HIV Physicians and Chronic Opioid Therapy: It’s Time to Raise the Bar


Clinical practice that utilizes chronic opioid therapy has been recognized as one major cause of the opioid crisis. Among patients living with HIV, the risks associated with chronic opioid therapy may be complicated by factors such as co-occurring mental health diagnoses, substance use, and economic marginalization. Improving opioid prescribing practices in HIV clinics requires attention to these and other characteristics common to HIV care. In the context of a randomized controlled trial testing an intervention to improve opioid prescribing practices in HIV outpatient clinics, we interviewed physicians about their perspectives on chronic opioid therapy. Overwhelmingly, physicians voiced ambivalence about their own knowledge and comfort with prescription opioids. They raised concerns about the impact of opioid prescribing on patient-provider relationships and the increasing workload associated with prescribing and monitoring patients. In this report, we explore these concerns and propose several strategies for improving clinical care in which chronic opioid therapy is addressed.

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  1. 1.

    Ahmad F, Rossen L, Spencer M, Warner M, Sutton P. Provisional drug overdose data [Internet]. National Center or Health Statistics; 2018. Available from:

  2. 2.

    Mars SG, Bourgois P, Karandinos G, Montero F, Ciccarone D. “Every ‘never’ I ever said came true”: transitions from opioid pills to heroin injecting. Int J Drug Policy. 2014;25(2):257–66.

    Article  PubMed  Google Scholar 

  3. 3.

    Ciccarone D. Editorial for “US Heroin in Transition: Supply Changes, Fentanyl Adulteration and Consequences” IJDP special section. Int J Drug Policy. 2017;46:107–11.

    Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Rummans TA, Burton MC, Dawson NL. How good intentions contributed to bad outcomes: the opioid crisis. Mayo Clin Proc. 2018;93(3):344–50.

    Article  PubMed  Google Scholar 

  5. 5.

    Uebelacker LA, Weisberg RB, Herman DS, Bailey GL, Pinkston-Camp MM, Stein MD. Chronic pain in HIV-infected patients: relationship to depression, substance use, and mental health and pain treatment. Pain Med Malden Mass. 2015;16(10):1870–81.

    Article  Google Scholar 

  6. 6.

    Colasanti J, Lira MC, Cheng DM, Liebschutz JM, Tsui JI, Forman LS, et al. Chronic opioid therapy in HIV-infected patients: patients’ perspectives on risks. Monitoring and Guidelines: Clin Infect Dis; 2018.

    Google Scholar 

  7. 7.

    Arentoft A, Byrd D, Monzones J, Coulehan K, Fuentes A, Rosario A, et al. Socioeconomic status and neuropsychological functioning: associations in an ethnically diverse HIV+ cohort. Clin Neuropsychol. 2015;29(2):232–54.

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Sionean C, Le BC, Hageman K, Oster AM, Wejnert C, Hess KL, et al. HIV Risk, prevention, and testing behaviors among heterosexuals at increased risk for HIV infection–National HIV Behavioral Surveillance System, 21 U.S. cities, 2010. Morb Mortal Wkly Rep Surveill Summ Wash DC 2002. Morb Mortal Wkly Rep Surveill Summ. 2002;63(14):1–39.

    Google Scholar 

  9. 9.

    Merlin JS, Walcott M, Kerns R, Bair MJ, Burgio KL, Turan JM. Pain self-management in HIV-infected individuals with chronic pain: a qualitative study. Pain Med Malden Mass. 2015;16(4):706–14.

    Article  Google Scholar 

  10. 10.

    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 

  11. 11.

    Namisango E, Harding R, Atuhaire L, Ddungu H, Katabira E, Muwanika FR, et al. Pain among ambulatory HIV/AIDS patients: multicenter study of prevalence, intensity, associated factors, and effect. J Pain Off J Am Pain Soc. 2012;13(7):704–13.

    Article  Google Scholar 

  12. 12.

    Merlin JS, Zinski A, Norton WE, Ritchie CS, Saag MS, Mugavero MJ, et al. A conceptual framework for understanding chronic pain in patients with HIV. Pain Pract. 2014;14(3):207–16.

    Article  PubMed  Google Scholar 

  13. 13.

    Lum PJ, Little S, Botsko M, Hersh D, Thawley RE, Egan JE, et al. Opioid-prescribing practices and provider confidence recognizing opioid analgesic abuse in HIV primary care settings. J Acquir Immune Defic Syndr. 2011;56(1):S91–7.

    Article  PubMed  Google Scholar 

  14. 14.

    Tsui JI, Walley AY, Lira MC, Chaisson CE, Forman LS, Colasanti JA, et al. Opioid Prescribing Attitudes and Risk Mitigation Practices in Two HIV Clinics. Conference presentation presented at: Annual Meeting of the College on Problems of Drug Dependence; 2017; Montreal.

  15. 15.

    Liebschutz JM, Xuan Z, Shanahan CW, LaRochelle M, Keosaian J, Beers D, et al. Improving adherence to long-term opioid therapy guidelines to reduce opioid misuse in primary care: a cluster-randomized clinical trial. JAMA Intern Med. 2017.

  16. 16.

    Bauer SR, Katz MH. Going beyond guideline-concordant opioid therapy to improve patient safety. JAMA Intern Med. 2017;177(9):1272.

    Article  PubMed  Google Scholar 

  17. 17.

    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 

  18. 18.

    Avorn J. Academic detailing: “Marketing” the best evidence to clinicians. JAMA. 2017;317(4):361–2.

    Article  PubMed  Google Scholar 

  19. 19.

    Bruce RD, Merlin J, Lum PJ, Ahmed E, Alexander C, Corbett AH, 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 

  20. 20.

    Katzman JG, Galloway K, Olivas C, McCoy-Stafford K, Duhigg D, Comerci G, et al. Expanding health care access through education: dissemination and implementation of the ECHO model. Mil Med. 2016;181(3):227–35.

    Article  PubMed  Google Scholar 

  21. 21.

    Weinstein RS, Lopez AM, Joseph BA, Erps KA, Holcomb M, Barker GP, et al. Telemedicine, telehealth, and mobile health applications that work: opportunities and barriers. Am J Med. 2014;127(3):183–7.

    Article  PubMed  Google Scholar 

  22. 22.

    Starrels JL, Peyser D, Haughton L, Fox A, Merlin JS, Arnsten JH, et al. When human immunodeficiency virus (HIV) treatment goals conflict with guideline-based opioid prescribing: a qualitative study of HIV treatment providers. Subst Abuse. 2016;37(1):148–53.

    Article  Google Scholar 

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This work was supported by the National Institutes of Health/National Institutes of Drug Abuse [R01DA037768 to J.H.S and C.d.R.]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug Abuse or the National Institutes of Health.

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Correspondence to Jennifer J. Carroll.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Carroll, J.J., Colasanti, J., Lira, M.C. et al. HIV Physicians and Chronic Opioid Therapy: It’s Time to Raise the Bar. AIDS Behav 23, 1057–1061 (2019).

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  • HIV
  • Opioids
  • Pain
  • Safety
  • Prescribing