental health treatment, and pain treatment. We collected data between October 2012 and November 2013. RESULTS Of the patients enrolled in this study, 107 reported no chronic pain, 24 reported mild chronic pain, and 107 reported moderate-severe chronic pain. Participants in the moderate-severe pain group were more likely to have high levels of depressive symptoms than those in the no chronic pain group. Similarly, there was a significant relationship between chronic pain status and interference with life activities due to pain. Participants with moderate-severe chronic pain were more likely to be taking an antidepressant medication than those with mild chronic pain, and more likely to be taking a prescription opioid than the other two groups. We did not find a significant relationship between problematic substance use and chronic pain status. CONCLUSIONS Despite pharmacologic treatment, moderate-severe chronic pain and elevated depression symptoms are common among HIV-infected patients and frequently co-occur.
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Affiliation(s)
- Lisa A Uebelacker
- Butler Hospital, Providence, Rhode Island.,Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Risa B Weisberg
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island.,Boston VA Healthcare System, Boston, Massachusetts
| | - Debra S Herman
- Butler Hospital, Providence, Rhode Island.,Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Genie L Bailey
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island.,Stanley Street Treatment and Resources, Fall River, Massachusetts
| | - Megan M Pinkston-Camp
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island.,The Immunology Center, The Miriam Hospital, Providence, Rhode Island, USA
| | - Michael D Stein
- Butler Hospital, Providence, Rhode Island.,Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island.,The Immunology Center, The Miriam Hospital, Providence, Rhode Island, USA
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29
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Gordon A, Cone EJ, DePriest AZ, Axford-Gatley RA, Passik SD. Prescribing Opioids for Chronic Noncancer Pain in Primary Care: Risk Assessment. Postgrad Med 2015; 126:159-66. [DOI: 10.3810/pgm.2014.09.2810] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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30
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Shacham E, Önen NF, Donovan MF, Rosenburg N, Overton ET. Psychiatric Diagnoses among an HIV-Infected Outpatient Clinic Population. J Int Assoc Provid AIDS Care 2014; 15:126-30. [PMID: 25348798 DOI: 10.1177/2325957414553846] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
As individuals with HIV infection are living longer, the management of psychiatric disorders has increasingly been incorporated into comprehensive care. Individuals were recruited from an outpatient HIV clinic to assess the prevalence and related associations of current psychiatric disorders and biomarkers. Of the 201 participants who completed the interviews, the median age was 43.5 years, and the majority was male and African American. Most were receiving HIV therapy and 78% of those had achieved virologic suppression. Prevalent psychiatric diagnoses included major depressive disorder, generalized anxiety, and agoraphobia. Alcohol and cocaine/crack abuse and dependence were common substance use disorders. Current receipt of HIV therapy was less common among those diagnosed with generalized anxiety disorder. Agoraphobia was the only disorder associated with unsuppressed viral load. Psychiatric and substance use disorders are highly prevalent among an urban HIV clinic population, although we identified few associations between psychiatric diagnoses and HIV diseases status.
