A study has found that opioid prescriptions, including receipt of prescriptions for long durations, appear to be common among people living with HIV who are in primary care. Efforts are needed to prevent chronic high-risk prescriptions in patients receiving HIV care with comorbid conditions.

Healthcare providers continue to face many challenges in ensuring effective chronic pain management while simultaneously preventing and addressing opioid misuse, opioid use disorders (OUD), and opioid-related morbidity among persons with HIV (PWH). Despite the availability of guidelines promoting safe and effective chronic pain management, studies conducted throughout the past decade have shown that PWH have a high prevalence of chronic pain at all stages of HIV and often have undertreated pain.

“Data on the prevalence of prescription opioid use show that PWH are more likely to have received opioid prescriptions, at higher doses, and for longer periods than the general population,” says Ana Ventuneac, PhD. “Given large-scale investments to address the opioid epidemic in the United States, it’s important to examine opioid prescription patterns among patients in HIV primary care in the context of policies that prioritize judicious opioid prescribing and emphasize non-opioid pharmacologic therapies to promote safe pain management.”

A Need for Pain Treatment Services

For a study published in Frontiers in Sociology, Dr. Ventuneac and colleagues sought to characterize opioid prescription patterns and identify risk factors for chronic high-risk opioid prescriptions and HIV outcomes among PWH in primary care. They examined EMRs for 8,882 patients receiving HIV care during a period of 18 months. Notably, the study was conducted following the publication of the 2016 CDC pain management guidelines.

“We found that 12% of patients received at least one opioid prescription during the study period, which was lower than estimates ranging between 17% and 53% that have been seen in earlier studies,” Dr. Ventuneac says. During the study, 56% of patients with an opioid prescription received one to three prescriptions for opioids and 40% received these prescriptions for longer than 1 year. “The presence of pain diagnoses, OUD, and mental health disorders were independently associated with an increased likelihood of having received at least one opioid prescription,” adds Dr. Ventuneac.

Overall, the number of monthly prescriptions decreased by 14% from the first month to the last month of the study period. This decrease occurred mostly in low morphine equivalent dose (MED) prescriptions, which represented about 80% of the prescriptions during the study. “However, an 18% increase was seen in PWH who received chronic high dose prescriptions (>120 MED), representing about 20% of prescriptions overall,” says Dr. Ventuneac.

Multivariate analyses were conducted to examine factors independently associated with either receipt of any opioid prescription, receipt of high MED, or viral load nonsuppression. After controlling for sociodemographic and clinical factors, the odds of PWH receiving any opioid prescription were higher among those with pain diagnoses and mental health disorders (Figure). “This finding highlights the need for comprehensive treatment services that focus on pain management,” Dr. Ventuneac says. “In terms of HIV outcomes, virologic failure was more likely in patients with substance use disorders.”

Curbing/Preventing Problematic Use

Collectively, Dr. Ventuneac says the findings have important implications for preventing chronic high-risk prescriptions in the clinical care of PWH and comorbid conditions, including pain-related mental health and substance use disorders. “Pain management strategies that emphasize nonpharmacologic therapies should be considered first when caring for patients,” she says. “For those with long-term or chronic highrisk prescriptions, treatment plans that effectively engage PWH about medication-assisted treatment options (eg, buprenorphine) and other evidence-based interventions could curb or prevent problematic use. Access to addiction specialists, as well as education, training, and support tools for the management of pain and comorbid conditions, could serve as critical supports for healthcare professionals.”

In the future, continuing examination of trends in prescribing patterns and identifying factors that impact the course of opioid use among PWH are critical. “While public health guidelines that directly address opioid prescribing practices have had an impact in reducing the overall number of prescriptions, our data suggest additional research is needed to better understand pain and its management,” says Dr. Ventuneac. “We also need research on trajectories that move beyond opioid use and misuse to opioid use disorders so that we can identify prevention and treatment targets to optimize patient outcomes.”