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Jawed AI, Papakyrikos C, Stewart R, Villagran K, Zwirlein C, Zaim N, Casella JF. Lost and found, safe and sound: a case report surrounding the stabilization of a medically complex young adult patient with opioid use disorder through an acute wrapround care approach. J Addict Dis 2023; 41:341-349. [PMID: 35946477 DOI: 10.1080/10550887.2022.2109377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Background: Hospitalization can be a critical time to stabilize chronically ill patients across levels that transcend medical and social determinants of health. The use of the biopsychosocial model can be instrumental in understanding both medically and psychosocially complex patient cases. An acute inpatient hospitalization provides an opportunity to mediate both intrinsic and extrinsic risk factors for both substance use disorder and suicide risk in the context of achieving medical stabilization and crisis mobilization. Case Presentation: Inpatient care of a 22-year-old African American female patient who was chronically ill involved tapping into existing resources within the larger academic hospital inclusive of both adult and pediatric expertise. This patient's care and treatment was multidisciplinary and involved a range of consults that further expanded both the depth and breadth of care and optimized stability from both medical and psychosocial standpoints. In fact, this patient's hospitalization presented a window of opportunity to facilitate a time of transition in chronic disease management and mobilize resources as part of securing wraparound care for her within a one-week timespan. Her care involved the integration of pediatrics (hematology, adolescent medicine), adult medicine (hematology, addiction medicine), and psychiatry. In addition to treating acute symptomology, underlying sources of pain stemming from her opioid use disorder were also alleviated. Furthermore, her care embodied the interface of chronic illness with opioid use, as her reported pain crises were determined to be motivated by intrinsic factors (e.g. poor coping skills from cumulative stressors) supporting her opioid use disorder. Conclusions: The biopsychosocial treatment approach taken for this patient also clearly delineated that physiological and mental health domains are interrelated aspects of chronic pain in chronic illness. Furthermore, this case also emphasized that chronically ill patients are at elevated risk of developing substance use disorders. This case study lends itself nicely to elucidating parity in physiological and mental health domains as crucial elements in promoting health and safety in patient care.
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Affiliation(s)
- Aysha I Jawed
- Department of Pediatric and OB/GYN Social Work, Charlotte R. Bloomberg Children's Center at the Johns Hopkins Hospital, Baltimore, MD, USA
| | - Cole Papakyrikos
- Department of Pediatrics, Charlotte R. Bloomberg Children's Center at the Johns Hopkins Hospital, Baltimore, MD, USA
| | - Rosalyn Stewart
- Department of Pediatrics, Division of Pediatric Hospital Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kyle Villagran
- Department of Pediatric Nursing, Charlotte R. Bloomberg Children's Center at the Johns Hopkins Hospital, Baltimore, MD, USA
| | - Christina Zwirlein
- Department of Pediatric Nursing, Charlotte R. Bloomberg Children's Center at the Johns Hopkins Hospital, Baltimore, MD, USA
| | - Nadia Zaim
- Division of Child and Adolescent Psychiatry, Charlotte R. Bloomberg Children's Center at the Johns Hopkins Hospital, Baltimore, MD, USA
| | - James F Casella
- Pediatric Hematology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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2
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Carroll JJ, Cushman PA, Lira MC, Colasanti JA, Del Rio C, Lasser KE, Parker V, Roy PJ, Samet JH, Liebschutz JM. Evidence-Based Interventions to Improve Opioid Prescribing in Primary Care: a Qualitative Assessment of Implementation in Two Studies. J Gen Intern Med 2023; 38:1794-1801. [PMID: 36396881 PMCID: PMC10271994 DOI: 10.1007/s11606-022-07909-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/27/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND The TOPCARE and TEACH randomized controlled trials demonstrated the efficacy of a multi-faceted intervention to promote guideline-adherent long-term opioid therapy (LTOT) in primary care settings. Intervention components included a full-time Nurse Care Manager (NCM), an electronic registry, and academic detailing sessions. OBJECTIVE This study sought to identify barriers, facilitators, and other issues germane to the wider implementation of this intervention. DESIGN We conducted a nested, qualitative study at 4 primary care clinics (TOPCARE) and 2 HIV primary care clinics (TEACH), where the trials had been conducted. APPROACH We purposively sampled primary care physicians and advanced practice providers (hereafter: PCPs) who had received the intervention. Semi-structured interviews explored perceptions of the intervention to identify unanticipated barriers to and facilitators of implementation. Interview transcripts were analyzed through iterative deductive and inductive coding exercises. KEY RESULTS We interviewed 32 intervention participants, 30 physicians and 2 advanced practice providers, who were majority White (66%) and female (63%). Acceptability of the intervention was high, with most PCPs valuing didactic and team-based intervention elements, especially co-management of LTOT patients with the NCM. Adoption of new prescribing practices was facilitated by proximity to expertise, available behavioral health care, and the NCM's support. Most participants were enthusiastic about the intervention, though a minority voiced concerns about the appropriateness in their particular clinical environments, threats to the patient-provider relationship, or long-term sustainability. CONCLUSION TOPCARE/TEACH participants found the intervention generally acceptable, appropriate, and easy to adopt in a variety of primary care environments, though some challenges were identified. Careful attention to the practical challenges of implementation and the professional relationships affected by the intervention may facilitate implementation and sustainability.
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Affiliation(s)
- Jennifer J Carroll
- Department of Sociology and Anthropology, North Carolina State University, Raleigh, NC, USA.
