OUD Stable Over Time in People Living With HIV, Chronic Pain

Patterns of opioid misuse and opioid use disorder (OUD) were found to be relatively stable or decreasing over time in people living with HIV (PLWH) and chronic pain, according to a study published in the Journal of Addiction Medicine. However, the prevalence of misuse and OUD was higher in this population than in previous estimates.

PLWH often have chronic pain, defined as pain that persists beyond 3 months, with 25% to 90% of PLWH reporting chronic pain. Opioids have been used to treat chronic pain in PLWH with about 8% to 17% prescribed some form of long-term opioid. As PLWH are at increased risk of opioid overdose and OUD, this study aimed to examine the misuse of opioids and OUD over time in these individuals. This comprised of identifying trajectories of opioid misuse and OUD and determining the association between prescription opioid dose and these trajectories.

Data from the Project PIMENTO prospective observational longitudinal study were used for this analysis. The study included PLWH and chronic pain who were enrolled from May 2017 to July 2019 from the Montefiore Medical Center in the Bronx, NY. Patients were included in this study if they had HIV; were aged 18 years or older; had chronic pain due to lower back pain, osteoarthritis, or neuropathy; could understand English; and had gone for 2 or more visits to Montefiore HIV primary care sites. Enrollment was restricted to participants who had been prescribed opioids in the previous 30 days after April 2019, and patients were excluded if they had malignancy or were unable to provide informed consent.

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Data were collected using research interviews conducted at baseline and every 3 months for a year, with trained research assistants making the OUD diagnoses formally. Prescription data for opioids were extracted from the monitoring program from New York State as well as the electronic medical record of Montefiore. Researchers used the mean daily dose of opioids prescribed in the previous 90 days to define prescription opioid dose, and used the Current Opioid Misuse Measure to measure opioid misuse, primarily through measuring if a patient used more opioids than prescribed, used opioids for nonpain symptoms, or was borrowing opioids. The scale used a 5-point scale from 0-4, with 4 representing “very often," and OUD was measured through the PRISM-OP-5.

A total of 139 patients consented and completed both the baseline and 12-month follow-up visit, with a median age of 55 (range, 27-76) years and 56.8% being women. Of this group, 54.7% identified as Black or African American and 34.5% identified as Hispanic or Latino. A total of 89.9% reported being unemployed, not working due to disability, not having stable employment, or being retired; 66.2% were covered by Medicaid and 29.7% were covered by Medicare.

There were 42.6% of participants who reported an active opioid prescription at baseline and 4.8% who had a long-acting opioid prescription at baseline. Most participants (82.4%) had lower back pain. A total of 43.2% of participants met criteria for lifetime OUD, 46.6% reported current opioid misuse at baseline, and 29.7% had current OUD.

There were 3 trajectories of opioid misuse over the 12 month period. No opioid misuse was found in 64 patients, 48 patients had infrequent and decreasing misuse and a mean score of 0.16-2.02 on the opioid misuse scale, and 36 patients had infrequent but consistent opioid misuse with a mean score of 2.32-3.03 on the scale.

OUD symptoms also had 3 trajectories over 12 months. A total of 84 patients had no OUD with a mean number of OUD criteria between 0.01 and 0.27, 52 patients had sub-threshold OUD with a mean number of OUD criteria between 1.06 and 2.08, and 12 patients had moderate OUD with a mean number of OUD criteria between 3.36 and 5.1. Increased baseline opioid dose was associated with a linear trend in OUD trajectory (F, 10.83) but not a linear trend in opioid misuse trajectory.

According to the researchers, these findings align with other studies that had a comparable misuse framework. However, the prevalence of misuse behaviors in the current sample of PLWH was notably higher compared with previous analyses.

"Whether this is due to ascertainment bias or due to secular trends in opioid misuse is unclear, but answering this question should be an important part of future research," the researchers said. "Opioid misuse in PLWHs has been associated with inadequate antiretroviral adherence and insufficient viral suppression, but opioid misuse assessments are not universally agreed upon in research or in clinical settings and, moreover, are infrequently used in clinically practice."

There were some limitations to this study, including that all PLWH in this study had consistent medical care and were not incarcerated at time of recruitment, which could have led to a cohort of patients with less burden of opioid misuse and OUD.

The researchers concluded that OUD and opioid misuse had a "mixed picture" among PLWH in this study.

"On one hand, patterns of opioid misuse and OUD were relatively stable or decreasing over time, providing comforting reassurance of stable risk of misuse or OUD," the researchers explained. "On the other hand, we found that the prevalence of misuse and OUD was relatively high and, in the case of OUD, higher than previous diagnosed estimates in similar patient populations. We believe this suggests large proportions of undiagnosed OUD in PLWHs and, further, suggests that assessment of opioid misuse and OUD may be an important strategy to reduce opioid-related morbidity and mortality."

Reference

Perez HR, Deng Y, Zhang C, et al. Trajectories of opioid misuse and opioid use disorder among adults with chronic pain and HIV: an observational study. J Addict Med. Published online January 25, 2024. doi:10.1097/ADM.0000000000001268