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Prescription of High-Dose Opioids Among People Living with HIV in British Columbia, Canada

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Abstract

People living with HIV (PLHIV) often experience pain for which opioid medications may be prescribed. Thus, these individuals are particularly vulnerable to opioid-related harms, including overdose, misuse, and addiction, particularly when prescribed at high doses. We used a comprehensive linked population-level database of PLHIV in British Columbia (BC) to identify demographic and clinical characteristics associated with being prescribed any high-dose opioid analgesic, defined as > 90 daily morphine milligram equivalents (MME/day). Among PLHIV who were prescribed opioids between 1996 and 2015 (n = 10,780), 28.2% received prescriptions of > 90 MME/day at least once during the study period. Factors positively associated with being prescribed high-dose opioid analgesics included: co-prescription of benzodiazepines (adjusted odds ratio [AOR] = 1.14; 95% confidence interval 1.11–1.17); presence of an AIDS-defining illness (ADI; AOR = 1.78; 95% CI 1.57–2.02); seen by an HIV specialist (AOR = 1.24; 95% CI 1.20–1.29); substance use disorder (AOR = 1.46; 95% CI 1.25–1.71); and more recent calendar year (AOR = 1.05; 95% CI 1.04–1.06). Given the known risks associated with high-dose opioid prescribing, future research efforts should focus on the clinical indication and outcomes associated with these prescribing practices.

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References

  1. Hewitt DJ, McDonald M, Portenoy RK, Rosenfeld B, Passik S, Breitbart W. Pain syndromes and etiologies in ambulatory AIDS patients. Pain. 1997;70(2):117–23.

    Article  CAS  PubMed  Google Scholar 

  2. Penfold J, Clark AJM. Pain syndromes in HIV infection. Can J Anaesth. 1992;39(7):724–30.

    Article  CAS  PubMed  Google Scholar 

  3. Parker R, Stein DJ, Jelsma J. Pain in people living with HIV/AIDS: a systematic review. J Int AIDS Soc. 2014;17(1):18719.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Merlin JS, Cen L, Praestgaard A, et al. Pain and physical and psychological symptoms in ambulatory HIV patients in the current treatment era. J Pain Symptom Manag. 2012;43(3):638–45.

    Article  Google Scholar 

  5. Aouizerat BE, Miaskowski CA, Gay C, et al. Risk factors and symptoms associated with pain in HIV-infected adults. J Assoc Nurses AIDS Care. 2010;21(2):125–33.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Koeppe J, Armon C, Lyda K, Nielsen C, Johnson S. Ongoing pain despite aggressive opioid pain management among persons with HIV. Clin J Pain. 2010;26(3):190.

    Article  PubMed  Google Scholar 

  7. Breitbart W, Rosenfeld BD, Passik SD, McDonald MV, Thaler H, Portenoy RK. The undertreatment of pain in ambulatory AIDS patients. Pain. 1996;65(2):243–9.

    Article  CAS  PubMed  Google Scholar 

  8. Tsao JCI, Stein JA, Dobalian A. Sex differences in pain and misuse of prescription analgesics among persons with HIV. Pain Med. 2010;11(6):815–24.

    Article  PubMed  Google Scholar 

  9. Miaskowski C, Penko JM, Guzman D, Mattson JE, Bangsberg DR, Kushel MB. Occurrence and characteristics of chronic pain in a community-based cohort of indigent adults living with HIV infection. J Pain. 2011;12(9):1004–16.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Bruce RD, Merlin J, Lum PJ, et al. 2017 HIVMA of IDSA clinical practice guideline for the management of chronic pain in patients living with HIV. Clin Infect Dis. 2017;65(10):e1–37.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Roy S, Ninkovic J, Banerjee S, et al. Opioid drug abuse and modulation of immune function: consequences in the susceptibility to opportunistic infections. J Neuroimmune Pharmacol. 2011;6(4):442.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Flores J, Liang Y, Ketchum NS, et al. Prescription opioid use is associated with virologic failure in people living with HIV. AIDS Behav. 2018;22(4):1323–8.

    Article  PubMed  Google Scholar 

  13. Meng J, Sindberg GM, Roy S. Disruption of gut homeostasis by opioids accelerates HIV disease progression. Front Microbiol [Internet]. 2015 [cited 2019 Apr 8]; https://www.frontiersin.org/articles/10.3389/fmicb.2015.00643/full.

  14. Busse JW, Craigie S, Juurlink DN, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017;189(18):E659–66.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Organization WH. Cancer pain relief and palliative care: report of a WHO expert committee. World Health Organ Tech Rep Ser. 1990;804:1–75.