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA.
| | - Phoebe A Cushman
- Department of Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Marlene C Lira
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Jonathan A Colasanti
- Division of Infectious Diseases, Emory University, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
| | - Carlos Del Rio
- Division of Infectious Diseases, Emory University, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
| | - Karen E Lasser
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Victoria Parker
- Department of Management, Peter. T. Paul College of Business & Economics, University of New Hampshire, Durham, NH, USA
| | - Payel J Roy
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jeffrey H Samet
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Jane M Liebschutz
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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3
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Loh J, Buxton J, Kaida A, Voon P, Grant C, Milloy MJ. Estimating the prevalence and correlates of pain among people living with HIV who use unregulated drugs in a Canadian setting. J Opioid Manag 2023; 19:225-237. [PMID: 37145925 PMCID: PMC10811581 DOI: 10.5055/jom.2023.0778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Although prevalent among people living with human immunodeficiency virus (HIV) (PLWH) and people who use unregulated drugs (PWUD), pain and its possible links to substance use patterns and engagement in HIV treatment remains poorly characterized. We sought to evaluate the prevalence and correlates of pain among a cohort of PLWH who use un-regulated drugs. Between December 2011 and November 2018, 709 participants were recruited, and data were analyzed using generalized linear mixed-effects (GLMM). At baseline, 374 (53 percent) individuals reported moderate-to-extreme pain in the previous 6 months. In a multivariable model, pain was significantly associated with nonmedical prescrip-tion-opioid use (adjusted odds ratio (AOR) = 1.63, 95 percent confidence interval (CI): 1.30-2.05), nonfatal overdose (AOR = 1.46, 95 percent CI: 1.11-1.93), self-managing pain (AOR = 2.25, 95 percent CI: 1.94-2.61), requesting pain medication in the previous 6 months (AOR = 2.01, 95 percent CI: 1.69-2.38), and ever being diagnosed with a mental illness (AOR = 1.47, 95 percent CI: 1.11-1.94). Establishing accessible pain management interventions that address the complex intersection of pain, drug use, and HIV-infection has potential to improve quality of life outcomes among this population.
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Affiliation(s)
- Jane Loh
- British Columbia Centre on Substance Use, School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Jane Buxton
- School of Population and Public Health, University of British Columbia, British Columbia Centre for Disease Control, Vancouver, Canada
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Pauline Voon
- British Columbia Centre on Substance Use, Vancouver, Canada
| | - Cameron Grant
- British Columbia Centre on Substance Use, Vancouver, Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, Department of Medicine, University of British Columbia, Vancouver, Canada
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4
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Pill Counting as an Intervention to Enhance Compliance and Reduce Adverse Outcomes with Analgesics Prescribed for Chronic Pain Conditions: A Systematic Review. Curr Pain Headache Rep 2022; 26:883-887. [PMID: 36459370 PMCID: PMC9716148 DOI: 10.1007/s11916-022-01091-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE OF REVIEW Appropriate use of opioid analgesics is a key concern within the field of pain medicine. Several methods exist to discourage abuse and facilitate effective treatment regimens. Pill counting is often cited as one such method and frequently employed in varying fashions within clinical practice. However, to date, there is no published review of the evidence to support this practice. This was a comprehensive review of the available literature that was conducted with analysis of the efficacy and practical application of pill counting during treatment of chronic pain conditions. RECENT FINDINGS There is paucity in data regarding pill count importance in pain management. Pill count is a very important tool to monitor compliance of opioids use which in turn can prevent several complications associated with opioid misuse. Pill counting may be used in conjunction with other abuse deterrents, although increased support for this practice requires standardized methods of pill counting and further analysis of its effectiveness.
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5
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Samet JH, Tsui JI, Cheng DM, Liebschutz JM, Lira MC, Walley AY, Colasanti JA, Forman LS, Root C, Shanahan CW, Sullivan MM, Bridden CL, Abrams C, Harris C, Outlaw K, Armstrong WS, del Rio C. Improving the Delivery of Chronic Opioid Therapy Among People Living With Human Immunodeficiency Virus: A Cluster Randomized Clinical Trial. Clin Infect Dis 2021; 73:e2052-e2058. [PMID: 32697847 PMCID: PMC8492355 DOI: 10.1093/cid/ciaa1025] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/16/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Chronic pain is prevalent among people living with human immunodeficiency virus (PLWH); managing pain with chronic opioid therapy (COT) is common. Human immunodeficiency virus (HIV) providers often diverge from prescribing guidelines. METHODS This 2-arm, unblinded, cluster-randomized clinical trial assessed whether the Targeting Effective Analgesia in Clinics for HIV (TEACH) intervention improves guideline-concordant care compared to usual care for PLWH on COT. The trial was implemented from 2015 to 2018 with 12-month follow-up at safety-net hospital-based HIV clinics in Boston and Atlanta. We enrolled 41 providers and their 187 patients on COT. Prescribers were randomized 1:1 to either a 12-month intervention consisting of a nurse care manager with an interactive electronic registry, opioid education, academic detailing, and access to addiction specialists or a control condition consisting of usual care. Two primary outcomes were assessed through electronic medical records: ≥2 urine drug tests and any early COT refills by 12 months. Other outcomes included possible adverse consequences. RESULTS At 12 months, the TEACH intervention arm had higher odds of ≥2 urine drug tests than the usual care arm (71% vs 20%; adjusted odds ratio [AOR], 13.38 [95% confidence interval {CI}, 5.85-30.60]; P < .0001). We did not detect a statistically significant difference in early refills (22% vs 30%; AOR, 0.55 [95% CI, .26-1.15]; P = .11), pain severity (6.30 vs 5.76; adjusted mean difference, 0.10 [95% CI, -1.56 to 1.75]; P = .91), or HIV viral load suppression (86.9% vs 82.1%; AOR, 1.21 [95% CI, .47-3.09]; P = .69). CONCLUSIONS TEACH is a promising intervention to improve adherence to COT guidelines without evident adverse consequences.
