Ongoing Pain Despite Aggressive Opioid Pain Management Among Persons With HIV (original) (raw)
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Journal of Palliative Care, 2015
Current or former injection drug using (IDU) persons with HIV/AIDS are at high risk for pain, which adversely affects quality of life and may increase risk for illicit drug use or relapse. We explored associations between pain symptoms and substance use among IDU study participants with HIV/AIDS and histories of heroin use. Using generalized estimating equations and controlling for prior substance use, pain in each six month period was associated with use of heroin and prescription opioids, but not use of non-opioid drugs or alcohol. Routine clinical assessment and improved management of pain symptoms may be needed in persons with HIV and a history of injection drug use, particularly those with chronic pain, for whom there is increased risk for heroin use.
Prescription Long-term Opioid Use in HIV-infected Patients
The Clinical Journal of Pain, 2012
Objectives-To examine changes in use of prescription opioids for the management of chronic non-cancer pain in HIV-infected patients and to identify patient characteristics associated with long-term use.
Opioids in the management of HIV-related pain
Pain physician
Background: Human Immunodeficiency Virus (HIV) patients have an increased rate of chronic pain, particularly peripheral neuropathy. This disease burden causes considerable disability and negatively affects quality of life. Pain is undertreated and more complex to manage in these patients for a number of reasons, including complex anti-retroviral drug regimens, higher risks of side effects, and higher rates of comorbid psychiatric illness and substance abuse. Pain management must take these factors into account and use all available modalities, including nonopioid pain relievers, adjuvant medications, and psychosocial therapies in addition to opioid analgesics. Here we review recent recommendations regarding acute and chronic opioid treatment of pain and the treatment of opioid dependence in HIV-infected patients, and provide suggestions regarding aberrant behavior in pain treatment.
Receipt of Opioid Analgesics by HIV-Infected and Uninfected Patients
Journal of General Internal Medicine, 2013
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).
The Association of Chronic Pain and Long-Term Opioid Therapy with HIV Treatment Outcomes
Journal of acquired immune deficiency syndromes (1999), 2018
Chronic pain occurs in up to 85% of persons living with HIV (PLWH) and is commonly treated with long-term opioid therapy (LTOT). We investigated the impact of chronic pain and LTOT on HIV outcomes. This was prospective cohort study conducted between 7/2015-7/2016 in five HIV primary care clinics. Chronic pain was defined as ≥moderate pain for ≥3 months on the Brief Chronic Pain Questionnaire and ≥4/10 on the Pain Enjoyment of life and General activity (PEG) questionnaire. Chronic pain and LTOT were assessed at an index visit. Suboptimal retention, defined as at least one "no-show" to primary care, and virologic failure were measured over the subsequent year. Multivariable logistic regression models were built for each outcome adjusting for site. Among 2334 participants, 25% had chronic pain, 27% had suboptimal retention, 12% had virologic failure, and 19% were prescribed LTOT. Among individuals not on LTOT, chronic pain was associated with increased odds of suboptimal rete...
PAIN, 1997
Concerns are often raised regarding the credibility of patients' report of pain and this concern is heightened among individuals with AIDS, where many patients have a history of injection drug use. This study compared the pain experience, adequacy of pain management and psychological well-being among patients with AIDS who reported a history of injection drug use (IDU) as their HIV transmission risk factor and patients with other HIV transmission risk factors. Five hundred and sixteen ambulatory AIDS patients participating in a quality of life study completed a series of self-report instruments including the Brief Pain Inventory, the Beck Depression Inventory, the Brief Symptom Inventory, the Functional Living Inventory and the Social Support Questionnaire. Results demonstrated that IDU and non-IDU subjects did not differ significantly in their report of pain prevalence, pain intensity or pain-related functional interference. However, IDU patients were significantly more likely to receive inadequate analgesic medications, reported lower levels of pain relief and a greater degree of psychological distress. There was also no difference in report of pain intensity, pain relief or functional interference among patients who acknowledged continued drug use, those who denied any recent drug use and patients participating in a methadone maintenance program. These data support the validity of AIDS patients' report of pain, at least in research settings, and suggest that undertreatment of pain is not restricted to patients who actively abuse drugs. © 1997 International Association for the Study of Pain. Published by Elsevier Science B.V.