    Google Scholar 

  16. Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487–92.

    Google Scholar 

  17. Estimated World Requirements of Narcotic Drugs Estimated World Requirements for 2016—Statistics for 2014. United Nations Pubns; 2016.

  18. Fischer B, Argento E. Prescription opioid related misuse, harms, diversion and interventions in Canada: a review. Pain Physician. 2012;15(3 Suppl):ES191–203.

    PubMed  Google Scholar 

  19. Fischer B, Jones W, Rehm J. High correlations between levels of consumption and mortality related to strong prescription opioid analgesics in British Columbia and Ontario, 2005–2009. Pharmacoepidemiol Drug Saf. 2013;22(4):438–42.

    Article  PubMed  Google Scholar 

  20. Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in drug and opioid overdose deaths—United States, 2000–2014. Am J Transpl. 2016;16(4):1323–7.

    Article  Google Scholar 

  21. Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011;171(7):686–91.

    Article  CAS  PubMed  Google Scholar 

  22. Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152(2):85–92.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Zedler B, Xie L, Wang L, et al. Risk factors for serious prescription opioid-related toxicity or overdose among veterans health administration patients. Pain Med. 2014;15(11):1911–29.

    Article  PubMed  Google Scholar 

  24. Bohnert ASB, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011;305(13):1315–21.

    Article  CAS  PubMed  Google Scholar 

  25. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315(15):1624–45.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Weisberg D, Gordon K, Barry D, et al. Long-term prescription opioids and/or benzodiazepines and mortality among HIV-infected and uninfected patients. J Acquir Immune Defic Syndr. 2015;69(2):223–33.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Heath K, Samji H, Nosyk B, et al. Cohort profile: seek and treat for the optimal prevention of HIV/AIDS in British Columbia (STOP HIV/AIDS BC). Int J Epidemiol. 2014;43(4):1073–81.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Nosyk B, Colley G, Yip B, et al. Application and validation of case-finding algorithms for identifying individuals with human immunodeficiency virus from administrative data in British Columbia, Canada. PLoS ONE. 2013;8(1):e54416.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Drug treatment program and virology registry. BC Centre for Excellence in HIV/AIDS; 2014.

  30. British Columbia Centre for Disease Control Public Health Laboratory. HIV laboratory testing datasets (tests: ELISA, Western blot, NAAT, p24, culture) [Internet]. Clinical Prevention Services, British Columbia Centre for Disease Control; 2016. http://www.bccdc.ca/about/accountability/data-access-requests/public-health-data.

  31. British Columbia Centre for Disease Control. HIV/AIDS Information System (HAISYS) [Internet]. Clinical Prevention Services, British Columbia Centre for Disease Control; 2016. http://www.bccdc.ca/about/accountability/data-access-requests/public-health-data.

  32. British Columbia Ministry of Health. Medical Services Plan (MSP) Payment Information File; Consolidation File (MSP Registration & Premium Billing); Home & Community Care (Continuing Care); Mental Health; PharmaNet [Internet]. British Columbia Ministry of Health; 2016. http://www2.gov.bc.ca/gov/content/health/conducting-health-research-evaluation/data-access-health-data-central.

  33. Canadian Institute for Health Information. Discharge Abstract Database (Hospital Separations) [Internet]. 2016. http://www2.gov.bc.ca/gov/content/health/conducting-health-research-evaluation/data-access-health-data-central.

  34. British Columbia Vital Statistics Agency. Vital Statistics. British Columbia Ministry of Health; 2016.

  35. Von Korff M, Saunders K, Ray GT, et al. Defacto long-term opioid therapy for non-cancer pain. Clin J Pain. 2008;24(6):521–7.

    Article  PubMed  Google Scholar 

  36. Merlin JS, Tamhane A, Starrels JL, Kertesz S, Saag M, Cropsey K. Factors associated with prescription of opioids and co-prescription of sedating medications in individuals with HIV. AIDS Behav. 2016;20(3):687–98.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Morasco BJ, Turk DC, Donovan DM, Dobscha SK. Risk for prescription opioid misuse among patients with a history of substance use disorder. Drug Alcohol Depend. 2013;127(1–3):193–9.

    Article  PubMed  Google Scholar 

  38. Whitehead AJ, Dobscha SK, Morasco BJ, Ruimy S, Bussell C, Hauser P. Pain, substance use disorders and opioid analgesic prescription patterns in veterans with hepatitis C. J Pain Symptom Manag. 2008;36(1):39–45.

    Article  Google Scholar 

  39. Edelman EJ, Gordon K, Becker WC, et al. Receipt of opioid analgesics by HIV-infected and uninfected patients. J Gen Intern Med. 2013;28(1):82–90.