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Affiliation(s)
- Jeffrey H Samet
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts, USA
- Clinical Addiction Research and Education Unit, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Judith I Tsui
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Debbie M Cheng
- Clinical Addiction Research and Education Unit, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Jane M Liebschutz
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Marlene C Lira
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts, USA
| | - Alexander Y Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts, USA
- Clinical Addiction Research and Education Unit, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jonathan A Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Leah S Forman
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Christin Root
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Christopher W Shanahan
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
- Clinical Addiction Research and Education Unit, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Margaret M Sullivan
- Clinical Addiction Research and Education Unit, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Carly L Bridden
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts, USA
| | - Catherine Abrams
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Catherine Harris
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Kishna Outlaw
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Wendy S Armstrong
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Carlos del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
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6
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Carroll JJ, Lira MC, Lunze K, Colasanti JA, Del Rio C, Samet JH. Painful Subjects: Treating Chronic Pain among People Living with HIV in the Age of Opioid Risk. Med Anthropol Q 2021; 35:141-158. [PMID: 33152133 PMCID: PMC8359200 DOI: 10.1111/maq.12618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 05/02/2020] [Accepted: 09/09/2020] [Indexed: 11/30/2022]
Abstract
Public narratives often attribute the opioid overdose epidemic in the United States to liberal prescribing practices by health care providers. Consequently, new monitoring guidelines for the management of opioid prescriptions in patients with chronic pain have become recognized as key strategies for slowing this tide of overdose deaths. This article examines the social and ontological terrain of opioid-based pain management in an HIV clinic in the context of today's opioid overdose epidemic. We engage with anthropological analyses of contemporary drug policy and the nonverbal/performative ways patients and clinicians communicate to theorize the social context of the opioid overdose epidemic as a "situation," arguing that the establishment of new monitoring strategies (essentially biomedical audit strategies) trouble patient subjectivity in the HIV clinic-a place where that subjectivity has historically been protected and prioritized in the establishment of care.
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Affiliation(s)
- Jennifer J Carroll
- Department of Sociology and Anthropology, Elon University.,Department of Medicine, Brown University
| | - Marlene C Lira
- Clinical Addiction Research and Education (CARE) Unit, Department of Medicine, Boston Medical Center
| | - Karsten Lunze
- Clinical Addiction Research and Education (CARE) Unit, Department of Medicine, Boston Medical Center.,School of Medicine, Boston University
| | - Jonathan A Colasanti
- Hubert Department of Global Health, Rollins Scholl of Public Health of Emory University.,Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
| | - Carlos Del Rio
- Hubert Department of Global Health, Rollins Scholl of Public Health of Emory University.,Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
| | - Jeffrey H Samet
- Clinical Addiction Research and Education (CARE) Unit, Department of Medicine, Boston Medical Center.,Department of Community Health Sciences, Boston University School of Public Health
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7
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Serota DP, Capozzi C, Lodi S, Colasanti JA, Forman LS, Tsui JI, Walley AY, Lira MC, Samet J, Del Rio C, Merlin JS. Predictors of pain-related functional impairment among people living with HIV on long-term opioid therapy. AIDS Care 2021; 33:507-515. [PMID: 32242463 PMCID: PMC7541400 DOI: 10.1080/09540121.2020.1748866] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
People living with HIV (PLWH) have high levels of functional impairment due to pain, also called pain interference. Long-term opioid therapy (LTOT) is commonly prescribed for chronic pain among PLWH. We sought to better understand the predictors of pain interference, measured with the Brief Pain Inventory Interference subscale (BPI-I), among PLWH with chronic pain on LTOT. Using a prospective cohort of PLWH on LTOT we developed a model to identify predictors of increased pain interference over 1 year of follow up. Participants (n = 166) were 34% female, 72% African American with a median age of 55 years, and 40% had severe pain interference (BPI-I ≥ 7). In multivariable models, substance use disorder, depressive symptoms, PTSD symptoms, financial instability, and higher opioid doses were associated with increased pain interference. Measures of behavioral health and socioeconomic status had the most consistent association with pain interference. In contrast, the biomedical aspects of chronic pain and LTOT - comorbidities, duration of pain - were not predictive of pain interference. PLWH with chronic pain on LTOT with lower socioeconomic status and behavioral health symptoms have higher risk of pain interference. Addressing the social determinants of health and providing access to behavioral health services could improve patients' pain-related functional status.
