“There are specific motivations for certain types of care,” Phillip O. Coffin, MD, MIA, FACP, FIDSA, notes. “HIV providers are motivated to ensure viral suppression, which comes from engagement in care. Anything that gets in the way of viral suppression could result in both sicker patients and more HIV transmission, which is even more relevant today as we are striving for zero new infections. Many providers felt that opioids were keeping patients engaged in HIV care. Personally, I didn’t believe that, so I wanted to find out.” For a study published in AIDS and Behavior, Dr. Coffin and colleagues aimed to determine associations between opioid dose changes and time to disengaging in HIV care, as well as virologic failure. “We utilized EMR data from 2012-2019 for 300 patients living with HIV who had received at least 3 months of contiguous opioid therapy for non-malignant chronic pain,” Dr. Coffin explains. “Our exposures were changes in opioid dose over a 3-month period: increase of at least 30%, decrease of at least 30%, or discontinuation. The outcomes were disengagement from care, defined as not getting two viral load assays in a year, and virologic failure, defined as an HIV viral load greater than 200 copies/mL.”
Discontinuing Opioids Impacts Engagement in Care
The median age of patients was 50 and most (73.7%) were male. All patients were prescribed opioids for at least 3 months from 2013-2015; the proportion of patients receiving opioids varied by year, from a peak of 93.5% in 2014 to a nadir of 58% in 2019. The mean daily dose prescribed in any given year ranged from 162 to 193 morphine milligram equivalents.
Most patients experienced a reduction or halt in opioid prescriptions during the study period. Discontinuation was associated with greater odds of disengagement from care in the next 3 months (OR, 2.23; 95% CI, 1.19-4.19), 6 months (OR, 3.67; 95% CI, 1.93-6.97), and 9 months (OR, 3.73; 95% CI, 1.77-7.86). However, the final analysis showed no significant association between opioid prescribing and viral suppression (Table).
“In earlier analyses, we saw a significant improvement in viral suppression with increasing opioid dose,” says Dr. Coffin. “This went away after adjusting for additional factors, although the confidence interval still approaches one, suggesting there was some signal. However, the main finding is the lack of an association between discontinuing opioids and subsequent virologic failure. This could be for several reasons, including a weakening of the association between engagement in care and virologic suppression. ART medications are much easier to take now than previously, so patients may be able to sustain virologic suppression for longer periods of time without being fully engaged in care.”
Systemic Changes Needed to Balance Opioid Harm Vs Benefit in HIV
The results highlight the need to balance opioid stewardship with maintaining engagement in care, according to the researchers. “These results certainly don’t mean that we should continue prescribing opioids when risks outweigh benefits, but we need to factor the risks of stopping opioids into the equation,” says Dr. Coffin.
Forthcoming guidelines on opioid prescribing from the CDC will “move away from arbitrary dose limits and clarify that patients who are already taking opioids need to be managed individually, with patient-centered plans of care, and with great caution when a taper is deemed necessary,” he says.
Research that Dr. Coffin describes as “the most clinically useful” is an effort to create patient-centered plans for opioid management. While this represents “complicated research,” it is an area in which clinicians need greater support.
Most importantly, a need exists for changes in policy, Dr. Coffin says. “One of the worst outcomes of opioid prescribing reform has been medical board and other regulatory investigations into overdose deaths, which have resulted in so many providers refusing to care for patients on opioid therapy. In California, hundreds of providers were investigated based on deaths that occurred nearly a decade earlier; they spent large sums of money on legal fees, and, in most cases, had no resulting complaint.”
The outcome had “such a chilling effect that many individual providers and entire clinic systems stopped prescribing opioids, refused to care for patients on opioids, and, in some cases, even abandoned plans to provide buprenorphine due to the regulatory risk of taking on care for patients with opioid use disorder,” Dr. Coffin says. “This is a disastrous outcome for vulnerable patients. Unfortunately, the situation won’t improve until regulators not only change their practice but are vocal about those changes.”