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Affiliation(s)
- Enbal Shacham
- Department of Behavioral Sciences and Health Education, College for Public Health and Social Justice, Saint Louis University, St Louis, MO, USA
| | - Nur F Önen
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | | | - Neal Rosenburg
- Nevada State College, School of Nursing, Henderson, NV, USA
| | - E Turner Overton
- Division of Infectious Diseases, Department of Medicine, University of Alabama School of Medicine, Birmingham, AL, USA
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31
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Gaither JR, Goulet JL, Becker WC, Crystal S, Edelman EJ, Gordon K, Kerns RD, Rimland D, Skanderson M, Weisberg DF, Justice AC, Fiellin DA. Guideline-concordant management of opioid therapy among human immunodeficiency virus (HIV)-infected and uninfected veterans. THE JOURNAL OF PAIN 2014; 15:1130-1140. [PMID: 25152300 DOI: 10.1016/j.jpain.2014.08.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 08/04/2014] [Accepted: 08/14/2014] [Indexed: 12/11/2022]
Abstract
UNLABELLED Whether patients receive guideline-concordant opioid therapy (OT) is largely unknown and may vary based on provider and patient characteristics. We assessed the extent to which human immunodeficiency virus (HIV)-infected and uninfected patients initiating long-term (≥ 90 days) OT received care concordant with American Pain Society/American Academy of Pain Medicine and Department of Veterans Affairs/Department of Defense guidelines by measuring receipt of 17 indicators during the first 6 months of OT. Of 20,753 patients, HIV-infected patients (n = 6,604) were more likely than uninfected patients to receive a primary care provider visit within 1 month (52.0% vs 30.9%) and 6 months (90.7% vs 73.7%) and urine drug tests within 1 month (14.8% vs 11.5%) and 6 months (19.5% vs 15.4%; all P < .001). HIV-infected patients were also more likely to receive OT concurrent with sedatives (24.6% vs 19.6%) and a current substance use disorder (21.6% vs 17.2%). Among both patient groups, only modest changes in guideline concordance were observed over time: urine drug tests and OT concurrent with current substance use disorders increased, whereas sedative coprescriptions decreased (all Ps for trend < .001). Over a 10-year period, on average, patients received no more than 40% of recommended care. OT guideline-concordant care is rare in primary care, varies by patient/provider characteristics, and has undergone few changes over time. PERSPECTIVE The promulgation of OT clinical guidelines has not resulted in substantive changes over time in OT management, which falls well short of the standard recommended by leading medical societies. Strategies are needed to increase the provision of OT guideline-concordant care for all patients.
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Affiliation(s)
- Julie R Gaither
- Yale School of Public Health, Yale University, New Haven, Connecticut; Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, Connecticut.
| | - Joseph L Goulet
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - William C Becker
- VA Connecticut Healthcare System, West Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Stephen Crystal
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, New Jersey
| | - E Jennifer Edelman
- Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Kirsha Gordon
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Robert D Kerns
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - David Rimland
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia; Atlanta VA Medical Center, Decatur, Georgia
| | | | - Daniel F Weisberg
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Amy C Justice
- Yale School of Public Health, Yale University, New Haven, Connecticut; Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - David A Fiellin
- Yale School of Public Health, Yale University, New Haven, Connecticut; Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
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32
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Abstract
SUMMARY Opioids are very useful analgesics but reports of abuse, addiction and occasionally death have led to an increase in scrutiny, particularly for chronic opioid therapy. The development of effective antiretroviral therapy has changed the focus of treatment of people living with HIV from palliative care to the management of a chronic disease. It is appropriate, therefore, to review the issues around opioid prescribing in HIV in light of this and recent research, and to review the guidance available. This review briefly examines the epidemiology of pain in people living with HIV and then the use and issues around strong opioid prescribing in this group.
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Affiliation(s)
- Sarah Cox
- Chelsea & Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK.
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33
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Abstract
Distal symmetric polyneuropathy (DSP) related to human immunodeficiency virus (HIV) is one of the most common neurologic complications of HIV, possibly affecting as many as 50% of all individuals infected with HIV. Two potentially neurotoxic mechanisms have been proposed to play a crucial role in the pathogenesis of HIV DSP: neurotoxicity resulting from the virus and its products; as well as adverse neurotoxic effects of medications used in the treatment of HIV. Clinically, HIV DSP is characterized by a combination of signs and symptoms that include decreased deep tendon reflexes at the ankles and decreased sensation in the distal extremities as well as paresthesias, dysesthesias, and pain in a symmetric stocking-glove distribution. These symptoms are generally static or slowly progressive over time, and depending on the severity, may interfere significantly with the patient's daily activities. In addition to the clinical picture, nerve conduction studies and skin biopsies are often pursued to support the diagnosis of HIV DSP. Anticonvulsants, antidepressants, topical agents, and nonspecific analgesics may help relieve neuropathic pain. Specifically, gabapentin, lamotrigine, pregabalin, amitriptyline, duloxetine, and high-dose topical capsaicin patches have been used in research and clinical practice. Further research is needed to elucidate the pathogenesis of HIV DSP, thus facilitating the development of novel treatment strategies. This review discusses the epidemiology, pathophysiology, clinical findings, diagnosis, and management of DSP in the setting of HIV.