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Affiliation(s)
- David P Serota
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, Georgia.,Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Christine Capozzi
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Sara Lodi
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Jonathan A Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, Georgia
| | - Leah S Forman
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA, USA
| | - Judith I Tsui
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Alexander Y Walley
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA.,Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Marlene C Lira
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Jeffrey Samet
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA.,Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Carlos Del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, Georgia
| | - Jessica S Merlin
- Division of General Internal Medicine, Center for Research on Healthcare, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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8
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Ngo B, Liebschutz JM, Cheng DM, Colasanti JA, Merlin JS, Armstrong WS, Forman LS, Lira MC, Samet JH, Del Rio C, Tsui JI. Hazardous alcohol use is associated with greater pain interference and prescription opioid misuse among persons living with HIV and chronic pain. BMC Public Health 2021; 21:564. [PMID: 33752634 PMCID: PMC7986380 DOI: 10.1186/s12889-021-10566-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Alcohol use is common among persons living with HIV (PLWH), who often experience chronic pain, yet its impact on pain and opioid misuse is not fully characterized. METHODS We assessed associations between hazardous alcohol use and pain interference, defined as the self-reported impact of pain on daily living, pain severity, and risk for opioid misuse among PLWH who were on long-term opioid therapy (LTOT). A cohort was recruited as part of the "Targeting Effective Analgesia in Clinics for HIV" (TEACH) study, a randomized controlled trial to improve LTOT in HIV clinics. The Alcohol Use Disorders Test (AUDIT), Brief Pain Inventory (BPI) and the Current Opioid Misuse Measure (COMM) were administered at both baseline and 12-months. Linear mixed and generalized estimating equation models, incorporating data from both time points, evaluated associations between hazardous alcohol use (AUDIT ≥8) and: pain interference (0-10), pain severity (0-10), and opioid misuse risk (COMM ≥13), adjusting for age, gender, depressive symptoms, use of non-alcohol substances, time-point, and study-arm. RESULTS The sample was comprised of 166 participants, of which 31 (19%) reported hazardous alcohol use. The majority were male (65%), black (72%), and the mean age was 54 (range: 29-77). Hazardous alcohol use was significantly associated with higher pain interference (adjusted mean difference [AMD]: 1.02; 95% CI: 0.08, 1.96) and higher odds of opioid misuse risk (AOR: 3.73, 95% CI: 1.88-7.39), but not pain severity (AMD: 0.47, 95% CI: - 0.35, 1.29). CONCLUSIONS Hazardous alcohol use was associated with greater functional impairment in daily living from their pain and higher odds for prescription opioid misuse in this study of PLWH on LTOT. Providers should be attentive to alcohol use among PLWH who are prescribed opioids given associations with pain and opioid misuse. TRIAL REGISTRATION ClinicalTrials.gov NCT02564341 (Intervention, September 30, 2015) and NCT02525731 (Patient Cohort, August 17, 2015). Both prospectively registered.
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Affiliation(s)
- Belle Ngo
- University of Washington School of Medicine, Seattle, WA, USA
| | - Jane M Liebschutz
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Debbie M Cheng
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jonathan A Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jessica S Merlin
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Wendy S Armstrong
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Leah S Forman
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Marlene C Lira
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jeffrey H Samet
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Carlos Del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Judith I Tsui
- University of Washington School of Medicine, Seattle, WA, USA.
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9
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Kimmel SD, Walley AY, Lodi S, Forman LS, Liebschutz JM, Lira MC, Kim TW, Del Rio C, Samet JH, Tsui JI. Naloxone receipt and overdose prevention care among people with HIV on chronic opioid therapy. AIDS 2021; 35:697-700. [PMID: 33587441 PMCID: PMC7904637 DOI: 10.1097/qad.0000000000002803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This cross-sectional study describes naloxone rescue kit receipt among people with HIV (PWH) on chronic opioid therapy (COT) and HIV clinician opioid overdose prevention care in two clinics between 2015 and 2017. Naloxone rescue kit receipt was uncommon. History of overdose was associated with receiving naloxone but having a clinician who reported providing overdose prevention care was not. This study suggests that clinicians prescribing COT to PWH should improve overdose prevention care, including naloxone co-prescribing.
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Affiliation(s)
- Simeon D Kimmel
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center/Boston University School of Medicine
| | - Alexander Y Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine
| | | | - Leah S Forman
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health
| | - Jane M Liebschutz
- Division of General Internal Medicine, Center for Research on Healthcare, Department of Medicine, University of Pittsburgh School of Medicine
| | - Marlene C Lira
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine
| | - Theresa W Kim
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine
| | - Carlos Del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine
| | - Jeffrey H Samet
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine
- Department of Community Health Sciences, Boston University School of Public Health
| | - Judith I Tsui
- Division of General Internal Medicine, Department of Medicine, Harborview Medical Center and University of Washington School of Medicine, Boston, Massachusetts, USA
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10
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Jantarada C, Silva C, Guimarães-Pereira L. Prevalence of Problematic Use of Opioids in Patients with Chronic Noncancer Pain: A Systematic Review with Meta-analysis. Pain Pract 2021; 21:715-729. [PMID: 33528858 DOI: 10.1111/papr.13001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 01/05/2021] [Accepted: 01/28/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Opioid prescription for chronic noncancer pain is associated with problematic use. We aimed to review and summarize the evidence on the prevalence of problematic use of opioids in adults with chronic noncancer pain and investigate whether the prevalence rates were changing over time. DATABASES AND DATA TREATMENT A systematic review of the literature was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We systematically searched the literature in the electronic databases MEDLINE, SCOPUS, and Web of Science and studies with adult participants with chronic noncancer pain using opioids with indication of one or more of the following terms about problematic opioid use: abuse, misuse, addiction, dependence, problematic use, and aberrant behavior/use were eligible for data extraction. Meta-analysis was performed to estimate the pooled prevalence rates using a random-effects model, and subanalysis was conducted. RESULTS Our search identified a total of 784 potentially relevant studies. After a thorough evaluation, 19 papers, mostly from the United States, were included in our qualitative and quantitative synthesis. The majority of the data came from speciality pain clinics. The estimated prevalence of problematic use of opioids in adults with chronic noncancer pain was 36.3% (95% confidence interval: 27.4 to 45.2%; I2 = 99.64%). Problematic opioid use was mostly identified using the questionnaire method. Thirteen studies (68%) presented a low risk of bias. CONCLUSIONS Our study presents an alarming estimate regarding the prevalence of problematic use of opioids among patients with noncancer pain. These results deserve special attention from health care professionals and health authorities.
