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

  • Jessica Clark
  • Nadia Fairbairn
  • Seonaid Nolan
  • Tian Li
  • Anthony Wu
  • Rolando Barrios
  • Julio Montaner
  • Lianping TiEmail author
  • the STOP HIV/AIDS in BC Study Group
Original Paper
  • 44 Downloads

Abstract

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

Keywords

Prescription opioids Analgesics Pain People living with HIV 

Notes

Acknowledgements

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

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

References

  1. 1.
    Hewitt DJ, McDonald M, Portenoy RK, Rosenfeld B, Passik S, Breitbart W. Pain syndromes and etiologies in ambulatory AIDS patients. Pain. 1997;70(2):117–23.Google Scholar
  2. 2.
    Penfold J, Clark AJM. Pain syndromes in HIV infection. Can J Anaesth. 1992;39(7):724–30.Google Scholar
  3. 3.
    Parker R, Stein DJ, Jelsma J. Pain in people living with HIV/AIDS: a systematic review. J Int AIDS Soc. 2014;17(1):18719.Google Scholar
  4. 4.
    Merlin JS, Cen L, Praestgaard A, et al. Pain and physical and psychological symptoms in ambulatory HIV patients in the current treatment era. J Pain Symptom Manag. 2012;43(3):638–45.Google Scholar
  5. 5.
    Aouizerat BE, Miaskowski CA, Gay C, et al. Risk factors and symptoms associated with pain in HIV-infected adults. J Assoc Nurses AIDS Care. 2010;21(2):125–33.Google Scholar
  6. 6.
    Koeppe J, Armon C, Lyda K, Nielsen C, Johnson S. Ongoing pain despite aggressive opioid pain management among persons with HIV. Clin J Pain. 2010;26(3):190.Google Scholar
  7. 7.
    Breitbart W, Rosenfeld BD, Passik SD, McDonald MV, Thaler H, Portenoy RK. The undertreatment of pain in ambulatory AIDS patients. Pain. 1996;65(2):243–9.Google Scholar
  8. 8.
    Tsao JCI, Stein JA, Dobalian A. Sex differences in pain and misuse of prescription analgesics among persons with HIV. Pain Med. 2010;11(6):815–24.Google Scholar
  9. 9.
    Miaskowski C, Penko JM, Guzman D, Mattson JE, Bangsberg DR, Kushel MB. Occurrence and characteristics of chronic pain in a community-based cohort of indigent adults living with HIV infection. J Pain. 2011;12(9):1004–16.Google Scholar
  10. 10.
    Bruce RD, Merlin J, Lum PJ, et al. 2017 HIVMA of IDSA clinical practice guideline for the management of chronic pain in patients living with HIV. Clin Infect Dis. 2017;65(10):e1–37.Google Scholar
  11. 11.
    Roy S, Ninkovic J, Banerjee S, et al. Opioid drug abuse and modulation of immune function: consequences in the susceptibility to opportunistic infections. J Neuroimmune Pharmacol. 2011;6(4):442.Google Scholar
  12. 12.
    Flores J, Liang Y, Ketchum NS, et al. Prescription opioid use is associated with virologic failure in people living with HIV. AIDS Behav. 2018;22(4):1323–8.Google Scholar
  13. 13.
    Meng J, Sindberg GM, Roy S. Disruption of gut homeostasis by opioids accelerates HIV disease progression. Front Microbiol [Internet]. 2015 [cited 2019 Apr 8]; https://www.frontiersin.org/articles/10.3389/fmicb.2015.00643/full.
  14. 14.
    Busse JW, Craigie S, Juurlink DN, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017;189(18):E659–66.Google Scholar
  15. 15.
    Organization WH. Cancer pain relief and palliative care: report of a WHO expert committee. World Health Organ Tech Rep Ser. 1990;804:1–75.Google Scholar
  16. 16.
    Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487–92.Google Scholar
  17. 17.
    Estimated World Requirements of Narcotic Drugs Estimated World Requirements for 2016—Statistics for 2014. United Nations Pubns; 2016.Google Scholar
  18. 18.
    Fischer B, Argento E. Prescription opioid related misuse, harms, diversion and interventions in Canada: a review. Pain Physician. 2012;15(3 Suppl):ES191–203.Google Scholar
  19. 19.
    Fischer B, Jones W, Rehm J. High correlations between levels of consumption and mortality related to strong prescription opioid analgesics in British Columbia and Ontario, 2005–2009. Pharmacoepidemiol Drug Saf. 2013;22(4):438–42.Google Scholar
  20. 20.
    Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in drug and opioid overdose deaths—United States, 2000–2014. Am J Transpl. 2016;16(4):1323–7.Google Scholar
  21. 21.
    Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011;171(7):686–91.Google Scholar
  22. 22.
    Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152(2):85–92.Google Scholar