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Affiliation(s)
- Sonja G Schütz
- Department of Neurology, Mount Sinai School of Medicine, New York, NY, USA
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34
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Edelman EJ, Gordon KS, Glover J, McNicholl IR, Fiellin DA, Justice AC. The next therapeutic challenge in HIV: polypharmacy. Drugs Aging 2013; 30:613-28. [PMID: 23740523 PMCID: PMC3715685 DOI: 10.1007/s40266-013-0093-9] [Citation(s) in RCA: 167] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
With the adoption of combination antiretroviral therapy (ART), most HIV-infected individuals in care are on five or more medications and at risk of harm from polypharmacy, a risk that likely increases with number of medications, age, and physiologic frailty. Established harms of polypharmacy include decreased medication adherence and increased serious adverse drug events, including organ system injury, hospitalization, geriatric syndromes (falls, fractures, and cognitive decline) and mortality. The literature on polypharmacy among those with HIV infection is limited, and the literature on polypharmacy among non-HIV patients requires adaptation to the special issues facing those on chronic ART. First, those aging with HIV infection often initiate ART in their 3rd or 4th decade of life and are expected to remain on ART for the rest of their lives. Second, those with HIV may be at higher risk for age-associated comorbid disease, further increasing their risk of polypharmacy. Third, those with HIV may have an enhanced susceptibility to harm from polypharmacy due to decreased organ system reserve, chronic inflammation, and ongoing immune dysfunction. Finally, because ART is life-extending, nonadherence to ART is particularly concerning. After reviewing the relevant literature, we propose an adapted framework with which to address polypharmacy among those on lifelong ART and suggest areas for future work.
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Affiliation(s)
| | | | | | - Ian R. McNicholl
- />UCSF Positive Health Program at San Francisco General Hospital, University of California, San Francisco, CA USA
| | - David A. Fiellin
- />Yale University Schools of Medicine and Public Health, New Haven, CT USA
| | - Amy C. Justice
- />Yale University Schools of Medicine and Public Health, New Haven, CT USA
- />VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516 USA
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Receipt of opioid analgesics by HIV-infected and uninfected patients. J Gen Intern Med 2013; 28:82-90. [PMID: 22895747 PMCID: PMC3539026 DOI: 10.1007/s11606-012-2189-z] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Revised: 07/02/2012] [Accepted: 07/23/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND Opioids are increasingly prescribed, but there are limited data on opioid receipt by HIV status. OBJECTIVES To describe patterns of opioid receipt by HIV status and the relationship between HIV status and receiving any, high-dose, and long-term opioids. DESIGN Cross-sectional analysis of the Veterans Aging Cohort Study. PARTICIPANTS HIV-infected (HIV+) patients receiving Veterans Health Administration care, and uninfected matched controls. MAIN MEASURES Pain-related diagnoses were determined using ICD-9 codes. Any opioid receipt was defined as at least one opioid prescription; high-dose was defined as an average daily dose ≥ 120 mg of morphine equivalents; long-term opioids was defined as ≥ 90 consecutive days, allowing a 30 day refill gap. Multivariable models were used to assess the relationship between HIV infection and the three outcomes. KEY RESULTS Among the HIV+ (n = 23,651) and uninfected (n = 55,097) patients, 31 % of HIV+ and 28 % of uninfected (p < 0.001) received opioids. Among patients receiving opioids, HIV+ patients were more likely to have an acute pain diagnosis (7 % vs. 4 %), but less likely to have a chronic pain diagnosis (53 % vs. 69 %). HIV+ patients received a higher mean daily morphine equivalent dose than uninfected patients (41 mg vs. 37 mg, p = 0.001) and were more likely to receive high-dose opioids (6 % vs. 5 %, p < 0.001). HIV+ patients received fewer days of opioids than uninfected patients (median 44 vs. 60, p < 0.001), and were less likely to receive long-term opioids (31 % vs. 34 %, p < 0.001). In multivariable analysis, HIV+ status was associated with receipt of any opioids (AOR 1.40, 95 % CI 1.35, 1.46) and high-dose opioids (AOR 1.22, 95 % CI 1.07, 1.39), but not long-term opioids (AOR 0.94, 95 % CI 0.88, 1.01). CONCLUSIONS Patients with HIV infection are more likely to be prescribed opioids than uninfected individuals, and there is a variable association with pain diagnoses. Efforts to standardize approaches to pain management may be warranted in this highly complex and vulnerable patient population.