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Affiliation(s)
- Cláudia Jantarada
- Department of Anesthesiology, Centro Hospitalar de São João, Porto, Portugal
| | - Catarina Silva
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Luís Guimarães-Pereira
- Department of Anesthesiology, Centro Hospitalar de São João, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal
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11
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Thakarar K, Kulkarni A, Lodi S, Walley AY, Lira MC, Forman LS, Colasanti JA, del Rio C, Samet JH. Emergency Department Utilization Among People Living With HIV on Chronic Opioid Therapy. J Int Assoc Provid AIDS Care 2021; 20:23259582211010952. [PMID: 33888001 PMCID: PMC8072919 DOI: 10.1177/23259582211010952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 03/17/2021] [Accepted: 03/23/2021] [Indexed: 11/17/2022] Open
Abstract
Chronic pain among people with HIV (PWH) is a driving factor of emergency department (ED) utilization, and it is often treated with chronic opioid therapy (COT). We conducted a cross-sectional analysis of a prospective observational cohort of PWH on COT at 2 hospital-based clinics to determine whether COT-specific factors are associated with ED utilization among PWH. The primary outcome was an ED visit within 12 months after study enrollment. We used stepwise logistic regression including age, gender, opioid duration, hepatitis C, depression, prior ED visits, and Charlson comorbidity index. Of 153 study participants, n = 69 (45%) had an ED visit; 25% of ED visits were pain-related. High dose opioids, benzodiazepine co-prescribing, and lack of opioid treatment agreements were not associated with ED utilization, but prior ED visits (p = 0.002), depression (p = 0.001) and higher Charlson comorbidity score (p = 0.003) were associated with ED utilization. COT-specific factors were not associated with increased ED utilization among PWH.
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Affiliation(s)
- Kinna Thakarar
- Maine Medical Center Research Institute, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA, USA
| | - Amoli Kulkarni
- Boston Medical Center / Boston University School of Medicine, Boston, MA, USA
| | - Sara Lodi
- Boston University School of Public Health, Boston, MA, USA
| | - Alexander Y. Walley
- Boston Medical Center / Boston University School of Medicine, Boston, MA, USA
| | - Marlene C. Lira
- Boston Medical Center / Boston University School of Medicine, Boston, MA, USA
| | - Leah S. Forman
- Boston University School of Public Health, Boston, MA, USA
| | | | - Carlos del Rio
- Emory University, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
| | - Jeffrey H. Samet
- Boston Medical Center / Boston University School of Medicine, Boston, MA, USA
- Boston University School of Public Health, Boston, MA, USA
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12
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Chichetto NE, Polanka BM, So-Armah KA, Sung M, Stewart JC, Koethe JR, Edelman EJ, Tindle HA, Freiberg MS. Contribution of Behavioral Health Factors to Non-AIDS-Related Comorbidities: an Updated Review. Curr HIV/AIDS Rep 2020; 17:354-372. [PMID: 32314325 PMCID: PMC7363585 DOI: 10.1007/s11904-020-00498-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW We summarize recent literature on the contribution of substance use and depression to non-AIDS-related comorbidities. Discussion of recent randomized clinical trials and implementation research to curtail risk attributed to each behavioral health issue is provided. RECENT FINDINGS Smoking, unhealthy alcohol use, opioid use, and depression are common among PWH and individually contribute to increased risk for non-AIDS-related comorbidities. The concurrence of these conditions is notable, yet understudied, and provides opportunity for linked-screening and potential treatment of more than one behavioral health factor. Current results from randomized clinical trials are inconsistent. Investigating interventions to reduce the impact of these behavioral health conditions with a focus on implementation into clinical care is important. Non-AIDS-defining cancers, cardiovascular disease, liver disease, and diabetes are leading causes of morbidity in people with HIV. Behavioral health factors including substance use and mental health issues, often co-occurring, likely contribute to the excess risk of non-AIDS-related comorbidities.
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Affiliation(s)
- Natalie E Chichetto
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Brittanny M Polanka
- Department of Psychology, Indiana University-Purdue University Indianapolis (IUPUI), Indianapolis, IN, USA
| | - Kaku A So-Armah
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Minhee Sung
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jesse C Stewart
- Department of Psychology, Indiana University-Purdue University Indianapolis (IUPUI), Indianapolis, IN, USA
| | - John R Koethe
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, USA
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Hilary A Tindle
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Centers, Nashville, TN, USA
| | - Matthew S Freiberg
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Centers, Nashville, TN, USA
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13
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Edelman EJ, Li Y, Barry D, Braden JB, Crystal S, Kerns RD, Gaither JR, Gordon KS, Manhapra A, Merlin JS, Moore BA, Oldfield BJ, Park LS, Rentsch CT, Skanderson M, Williams EC, Justice AC, Tate JP, Becker WC, Marshall BD. Trajectories of Self-Reported Opioid Use Among Patients With HIV Engaged in Care: Results From a National Cohort Study. J Acquir Immune Defic Syndr 2020; 84:26-36. [PMID: 32267658 PMCID: PMC7147724 DOI: 10.1097/qai.0000000000002310] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND No prior studies have characterized long-term patterns of opioid use regardless of source or reason for use among patients with HIV (PWH). We sought to identify trajectories of self-reported opioid use and their correlates among a national sample of PWH engaged in care. SETTING Veterans Aging Cohort Study, a prospective cohort including PWH receiving care at 8 US Veterans Health Administration (VA) sites. METHODS Between 2002 and 2018, we assessed past year opioid use frequency based on self-reported "prescription painkillers" and/or heroin use at baseline and follow-up. We used group-based trajectory models to identify opioid use trajectories and multinomial logistic regression to determine baseline factors independently associated with escalating opioid use compared to stable, infrequent use. RESULTS Among 3702 PWH, we identified 4 opioid use trajectories: (1) no lifetime use (25%); (2) stable, infrequent use (58%); (3) escalating use (7%); and (4) de-escalating use (11%). In bivariate analysis, anxiety; pain interference; prescribed opioids, benzodiazepines and gabapentinoids; and marijuana use were associated with escalating opioid group membership compared to stable, infrequent use. In multivariable analysis, illness severity, pain interference, receipt of prescribed benzodiazepine medications, and marijuana use were associated with escalating opioid group membership compared to stable, infrequent use. CONCLUSION Among PWH engaged in VA care, 1 in 15 reported escalating opioid use. Future research is needed to understand the impact of psychoactive medications and marijuana use on opioid use and whether enhanced uptake of evidence-based treatment of pain and psychiatric symptoms can prevent escalating use among PWH.