  23. 23.
    Zedler B, Xie L, Wang L, et al. Risk factors for serious prescription opioid-related toxicity or overdose among veterans health administration patients. Pain Med. 2014;15(11):1911–29.Google Scholar
  24. 24.
    Bohnert ASB, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011;305(13):1315–21.Google Scholar
  25. 25.
    Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315(15):1624–45.Google Scholar
  26. 26.
    Weisberg D, Gordon K, Barry D, et al. Long-term prescription opioids and/or benzodiazepines and mortality among HIV-infected and uninfected patients. J Acquir Immune Defic Syndr. 2015;69(2):223–33.Google Scholar
  27. 27.
    Heath K, Samji H, Nosyk B, et al. Cohort profile: seek and treat for the optimal prevention of HIV/AIDS in British Columbia (STOP HIV/AIDS BC). Int J Epidemiol. 2014;43(4):1073–81.Google Scholar
  28. 28.
    Nosyk B, Colley G, Yip B, et al. Application and validation of case-finding algorithms for identifying individuals with human immunodeficiency virus from administrative data in British Columbia, Canada. PLoS ONE. 2013;8(1):e54416.Google Scholar
  29. 29.
    Drug treatment program and virology registry. BC Centre for Excellence in HIV/AIDS; 2014.Google Scholar
  30. 30.
    British Columbia Centre for Disease Control Public Health Laboratory. HIV laboratory testing datasets (tests: ELISA, Western blot, NAAT, p24, culture) [Internet]. Clinical Prevention Services, British Columbia Centre for Disease Control; 2016. http://www.bccdc.ca/about/accountability/data-access-requests/public-health-data.
  31. 31.
    British Columbia Centre for Disease Control. HIV/AIDS Information System (HAISYS) [Internet]. Clinical Prevention Services, British Columbia Centre for Disease Control; 2016. http://www.bccdc.ca/about/accountability/data-access-requests/public-health-data.
  32. 32.
    British Columbia Ministry of Health. Medical Services Plan (MSP) Payment Information File; Consolidation File (MSP Registration & Premium Billing); Home & Community Care (Continuing Care); Mental Health; PharmaNet [Internet]. British Columbia Ministry of Health; 2016. http://www2.gov.bc.ca/gov/content/health/conducting-health-research-evaluation/data-access-health-data-central.
  33. 33.
    Canadian Institute for Health Information. Discharge Abstract Database (Hospital Separations) [Internet]. 2016. http://www2.gov.bc.ca/gov/content/health/conducting-health-research-evaluation/data-access-health-data-central.
  34. 34.
    British Columbia Vital Statistics Agency. Vital Statistics. British Columbia Ministry of Health; 2016.Google Scholar
  35. 35.
    Von Korff M, Saunders K, Ray GT, et al. Defacto long-term opioid therapy for non-cancer pain. Clin J Pain. 2008;24(6):521–7.Google Scholar
  36. 36.
    Merlin JS, Tamhane A, Starrels JL, Kertesz S, Saag M, Cropsey K. Factors associated with prescription of opioids and co-prescription of sedating medications in individuals with HIV. AIDS Behav. 2016;20(3):687–98.Google Scholar
  37. 37.
    Morasco BJ, Turk DC, Donovan DM, Dobscha SK. Risk for prescription opioid misuse among patients with a history of substance use disorder. Drug Alcohol Depend. 2013;127(1–3):193–9.Google Scholar
  38. 38.
    Whitehead AJ, Dobscha SK, Morasco BJ, Ruimy S, Bussell C, Hauser P. Pain, substance use disorders and opioid analgesic prescription patterns in veterans with hepatitis C. J Pain Symptom Manag. 2008;36(1):39–45.Google Scholar
  39. 39.
    Edelman EJ, Gordon K, Becker WC, et al. Receipt of opioid analgesics by HIV-infected and uninfected patients. J Gen Intern Med. 2013;28(1):82–90.Google Scholar
  40. 40.
    Becker WC, Gordon K, Edelman JE, et al. Trends in any and high-dose opioid analgesic receipt among aging patients with and without HIV. AIDS Behav. 2016;20(3):679–86.Google Scholar
  41. 41.
    Sullivan MD, Bauer AM, Fulton-Kehoe D, et al. Trends in opioid dosing among Washington State medicaid patients before and after opioid dosing guideline implementation. J Pain. 2016;17(5):561–8.Google Scholar
  42. 42.
    Morden NE, Munson JC, Colla CH, et al. Prescription opioid use among disabled medicare beneficiaries: intensity, trends and regional variation. Med Care. 2014;52(9):852–9.Google Scholar
  43. 43.
    Gomes T, Mamdani MM, Paterson JM, Dhalla IA, Juurlink DN. Trends in high-dose opioid prescribing in Canada. Can Fam Physician. 2014;60(9):826–32.Google Scholar
