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Colasanti JA, Del Rio C, Cheng DM, Liebschutz JM, Lira MC, Tsui JI, Walley AY, Forman LS, Root C, Shanahan CW, Bridden CL, Harris C, Outlaw K, Armstrong WS, Samet JH. A collaborative care intervention to improve opioid prescribing among providers caring for persons with HIV: Impact on satisfaction, confidence, and trust. Drug Alcohol Depend 2022; 231:109250. [PMID: 34998255 PMCID: PMC10763596 DOI: 10.1016/j.drugalcdep.2021.109250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/20/2021] [Accepted: 12/06/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND HIV clinicians report low confidence and satisfaction prescribing chronic opioid therapy (COT). We hypothesized that the Targeting Effective Analgesia in Clinics for HIV (TEACH) intervention [a system-level improvement to increase guideline concordant care for COT] would improve satisfaction, confidence, and trust among PWH and their clinicians. METHODS We conducted a two-arm, unblinded cluster randomized controlled trial (RCT) to assess the TEACH intervention. Clinicians were randomized in a 1:1 ratio to receive either the TEACH intervention (an IT-enabled nurse care manager, opioid education, academic detailing, and access to addiction specialists) or usual care. Outcomes were the following: clinician satisfaction (primary); confidence prescribing COT; patient satisfaction with COT; and trust in clinician. Intention-to-treat analyses were conducted using linear and logistic regression models. RESULTS Clinicians (n = 41) were randomized and their 114 patients assessed. At 12 months, the adjusted mean difference in satisfaction with COT was 1.11 points for intervention vs control clinicians (Scale 1-10; 95% confidence interval [CI]: -0.04 to 2.26, p = 0.06). The adjusted mean confidence with prescribing COT was 1.01 points higher among intervention clinicians (Scale 1-10; 95% CI: 0.05-1.96, p = 0.04). There were no significant differences in patient satisfaction with COT (adjusted odds ratio (AOR) 1.17, 95% CI: 0.50-2.76, p = 0.72) or trust in provider (AOR 1.63, 95% CI: 0.65-4.09, p = 0.30). CONCLUSIONS TEACH did not significantly affect prescriber satisfaction, patient satisfaction with pain management or patient trust; however, it did improve prescriber confidence. TEACH is a promising strategy to improve provider prescribing of COT for PWH without adverse patient satisfaction or trust in provider.
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Affiliation(s)
- Jonathan A Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States; Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30329, United States.
| | - Carlos Del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States; Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30329, United States.
| | - Debbie M Cheng
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Ave., 3rd Floor, Boston, MA 02118, United States.
| | - Jane M Liebschutz
- Department of Medicine, University of Pittsburgh School of Medicine, 1218 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, United States.
| | - Marlene C Lira
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, 801 Massachusetts Ave., 2nd Floor, Boston, MA, United States.
| | - Judith I Tsui
- Department of Medicine, University of Washington School of Medicine, RR-512, Health Sciences Building, Box 356420, 1959 NE Pacific Street, Seattle, WA 98195-6420, United States.
| | - Alexander Y Walley
- Department of Medicine, University of Pittsburgh School of Medicine, 1218 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, United States.
| | - Leah S Forman
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, 85 East Newton Street, M921, Boston, MA 02118, United States.
| | - Christin Root
- Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30329, United States.
| | - Christopher W Shanahan
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, 801 Massachusetts Ave., 2nd Floor, Boston, MA, United States.
| | - Carly L Bridden
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, 801 Massachusetts Ave., 2nd Floor, Boston, MA, United States.
| | - Catherine Harris
- Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30329, United States.
| | - Kishna Outlaw
- Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30329, United States.
| | - Wendy S Armstrong
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States.
| | - Jeffrey H Samet
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, 801 Massachusetts Ave., 2nd Floor, Boston, MA, United States; Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Ave., 4th Floor, Boston MA 02118, United States.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Colasanti J, Lira MC, Cheng DM, Liebschutz JM, Tsui JI, Forman LS, Sullivan M, Walley AY, Bridden C, Root C, Podolsky M, Abrams C, Outlaw K, Harris CE, Armstrong WS, Samet JH, Del Rio C. Chronic Opioid Therapy in People Living With Human Immunodeficiency Virus: Patients' Perspectives on Risks, Monitoring, and Guidelines. Clin Infect Dis 2020; 68:291-297. [PMID: 29860411 DOI: 10.1093/cid/ciy452] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 05/29/2018] [Indexed: 12/24/2022] Open
Abstract
Background Chronic opioid therapy (COT) is common in people living with human immunodeficiency virus (PLHIV), but is not well studied. We assessed opioid risk behaviors, perceptions of risk, opioid monitoring, and associated Current Opioid Misuse Measure (COMM) scores of PLHIV on COT. Methods COT was defined as ≥3 opioid prescriptions ≥21 days apart in the past 6 months. Demographics, substance use, COMM score, and perceptions of and satisfaction with COT monitoring were assessed among PLHIV on COT from 2 HIV clinics. Results Among participants (N = 165) on COT, 66% were male and 72% were black, with a median age of 55 (standard deviation, 8) years. Alcohol and drug use disorders were present in 17% and 19%, respectively. In 43%, the COMM score, a measure of potential opioid misuse, was high. Thirty percent had an opioid treatment agreement, 66% a urine drug test (UDT), and 12% a pill count. Ninety percent acknowledged opioids' addictive potential. Median (interquartile range) satisfaction levels (1-10 [10 = highest]) were 10 (7-10) for opioid treatment agreements, 9.5 (6-10) for pill counts, and 10 (8-10) for UDT. No association was found between higher COMM score and receipt of or satisfaction with COT monitoring. Conclusions Among PLHIV on COT, opioid misuse and awareness of the addictive potential of COT are common, yet COT monitoring practices were not guideline concordant. Patients who received monitoring practices reported high satisfaction. Patient attitudes suggest high acceptance of guideline concordant care for PLHIV on COT when it occurs.
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Affiliation(s)
- Jonathan Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Marlene C Lira
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Massachusetts
| | - Debbie M Cheng
- Department of Biostatistics, Boston University School of Public Health, Massachusetts
| | - Jane M Liebschutz
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Judith I Tsui
- Section of General Internal Medicine, Department of Medicine, University of Washington and Harborview Medical Center, Seattle
| | - Leah S Forman
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Massachusetts
| | - Meg Sullivan
- Section of Infectious Disease, Department of Medicine, Boston University School of Medicine, Massachusetts
| | - Alexander Y Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Massachusetts
| | - Carly Bridden
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Massachusetts
| | - Christin Root
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Melissa Podolsky
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Massachusetts
| | - Catherine Abrams
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kishna Outlaw
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Catherine E Harris
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Wendy S Armstrong
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jeffrey H Samet
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Massachusetts
| | - Carlos Del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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