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Benzon HT, Kendall MC, Katz JA, Benzon HA, Malik K, Cox P, Dean K, Avram MJ. Prescription Patterns of Pain Medicine Physicians. Pain Pract 2012; 13:440-50. [DOI: 10.1111/papr.12011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 09/18/2012] [Indexed: 12/26/2022]
Affiliation(s)
- Honorio T. Benzon
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago; Illinois; U.S.A
| | - Mark C. Kendall
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago; Illinois; U.S.A
| | - Jeffrey A. Katz
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago; Illinois; U.S.A
| | - Hubert A. Benzon
- Department of Anesthesiology; Boston Children's Hospital; Boston; Massachusetts; U.S.A
| | - Khalid Malik
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago; Illinois; U.S.A
| | - Paul Cox
- Temecula Valley Anesthesiologist; Temecula; California; U.S.A
| | - Kathryn Dean
- Transitional Year; Department of Medicine; North Shore Hospital; University of Chicago; Evanston; Illinois; U.S.A
| | - Michael J. Avram
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago; Illinois; U.S.A
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Pain, mood, and substance abuse in HIV: implications for clinic visit utilization, antiretroviral therapy adherence, and virologic failure. J Acquir Immune Defic Syndr 2012; 61:164-70. [PMID: 22766967 DOI: 10.1097/qai.0b013e3182662215] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cooccurring pain, mood disorders, and substance abuse are common in HIV-infected patients. Our objective was to investigate the relationship between pain, alone and in the context of mood disorders and substance abuse, on clinic utilization, antiretroviral therapy adherence, and virologic suppression. METHODS Pain, mood disorders, and substance abuse were assessed at the first visit. No-show and urgent visits were measured over a 1-year period. Models were adjusted for age, race, sex, insurance status, CD4(+) T-lymphocyte count, and HIV risk factor. RESULTS Among 1521 participants, 509 (34%) reported pain, 239 (16%) had pain alone, 189 (13%) had pain and a mood disorder, and 30 (2%) had pain and substance abuse. In univariate models, participants with pain, mood disorders, and substance abuse had higher odds of a no-show visit than those without these conditions [odds ratio (OR), 1.4; 95% confidence interval (CI), 1.1-1.8; OR, 1.5; 95% CI, 1.2-1.9; OR, 2.0; 95% CI, 1.4-2.8, respectively]. In the multivariable model, pain increased the odds of a no-show visit only in participants without substance abuse (OR, 1.5; 95% CI, 1.1-1.9) and pain reduced the odds of a no-show visit in participants with substance abuse (OR, 0.5; 95% CI, 0.2-0.9; P for interaction = 0.0022). CONCLUSIONS In this study, pain increased the odds of no-show visits but only for participants without substance abuse. Because pain, mood disorders, and substance abuse are highly prevalent in HIV-infected patients, our findings have implications for HIV treatment success. Interventions that incorporate pain management may be important for improving health outcomes in patients living with HIV infection.
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