PLOS ONE, 2020
BackgroundOpioid overdose mortality continues to increase in the United States despite significant investments to reverse the epidemic. The national response to-date has focused primarily on reducing opioid prescribing, yet reductions in prescribing have been associated with patients reporting uncontrolled pain, psychological distress, and transition to illicit substances. The aim of this study is to qualitatively explore chronic pain management experiences among PLWH with a history of illicit substance use after long-term opioid therapy reductions or discontinuations.MethodsWe analyzed 18 interviews, stopping upon reaching thematic saturation, with HIV-positive participants with a history of substance use who were enrolled in a longitudinal cohort study to assess the impact of prescribing changes among patients with chronic pain. Participants in this nested qualitative study had been reduced/discontinued from opioid pain relievers (OPRs) within the 12 months prior to interview. Interviews were audio-recorded and transcribed verbatim. Two analysts coded all interviews, interrater reliability was measured, and coding discrepancies discussed. The study took place in San Francisco, California in 2018.ResultsEleven participants were male with a mean age of 55; 8 were African American and 8 were White. All participants were HIV-positive, actively engaged in primary care, and had a lifetime history of illicit substance use. Twelve reported using illicit substances within the past year, including non-prescription opioids/heroin (10), and stimulant use (10). After being reduced/discontinued from their long-term opioid therapy, patients reported developing complex multimodal pain management systems that often included both nonpharmacological approaches and illicit substance use. Participants encountered a range of barriers to nonpharmacological therapies including issues related to accessibility and availability. Participants often reported attempts to replicate their prior OPR prescription by seeking out the same medication and dose from illicit sources and reported transitioning to heroin after exhausting other options.ConclusionAfter being reduced/discontinued from OPRs, HIV-positive patients with a history of substance use reported experimenting with a range of pain management modalities including nonpharmacological therapies and illicit substance use to manage symptoms of opioid withdrawal and pain. Providers should consider that any change to a patients’ long-term opioid therapy may result in experimentation with pain management outside of the medical setting and may want to employ patient-centered, holistic approaches when managing patients’ opioid prescriptions and chronic pain.
The Journal of Pain, 2011
Pain is common among people living with HIV/AIDS (PLWHA), but little is known about chronic pain in socioeconomically disadvantaged HIV-infected populations with high rates of substance abuse in the post-antiretroviral era. This cross-sectional study describes the occurrence and characteristics of pain in a community-based cohort of 296 indigent PLWHA. Participants completed questionnaires about sociodemographics, substance use, depression and pain. Cut-point analysis was used to generate categories of pain severity. Of the 270 participants who reported pain or the use of a pain medication in the past week, 8.2% had mild pain, 38.1% had moderate pain, and 53.7% had severe pain. Female sex and less education were associated with more severe pain. Depression was more common among participants with severe pain than among those with mild pain. Increasing pain severity was associated with daily pain and with chronic pain. Over half of the participants reported having a prescription for an opioid analgesic. Findings from this study suggest that chronic pain is a significant problem in this high risk, socioeconomically disadvantaged group of patients with HIV disease and high rates of previous or concurrent use of illicit drugs.
Journal of Substance Abuse Treatment, 2007
Clinicians treating human immunodeficiency virus (HIV)-infected patients with substance use disorders often face the challenge of managing patients' acute or chronic pain conditions while keeping in mind the potential dangers of prescription opiate dependence. In this clinical review, we critically appraise the existing data concerning barriers to appropriate treatment of pain among HIVinfected patients with substance use disorders. We then analyze published studies concerning the choice of pharmacological pain control regimens for acute and chronic pain conditions in HIVinfected patients, keeping in mind HIV-specific issues related to drug interactions and substance use disorders. We summarize this information in the form of flowcharts for physicians approaching HIVinfected patients who present with complaints of pain, providing evidence-based guidance for the structuring of pain management services and for addressing aberrant drug-taking behaviors. these keywords; of these articles, 1,941 were immediately excluded by two of the authors (S.B. and R.D.B.) for having no relevance to the subject at hand. Of the 142 remaining references, 54 failed to comment on aspects of pain management for HIV-infected patients, mentioning HIV only in passing and without accompanying data or other potentially useful clinical information. The remaining 88 references formed the basis for this review. Of these, 22 described prospective randomized controlled trials, 32 described retrospective case-control studies, 13 presented case reports, and the remaining involved guidelines from authoritative bodies (n = 5) or prior reviews of relevant literature (n = 16).
JAIDS Journal of Acquired Immune Deficiency Syndromes, 2020
Background: No prior studies have characterized long-term patterns of opioid use regardless of source or reason for use among patients with HIV (PWH). We sought to identify trajectories of selfreported opioid use and their correlates among a national sample of PWH engaged in care. Setting: Veterans Aging Cohort Study, a prospective cohort including PWH receiving care at eight US Veterans Health Administration (VA) sites. Methods: Between 2002 and 2018, we assessed past year opioid use frequency based on selfreported "prescription painkillers" and/or heroin use at baseline and follow-up. We used groupbased trajectory models to identify opioid use trajectories and multinomial logistic regression to determine baseline factors independently associated with escalating opioid use compared to stable, infrequent use. Results: Among 3,702 PWH, we identified four opioid use trajectories: 1) no lifetime use (25%); 2) stable, infrequent use (58%); 3) escalating use (7%); and 4) de-escalating use 11%). In bivariate analysis, anxiety; pain interference; prescribed opioids, benzodiazepines and gabapentinoids; and marijuana use were associated with escalating opioid group membership compared to stable, infrequent use. In multivariable analysis, illness severity, pain interference, receipt of prescribed benzodiazepine medications and marijuana use were associated with escalating opioid group membership compared to stable, infrequent use. Conclusion: Among PWH engaged in VA care, one in 15 reported escalating opioid use. Future research is needed to understand the impact of psychoactive medications and marijuana use on opioid use and whether enhanced uptake of evidence-based treatment of pain and psychiatric symptoms can prevent escalating use among PWH.