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Affiliation(s)
- E. Jennifer Edelman
- Yale School of Medicine, New Haven, CT
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT
| | - Yu Li
- Brown University School of Public Health, Providence, RI
| | | | - Jennifer Brennan Braden
- University of Washington School of Medicine, Seattle, WA
- Valley Medical Center Psychiatry and Counseling, Behavioral Health Integration Program
| | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Rutgers University, Rutgers, NJ
| | - Robert D. Kerns
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | | | - Kirsha S. Gordon
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Ajay Manhapra
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | | | - Brent A. Moore
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | | | | | - Christopher T. Rentsch
- VA Connecticut Healthcare System, West Haven, CT
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Emily C. Williams
- VA Puget Sound Health Services Research and Development and Department of Health Services, University of Washington, Seattle, WA
| | - Amy C. Justice
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Janet P. Tate
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - William C. Becker
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
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14
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Abstract
PURPOSE OF REVIEW Update findings regarding polypharmacy among people with HIV (PWH) and consider what research is most needed. RECENT FINDINGS Among PWH, polypharmacy is common, occurs in middle age, and is predominantly driven by nonantiretroviral (ARV) medications. Many studies have demonstrated strong associations between polypharmacy and receipt of potentially inappropriate medications (PIMS), but few have considered actual adverse events. Falls, delirium, pneumonia, hospitalization, and mortality are associated with polypharmacy among PWH and risks remain after adjustment for severity of illness. SUMMARY Polypharmacy is a growing problem and mechanisms of injury likely include potentially inappropriate medications, total drug burden, known pairwise drug interactions, higher level drug interactions, drug--gene interactions, and drug--substance use interactions (alcohol, extra-medical prescription medication, and drug use). Before we can effectively design interventions, we need to use observational data to gain a better understanding of the modifiable mechanisms of injury. As sicker individuals take more medications, analyses must account for severity of illness. As self-report of substance use may be inaccurate, direct biomarkers, such as phosphatidylethanol (PEth) for alcohol are needed. Large samples including electronic health records, genetics, accurate measures of substance use, and state of the art statistical and artificial intelligence techniques are needed to advance our understanding and inform clinical management of polypharmacy in PWH.
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Affiliation(s)
| | - Christopher T. Rentsch
- VA Connecticut Healthcare System, West Haven, CT
- London School of Hygiene & Tropical Medicine, London, UK
| | - Amy C. Justice
- Yale Schools of Medicine and Public Health, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
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15
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Schranz AJ, Davy-Mendez T, Eron JJ, Napravnik S. Opioid misuse among persons with HIV engaged in care in the Southeastern US. AIDS Care 2019; 33:148-153. [PMID: 31814449 DOI: 10.1080/09540121.2019.1699644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The prevalence of opioid misuse by people living with HIV (PLWH) during the current US opioid epidemic has not been fully described. Among a cohort of persons engaged in HIV care in North Carolina, we examined the prevalence of and risk factors for opioid misuse, defined as self-reported "street" opioid use (e.g., heroin) or nonmedical prescription opioid use on a patient reported outcomes survey. Recent (past three-month) opioid misuse among 1,440 PLWH in care 2012-2017 was 2% (95% CI 2-3%) and lifetime misuse 15% (13-16%). Persons reporting lifetime or recent misuse more commonly had hepatitis C and reported injecting drugs. In multivariable logistic regression models, male-to-male sexual contact was inversely associated with recent or lifetime misuse. White/non-Hispanic race/ethnicity was associated with lifetime misuse and CD4 count and viral load were not associated with opioid misuse. Among 32 persons reporting recent misuse, 81% had a contemporaneous viral load <50 copies/mL. In this cohort of PLWH engaged in care, recent opioid misuse prevalence was similar to general population estimates. Assessments of opioid misuse among PLWH not in care are urgently needed to fully characterize the impact of opioids on all PLWH.
