A new study reveals that HIV clinicians may not be doing enough to monitor for opioid abuse/misuse among patients.
What is less known, however, is how people living with HIV/AIDS are using opioids, and whether such use is being properly assessed for risk for abuse and/or misuse. And, a new study published May 31 by Clinical Infectious Diseases (CID) suggests that we may have a problem on our hands.
“People living with HIV are a group who bear a disproportionate burden of chronic pain in the United States due to a combination of the pathophysiology of the virus itself, as well as adverse effects of many of the antivirals that were used in the early days of the epidemic,” Jonathan Colasanti, MD, study co-author and instructor, division of infectious diseases, Emory University School of Medicine and Rollins School of Public Health, Emory University, Atlanta, Georgie, told Contagion®. “[Members of the study team] knew from experience in their own clinics that the monitoring around opioid prescribing could and had to be improved. We felt that it was important to share [patients’] perspectives on how their opioid use was being monitored, whether they knew the potential dangers of opioid therapy and, ultimately, if they were satisfied with being monitoring on their chronic opioid therapy.”
The patient cohort study that resulted from the authors’ clinical experiences only reinforced their perceptions.
Dr. Colasanti and his colleagues assessed opioid risk behaviors, perceptions of risk, opioid monitoring and associated Current Opioid Misuse Measure (COMM; a measure of potential opioid misuse) scores among 166 people living with HIV and on prescribed chronic opioid therapy (defined as ≥3 opioid prescriptions ≥21 days apart in the past 6 months) receiving care at 2 HIV clinics.
According to Dr. Colasanti, he and his co-authors knew from other studies that HIV clinicians “may be reluctant to address unsafe prescription opioid use… for fear of driving patients away, who may otherwise be doing well with regard to retention in HIV care and viral suppression, which HIV clinicians may view as their primary responsibility.” Among the subjects enrolled in their study, they found that alcohol and drug use disorders were present in 17% and 19%—meaning, that abuse/misuse is a relevant concern. In fact, 25% of the study subjects reported that they had previously used opioids illegally.
In all, 43% of the study subjects had a high COMM score (≥9). Although 90% of the study subjects were aware that opioids “can be addictive,” only 30% of them had an opioid treatment agreement, a commonly used tool in pain management designed to mitigate abuse/misuse risk.
“Practically speaking, conducting comprehensive chronic opioid therapy monitoring can weigh heavily on the individual clinician as it requires difficult, often time-intensive discussions with patients, in-depth risk assessments, diligence to ensure things like pill counts and urine drug tests are conducted regularly, and ultimately training that many of us lack,” Dr. Colasanti said. “That’s not an excuse, but rather the reality. As more and more administrative requirements are placed on clinicians, adding the expectation of truly comprehensive chronic opioid therapy monitoring is setting us up for failure.”
To explore this issue further, a subsequent randomized control trial is in the works; in part, it will assess whether “placing a nurse case manager in a role to oversee and guide much of this monitoring and provide clinicians with additional academic detailing around chronic pain management and/or monitoring will prove an effective mechanism to improve this process for both patients and clinicians alike,” he added.
Notably, within the patient cohort for the CID study, 66% underwent routine urine drug tests and only 12% were subject to regular pill counts, both of which are commonly used techniques for monitoring for abuse/misuse. At least among the study subjects, Dr. Colasanti et al found that patient satisfaction remained high, even when these abuse/misuse risk management tools were being used.
“We have to be careful that the pendulum does not swing too far in the opposite direction with regard to the condemnation of all opioid prescribing,” Dr. Colasanti said. “In carefully selected patients with appropriate monitoring, it may well be the best therapy for that individual. For many [with HIV] who suffer from severe avascular necrosis or peripheral neuropathy, chronic opioid therapy allows them to function and heightens their quality of life. Yet, we are all taught that we should have a step-wise approach to pain management that includes nonopioid analgesics and alternative approaches to pain management such as yoga, massage, and acupuncture. We must ensure that people living with HIV, who have a baseline higher risk of suffering from chronic pain, have access to all evidence-based pain management options.”
Indeed, the relationship between the opioid epidemic and certain infectious diseases has already been well documented. If the results of the CID study are any indication, it’s at least in part up to ID specialists to ensure that the related challenges don’t get any worse.
Brian P. Dunleavy is a medical writer and editor based in New York. His work has appeared in numerous health care-related publications. He is the former editor of Infectious Disease Special Edition.