    Article  PubMed  Google Scholar 

  40. Becker WC, Gordon K, Edelman JE, et al. Trends in any and high-dose opioid analgesic receipt among aging patients with and without HIV. AIDS Behav. 2016;20(3):679–86.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Sullivan MD, Bauer AM, Fulton-Kehoe D, et al. Trends in opioid dosing among Washington State medicaid patients before and after opioid dosing guideline implementation. J Pain. 2016;17(5):561–8.

    Article  PubMed  Google Scholar 

  42. Morden NE, Munson JC, Colla CH, et al. Prescription opioid use among disabled medicare beneficiaries: intensity, trends and regional variation. Med Care. 2014;52(9):852–9.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Gomes T, Mamdani MM, Paterson JM, Dhalla IA, Juurlink DN. Trends in high-dose opioid prescribing in Canada. Can Fam Physician. 2014;60(9):826–32.

    PubMed  PubMed Central  Google Scholar 

  44. King NB, Fraser V, Boikos C, Richardson R, Harper S. Determinants of increased opioid-related mortality in the United States and Canada, 1990–2013: a systematic review. Am J Public Health. 2014;104(8):e32–42.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Martin C, Pehrsson P, Österberg A, Sönnerborg A, Hansson P. Pain in ambulatory HIV-infected patients with and without intravenous drug use. Eur J Pain. 1999;3(2):157–64.

    Article  CAS  PubMed  Google Scholar 

  46. Dobalian A, Tsao JCI, Duncan RP. Pain and the use of outpatient services among persons with HIV: results from a Nationally Representative Survey. Med Care. 2004;42(2):129–38.

    Article  PubMed  Google Scholar 

  47. Nair SN, Mary TR, Prarthana S, Harrison P. Prevalence of pain in patients with HIV/AIDS: a cross-sectional survey in a South Indian State. Indian J Palliat Care. 2009;15(1):67–70.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Krüsi A, Wood E, Montaner J, Kerr T. Social and structural determinants of HAART access and adherence among injection drug users. Int J Drug Policy. 2010;21(1):4–9.

    Article  PubMed  Google Scholar 

  49. Palepu A, Tyndall MW, Joy R, et al. Antiretroviral adherence and HIV treatment outcomes among HIV/HCV co-infected injection drug users: the role of methadone maintenance therapy. Drug Alcohol Depend. 2006;84(2):188–94.

    Article  PubMed  Google Scholar 

  50. Uhlmann S, Milloy M-J, Kerr T, et al. Methadone maintenance therapy promotes initiation of antiretroviral therapy among injection drug users. Addiction. 2010;105(5):907–13.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Jones CM, McAninch JK. Emergency department visits and overdose deaths from combined use of opioids and benzodiazepines. Am J Prev Med. 2015;49(4):493–501.

    Article  PubMed  Google Scholar 

  52. Dasgupta N, Funk MJ, Proescholdbell S, Hirsch A, Ribisl KM, Marshall S. Cohort study of the impact of high-dose opioid analgesics on overdose mortality. Pain Med. 2016;17(1):85–98.

    PubMed  Google Scholar 

  53. Morasco BJ, Duckart JP, Carr TP, Deyo RA, Dobscha SK. Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-cancer pain. PAIN®. 2010;151(3):625–32.

    Article  Google Scholar 

  54. Saunders KW, Von Korff M, Campbell CI, et al. Concurrent use of alcohol and sedatives among persons prescribed chronic opioid therapy: prevalence and risk factors. J Pain. 2012;13(3):266–75.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Bing EG, Burnam MA, Longshore D, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry. 2001;58(8):721–8.

    Article  CAS  PubMed  Google Scholar 

  56. Gaynes BN, Pence BW, Eron JJ, Miller WC. Prevalence and comorbidity of psychiatric diagnoses based on reference standard in an HIV + patient population. Psychosom Med. 2008;70(4):505–11.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Starrels JL, Peyser D, Haughton L, et al. When HIV treatment goals conflict with guideline-based opioid prescribing: a qualitative study of HIV providers. Subst Abus. 2016;37(1):148–53.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Hansen L, Penko J, Guzman D, Bangsberg DR, Miaskowski C, Kushel MB. Aberrant behaviors with prescription opioids and problem drug use history in a community-based cohort of HIV-infected individuals. J Pain Symptom Manag. 2011;42(6):893–902.