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Affiliation(s)
- Asher J Schranz
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Thibaut Davy-Mendez
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
| | - Joseph J Eron
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Sonia Napravnik
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.,Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
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16
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Merlin JS, Samet JH, Cheng DM, Lira MC, Tsui JI, Forman LS, Colasanti J, Walley AY, Del Rio C, Liebschutz JM. Marijuana Use and Its Associations With Pain, Opioid Dose, and HIV Viral Suppression Among Persons Living With HIV on Chronic Opioid Therapy. J Acquir Immune Defic Syndr 2019; 82:195-201. [PMID: 31513554 PMCID: PMC6746234 DOI: 10.1097/qai.0000000000002119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Medical marijuana is legal in 29 US states and the District of Columbia: both HIV and chronic pain are "approved conditions" for receipt. Chronic pain is common among people living with HIV (PLWH). We anticipate PLWH will question their providers about medical marijuana for chronic pain. We examined marijuana use and its associations with pain, opioid dose, and HIV viral suppression among PLWH receiving chronic opioid therapy. METHODS PLWH prescribed chronic opioid therapy were recruited into the Targeting Effective Analgesia in Clinics for HIV cohort. The main exposure variable was any past 12-month marijuana use. The primary outcomes were (1) opioid misuse (≥9 on the Current Opioid Misuse Measure) and (2) opioid dose (morphine equivalent daily dose). HIV viral load (VL) suppression (<200 copies/μL) and pain severity and interference using the Brief Pain Inventory were exploratory outcomes. RESULTS Participants (n = 166) were men (65%), Black (72%), and had an undetectable VL (89%). We found no significant association between current marijuana use and opioid misuse, opioid dose, or pain. Current marijuana use was associated with 3.03 times the odds of having a detectable VL (95% odds ratio: 1.11-8.31, P = 0.03) while controlling for depressive symptoms and other substance use. DISCUSSION We did not detect an association between marijuana use and opioid misuse behaviors, opioid dose, or pain. In an exploratory analysis, current marijuana use was associated with 3× greater odds of having a detectable VL. This study provides insights into potential consequences of marijuana use among PLWH with chronic pain.
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Affiliation(s)
- Jessica S Merlin
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jeffrey H Samet
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
- Department of Medicine, Boston University School of Medicine, Boston, MA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA
| | - Debbie M Cheng
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Marlene C Lira
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
| | - Judith I Tsui
- Section of General Internal Medicine, Department of Medicine, University of Washington and Harborview Medical Center, Seattle, WA
| | - Leah S Forman
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA
| | - Jonathan Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Alexander Y Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Carlos Del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Jane M Liebschutz
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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17
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DiBenedetto DJ, Wawrzyniak KM, Schatman ME, Shapiro H, Kulich RJ. Increased frequency of urine drug testing in chronic opioid therapy: rationale for strategies for enhancing patient adherence and safety. J Pain Res 2019; 12:2239-2246. [PMID: 31413622 PMCID: PMC6661994 DOI: 10.2147/jpr.s213536] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 06/23/2019] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To determine the average amount of time required to detect opioid aberrancy based upon varying frequencies of urine drug testing (UDT) in a community-based, tertiary care pain management center. SUBJECTS This study was a retrospective analysis of 513 consecutive patients enrolled in a medication management program, receiving chronic opioid therapy between January 1, 2018 and December 31, 2018. METHODS Data were extracted from medical records including age at start of the study period, sex, ethnicity, marital status, and smoking status. UDT was performed at each prescribing visit via semi-quantitative immunoassay, and at the discretion of the clinician, a sample was sent for external confirmation using gas chromatography or mass spectrometry testing to clarify questions of inconsistency with patients' reports or prescribed medications. For purposes of the study, "opioid aberrancy" was defined through inconsistent UDT. RESULTS One hundred and fifteen patients (22.4%) had at least one inconsistent UDT during the study period, and 160 (2.8%) of all UDTs were inconsistent. At this rate of inconsistency, it was determined that with monthly screening, it would require up to 36 months to detect a single aberrancy, and semi-annual testing would require as long as 216 months to detect an aberrancy. CONCLUSIONS More frequent UDT can be helpful in terms of earlier detection of opioid aberrancy. This has significant implications for helping avoid misuse, overdose, and potential diversion. Furthermore, early detection will ideally result in earlier implementation of treatment of the emotional and behavioral factors causing aberrancy. Such early intervention is more likely to be successful in terms of reducing substance misuse in a chronic pain population, providing a higher degree of patient adherence and safety, as well as producing superior overall patient outcomes. Finally, economic benefits may include substantial savings through avoidance of the necessity for drug rehabilitation and the empirically established higher costs of treating opioid misuse comorbidities.
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Affiliation(s)
- David J DiBenedetto
- Research and Network Development, Boston PainCare, Waltham, MA, USA
- Department of Diagnostic Sciences, Tufts School of Dental Medicine, Boston, MA, USA
| | - Kelly M Wawrzyniak
- Research and Network Development, Boston PainCare, Waltham, MA, USA
- Department of Diagnostic Sciences, Tufts School of Dental Medicine, Boston, MA, USA
| | - Michael E Schatman
- Research and Network Development, Boston PainCare, Waltham, MA, USA
- Deparment of Public Health and Community Medicine, Tufts School of Medicine, Boston, MA, USA
| | - Hannah Shapiro
- Research and Network Development, Boston PainCare, Waltham, MA, USA
- Department of Biopsychology, Tufts University, Medford, MA, USA
| | - Ronald J Kulich
- Department of Diagnostic Sciences, Tufts School of Dental Medicine, Boston, MA, USA
- Department of Anesthesia Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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18
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Kim YM. Discovering major opioid-related research themes over time: A text mining technique. AMIA JOINT SUMMITS ON TRANSLATIONAL SCIENCE PROCEEDINGS. AMIA JOINT SUMMITS ON TRANSLATIONAL SCIENCE 2019; 2019:751-760. [PMID: 31259032 PMCID: PMC6568063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The recent health crisis concerning opioid overdose has prompted watershed levels of publications. This study explores how opioid-related research themes have changed since 2000, using a text mining technique. The textual data were obtained from PubMed, and the research periods were divided into three periods. While a few topics appear throughout each period, many new health problems emerged as opioid abuse problems magnified. Topics such as HIV, methadone maintenance treatment, and world health organization appear consistently but diminish over time, while topics like injecting drugs, neonatal abstinence syndrome, and public health concerns are rapidly increasing. Recent widespread opioid abuse problems led to new research topics, including prescription drug monitoring programs, veteran's health issue, posttraumatic stress disorder, HCV, opioid-related deaths, and emergency department visits. Examination of scholarly publications reveals that the expanded use of opioids worsened opioid abuse problems and accelerated the emergence of new health problems.
