Appropriate and inappropriate prescribing of narcotics for ambulatory HIV-positive patients

Abstract

Objective: To assess the appropriateness of narcotic-prescribing practices in an ambulatory clinic for patients infected with HIV.

Design, setting, and patients: The medical records of 220 (190 HIV-positive) patients, seen in a clinic primarily designed for the long-term follow-up of ambulatory HIV-infected patients and located in an inner-city, public teaching hospital, were retrospectively reviewed to determine the prevalence and appropriateness of prescribing Drug Enforcement Administration schedule 2 narcotics. Appropriateness was based on published guidelines for the use of narcotics in the treatment of cancer patients.

Measurements and main results: The prevalence of narcotic use among the HIV-positive patients was 15%. Narcotics were prescribed for 38% of the patients who died, 33% of those with AIDS [Centers for Disease Control and Prevention (CDC) clinical class C], 4% of those with AIDS-related complex (ARC) (CDC clinical class B), and 5% of asymp?tomatic HIV-positive patients (CDC clinical class A). None of the HIV-negative patients seen in the clinic received narcotics. Narcotics were more likely to be prescribed for patients with AIDS than for patients with ARC (p<0.001) or for HIV-positive patients (p<0.001). For the three CDC clinical classes, there was no significant difference among the proportions of patients receiving narcotics inappropriately (p=0.108). Among the risk groups, intravenous drug abusers were more likely to be prescribed narcotics inappropriately than were men who were homosexual (p<0.001) or individuals who were hetero?sexual (p=0.013); transfusion recipients were also more likely to be prescribed narcotics inappropriately than were homosexual men (p=0.026) or heterosexual men or women (p=0.032). Narcotics were more likely to be prescribed for patients with disseminated histoplasmosis (p=0.022),Pneumocystis carinii pneumonia (p=0.001), candidal esophagitis (p=0.020), Kaposi’s sarcoma (p<0.001), or wasted appearance (p=0.043). Inappropriate prescrip?tions were more likely to be given to patients with dementia (p=0.005) or wasted appearance (p=0.019).

Conclusions: Physicians tend to prescribe narcotics inappropriately to patients known to have previously abused drugs and to those who appear wasted or have dementia. Physicians have a duty to prescribe narcotics appropriately as guided by recognized medical indications and the patients’ views concerning their current medical needs.