    Article  Google Scholar 

  59. Kaplovitch E, Gomes T, Camacho X, Dhalla IA, Mamdani MM, Juurlink DN. Sex differences in dose escalation and overdose death during chronic opioid therapy: a population-based cohort study. PLoS ONE. 2015;10(8):e0134550.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  60. Lau HS, de Boer A, Beuning KS, Porsius A. Validation of pharmacy records in drug exposure assessment. J Clin Epidemiol. 1997;50(5):619–25.

    Article  CAS  PubMed  Google Scholar 

  61. Cervia LD, McGowan JP, Weseley AJ. Clinical and demographic variables related to pain in HIV-infected individuals treated with effective, combination antiretroviral therapy (cART). Pain Med. 2010;11(4):498–503.

    Article  PubMed  Google Scholar 

  62. Lee KA, Gay C, Portillo CJ, et al. Symptom experience in HIV-infected adults: a function of demographic and clinical characteristics. J Pain Symptom Manag. 2009;38(6):882–93.

    Article  Google Scholar 

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Acknowledgements

We thank the participants that make up the Seek and Treat for Optimal Prevention of HIV/AIDS in BC cohort and the physicians, nurses, social workers and volunteers who support them. This study was funded by the British Colombia Ministry of Health (BCMoH), which-funded Seek and treat for optimal prevention of HIV & AIDS in BC pilot project, and an Avant-Garde Award (Number 1DP1DA026182) and Grant 1R01DA036307-01 from the National Institute of Drug Abuse, at the US National Institutes of Health. The funder had no direct role in the conduct of the analysis or the decision to submit the manuscript for publication. We thank BCMoH and Vancouver Coastal Health Decision support staff involved in data access and procurement, including Joleen Wright and Karen Luers, Vancouver Coastal Health decision support. We would also like to acknowledge Ciro Panessa, Nancy South, and Mark Gilbert for their contributions to the STOP HIV/AIDS in BC study group. LT and SN are supported by the Michael Smith Foundation for Health Research. NF is supported by a Michael Smith Foundation for Health Research/St. Paul’s Foundation Scholar Award. Dr. Montaner’s Treatment as Prevention (TasP) research, paid to institution, has received support from the Public Health Agency of Canada, BC-Ministry of Health and US NIH (NIDA R01DA036307 and CTN 248). Institutional grants have been provided by J&J, Merck and a Knowledge Translation Award from CIHR and he has served as an advisor to the federal and BC governments, UNAIDS, WHO in the last year.

The STOP HIV/AIDS in BC Study Group Rolando Barrios, MD, FRCPC, Senior Medical Director, VCH; Adjunct Professor, School of Population and Public Health, UBC. Patty Daly, MD, Vancouver Coastal Health Authority. Mark Gilbert, Clinical Prevention Services, BC Centre for Disease Control; School of Population and Public Health, University of British Columbia. Reka Gustafson, MD, Vancouver Coastal Health Authority. Perry R.W. Kendall, OBC, MBBS, MSc, FRCPC, Provincial Health Officer, British Columbia Ministry of Health; Clinical Professor, Faculty of Medicine UBC. Ciro Panessa, British Columbia Ministry of Health. Gina McGowan, British Columbia Ministry of Health. Nancy South, British Columbia Ministry of Health. Kate Heath, Robert S. Hogg, and Julio S.G. Montaner, BC Centre for Excellence in HIV/AIDS.

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Authors and Affiliations

  1. Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada

    Jessica Clark, Nadia Fairbairn, Seonaid Nolan, Julio Montaner & Lianping Ti

  2. British Columbia Centre on Substance Use, St. Paul’s Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada

    Nadia Fairbairn & Seonaid Nolan

  3. British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada

    Tian Li, Anthony Wu, Rolando Barrios, Julio Montaner & Lianping Ti

  4. Vancouver Coastal Health Authority, 520 West 6th Avenue, Vancouver, BC, V6Z 4H5, Canada

    Rolando Barrios

  5. British Columbia Centre on Substance Use, 400-1045 Howe St, Vancouver, BC, V6Z 2A9, Canada

    Lianping Ti

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  1. Jessica Clark
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the STOP HIV/AIDS in BC Study Group

  • Rolando Barrios
  • , Patty Daly
  • , Reka Gustafson
  • , Perry R. W. Kendall
  • , Ciro Panessa
  • , Kate Heath
  • , Robert S. Hogg
  •  & Julio S. G. Montaner

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Correspondence to Lianping Ti.

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Clark, J., Fairbairn, N., Nolan, S. et al. Prescription of High-Dose Opioids Among People Living with HIV in British Columbia, Canada. AIDS Behav 23, 3331–3339 (2019). https://doi.org/10.1007/s10461-019-02589-3

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