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19
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Lira MC, Tsui JI, Liebschutz JM, Colasanti J, Root C, Cheng DM, Walley AY, Sullivan M, Shanahan C, O’Connor K, Abrams C, Forman LS, Chaisson C, Bridden C, Podolsky MC, Outlaw K, Harris CE, Armstrong WS, del Rio C, Samet JH. Study protocol for the targeting effective analgesia in clinics for HIV (TEACH) study - a cluster randomized controlled trial and parallel cohort to increase guideline concordant care for long-term opioid therapy among people living with HIV. HIV Res Clin Pract 2019; 20:48-63. [PMID: 31303143 PMCID: PMC6693587 DOI: 10.1080/15284336.2019.1627509] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 04/26/2019] [Accepted: 05/30/2019] [Indexed: 12/12/2022]
Abstract
Background: People living with HIV (PLWH) frequently experience chronic pain and receive long-term opioid therapy (LTOT). Adherence to opioid prescribing guidelines among their providers is suboptimal. Objective: This paper describes the protocol of a cluster randomized trial, targeting effective analgesia in clinics for HIV (TEACH), which tested a collaborative care intervention to increase guideline-concordant care for LTOT among PLWH. Methods: HIV physicians and advanced practice providers (n = 41) were recruited from September 2015 to December 2016 from two HIV clinics in Boston and Atlanta. Patients receiving LTOT from participating providers were enrolled through a waiver of informed consent (n = 187). After baseline assessment, providers were randomized to the control group or the year-long TEACH intervention involving: (1) a nurse care manager and electronic registry to assist with patient management; (2) opioid education and academic detailing; and (3) facilitated access to addiction specialists. Randomization was stratified by site and LTOT patient volume. Primary outcomes (≥2 urine drug tests, early refills, provider satisfaction) were collected at 12 months. In parallel, PLWH receiving LTOT (n = 170) were recruited into a longitudinal cohort at both clinics and underwent baseline and 12-month assessments. Secondary outcomes were obtained through patient self-report among participants enrolled in both the cohort and the RCT (n = 117). Conclusions: TEACH will report the effects of an intervention on opioid prescribing for chronic pain on both provider and patient-level outcomes. The results may inform delivery of care for PLWH on LTOT for chronic pain at a time when opioid practices are being questioned in the US.
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Affiliation(s)
- Marlene C. Lira
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
| | - Judith I. Tsui
- Section of General Internal Medicine, Department of Medicine, University of Washington and Harborview Medical Center
| | - Jane M. Liebschutz
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jonathan Colasanti
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Christin Root
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Debbie M. Cheng
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Alexander Y. Walley
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Meg Sullivan
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Christopher Shanahan
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Kristen O’Connor
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
| | - Catherine Abrams
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Leah S. Forman
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA
| | - Christine Chaisson
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA
| | - Carly Bridden
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
| | - Melissa C. Podolsky
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
| | - Kishna Outlaw
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Catherine E. Harris
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Wendy S. Armstrong
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Carlos del Rio
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jeffrey H. Samet
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
- Department of Medicine, Boston University School of Medicine, Boston, MA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA
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20
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Chronic Pain Mitigation and Opioid Weaning at a Multidisciplinary AIDS Clinic: A Case Report. REHABILITATION ONCOLOGY 2019; 37:37-42. [PMID: 31086750 DOI: 10.1097/01.reo.0000000000000159] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background and Purpose Chronic pain has emerged as a treatment priority among people living with HIV (PLHIV). Recent studies indicate the use of physical therapy (PT) for chronic pain mitigation among PLHIV, however there is a paucity of literature regarding PT as part of multidisciplinary collaboration to address the intersection of HIV, chronic pain and opioid use. Case Description This case report examined the effect of a 24-session PT intervention aimed at decreasing chronic pain and opioid weaning for a 64 year-old patient at a multidisciplinary AIDS clinic in Atlanta, Georgia. The PT intervention focused on pain mitigation, utilizing using pain-relief techniques such as a home TENS unit, home stretching regimen, diaphragmatic breathing techniques. In addition, the physical therapist communicated regularly with the patient's primary HIV provider regarding patient progress. Outcomes After the intervention, outcomes included: decreased pain from 10/10 to 0/10, independent pain management, and increased independence in functional activities. In addition, the patient decreased opioid usage from 15 to 2.5 mg Hydrocodone, an 83.3% decrease. Discussion In a complex chronic pain case with a patient on chronic opioid therapy, multidisciplinary communication is key in successful management. To truly address opiate weaning in the context of pain management, physical therapists' expertise in pain management should ideally be complemented by close communication with the patient's primary medical provider. This allows for open dialogue, and acknowledges the importance of various specialty areas committed to a joint effort of not simply opioid weaning, but of patient-centered, multidisciplinary chronic pain control.
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