  44. 44.
    King NB, Fraser V, Boikos C, Richardson R, Harper S. Determinants of increased opioid-related mortality in the United States and Canada, 1990–2013: a systematic review. Am J Public Health. 2014;104(8):e32–42.Google Scholar
  45. 45.
    Martin C, Pehrsson P, Österberg A, Sönnerborg A, Hansson P. Pain in ambulatory HIV-infected patients with and without intravenous drug use. Eur J Pain. 1999;3(2):157–64.Google Scholar
  46. 46.
    Dobalian A, Tsao JCI, Duncan RP. Pain and the use of outpatient services among persons with HIV: results from a Nationally Representative Survey. Med Care. 2004;42(2):129–38.Google Scholar
  47. 47.
    Nair SN, Mary TR, Prarthana S, Harrison P. Prevalence of pain in patients with HIV/AIDS: a cross-sectional survey in a South Indian State. Indian J Palliat Care. 2009;15(1):67–70.Google Scholar
  48. 48.
    Krüsi A, Wood E, Montaner J, Kerr T. Social and structural determinants of HAART access and adherence among injection drug users. Int J Drug Policy. 2010;21(1):4–9.Google Scholar
  49. 49.
    Palepu A, Tyndall MW, Joy R, et al. Antiretroviral adherence and HIV treatment outcomes among HIV/HCV co-infected injection drug users: the role of methadone maintenance therapy. Drug Alcohol Depend. 2006;84(2):188–94.Google Scholar
  50. 50.
    Uhlmann S, Milloy M-J, Kerr T, et al. Methadone maintenance therapy promotes initiation of antiretroviral therapy among injection drug users. Addiction. 2010;105(5):907–13.Google Scholar
  51. 51.
    Jones CM, McAninch JK. Emergency department visits and overdose deaths from combined use of opioids and benzodiazepines. Am J Prev Med. 2015;49(4):493–501.Google Scholar
  52. 52.
    Dasgupta N, Funk MJ, Proescholdbell S, Hirsch A, Ribisl KM, Marshall S. Cohort study of the impact of high-dose opioid analgesics on overdose mortality. Pain Med. 2016;17(1):85–98.Google Scholar
  53. 53.
    Morasco BJ, Duckart JP, Carr TP, Deyo RA, Dobscha SK. Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-cancer pain. PAIN®. 2010;151(3):625–32.Google Scholar
  54. 54.
    Saunders KW, Von Korff M, Campbell CI, et al. Concurrent use of alcohol and sedatives among persons prescribed chronic opioid therapy: prevalence and risk factors. J Pain. 2012;13(3):266–75.Google Scholar
  55. 55.
    Bing EG, Burnam MA, Longshore D, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry. 2001;58(8):721–8.Google Scholar
  56. 56.
    Gaynes BN, Pence BW, Eron JJ, Miller WC. Prevalence and comorbidity of psychiatric diagnoses based on reference standard in an HIV + patient population. Psychosom Med. 2008;70(4):505–11.Google Scholar
  57. 57.
    Starrels JL, Peyser D, Haughton L, et al. When HIV treatment goals conflict with guideline-based opioid prescribing: a qualitative study of HIV providers. Subst Abus. 2016;37(1):148–53.Google Scholar
  58. 58.
    Hansen L, Penko J, Guzman D, Bangsberg DR, Miaskowski C, Kushel MB. Aberrant behaviors with prescription opioids and problem drug use history in a community-based cohort of HIV-infected individuals. J Pain Symptom Manag. 2011;42(6):893–902.Google Scholar
  59. 59.
    Kaplovitch E, Gomes T, Camacho X, Dhalla IA, Mamdani MM, Juurlink DN. Sex differences in dose escalation and overdose death during chronic opioid therapy: a population-based cohort study. PLoS ONE. 2015;10(8):e0134550.Google Scholar
  60. 60.
    Lau HS, de Boer A, Beuning KS, Porsius A. Validation of pharmacy records in drug exposure assessment. J Clin Epidemiol. 1997;50(5):619–25.Google Scholar
  61. 61.
    Cervia LD, McGowan JP, Weseley AJ. Clinical and demographic variables related to pain in HIV-infected individuals treated with effective, combination antiretroviral therapy (cART). Pain Med. 2010;11(4):498–503.Google Scholar
  62. 62.
    Lee KA, Gay C, Portillo CJ, et al. Symptom experience in HIV-infected adults: a function of demographic and clinical characteristics. J Pain Symptom Manag. 2009;38(6):882–93.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of MedicineUniversity of British ColumbiaVancouverCanada
  2. 2.British Columbia Centre on Substance Use, St. Paul’s HospitalVancouverCanada
  3. 3.British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s HospitalVancouverCanada
  4. 4.Vancouver Coastal Health AuthorityVancouverCanada
  5. 5.British Columbia Centre on Substance UseVancouverCanada

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