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Prescription of opioid painkillers falls with longer time in HIV care.

More than one quarter of a large HIV group in North Carolina had a prescription for opioid painkillers at least 2 years in a row, and many of those people had opioid prescriptions more than half of the time they spent in care for HIV. (1) But opioid prescriptions dropped substantially with longer time in HIV care.

Opioids are strong pain medications that a provider can prescribe or that can be obtained illegally (see "What you should know about opioid painkillers," (2,3)). An opioid use crisis has spread through many parts of the United States. (2) Health authorities estimate that in 2015 about 2 million people in the United States misused prescription opioid pain relievers. (2) Some research indicates that people with HIV get opioid prescriptions twice as often as people without HIV. (4) The Centers for Disease Control and Prevention (CDC) has guidelines on proper opioid prescribing, (5) but some work indicates that these guidelines are not always followed in people with HIV. (6)

Because little is known about trends in opioid prescriptions over time in people with HIV, researchers at the University of North Carolina conducted this study of people in care for HIV at their HIV clinic.

* How the study worked. The researchers focused on adults in North Carolina who had at least one HIV care visit per year in at least 5 years between 2000 and 2014. For each person, the study start date was the first year of their HIV care in 2000 or later.

The research team checked medical records of these people to see how often they received a prescription for an opioid. They divided study participants into three opioid prescription groups:

> Never/sporadic use: no opioid prescription or rare prescription

> Episodic use: at least 1 opioid prescription in at least 2 consecutive years

> Chronic use: an opioid prescription during at least half of the years in care

The researchers used a standard statistical method to identify factors that raised chances of belonging to the episodic opioid use group or the chronic opioid use group. This kind of analysis identifies individual risk factors that have an impact regardless of whatever other risk factors a person has.

* What the study found. The study group included 1239 people in care for HIV infection between 2000 and 2014. Group members received care for a median* (midpoint) of 9 years. Most study participants were men (70%), and most were black (60%). The midpoint age when these people began care was 39. Only 25 study participants (2%) had a medical record noting chronic pain, a common reason for having an opioid prescription.

The researchers determined that 898 study group members (72%) fell into the never/sporadic use group, 141 (11%) were episodic users, and 200 (16%) were chronic users. After 1, 5, 10, and 15 years of care, opioid prescription probabilities were 16%, 8%, 8%, and 6% in never/sporadic users, 7%, 22%, 51%, and 14% in episodic users, and 64%, 69%, 60%, and 35% in chronic users (Figure 1). Thus opioid prescriptions fell sharply over time in episodic users and chronic users.

Statistical analysis pinpointed several independent predictors of belonging to the episodic use group or the chronic use group. Compared with never/sporadic users, episodic users were more likely to be women, to have depression, to have a drug-related diagnosis, to use antiretroviral therapy, and to have an undetectable viral load. Compared with never/sporadic users, chronic users were more likely to be women, to be older, and to have a mental illness.

* What the findings mean for you. This 15-year study of more than 1200 people with HIV in North Carolina found that 27% of them--more than one quarter--used prescription opioids episodically (at least 1 opioid prescription in at least 2 consecutive years) or chronically (an opioid prescription during at least half of the years in care). Episodic or chronic opioid users were more likely to be women, older people, and people with depression or other mental illness.

Opioids include prescription drugs like oxycodone (OxyContin), hydrocodone (Vicodin), fentanyl, codeine, and morphine--as well as illegal drugs like heroin. These drugs are powerful painkillers that providers can prescribe to help people cope with pain, for example, after surgery. But opioids can also give users a sense of intense happiness or well-being. As a result, using them over a prolonged period can be addictive. Some people who start with prescription opioids go on to acquire them illegally, and some end up using heroin. (2)

The National Institute of Drug Addiction warns that the United States faces an opioid crisis. (2) Researchers estimate that about one quarter of people who take prescription opioids misuse them. (2) Misuse can result in overdose and death. In 2015 more than 33,000 people in the United States died of opioid overdose, including overdose of prescription opioids, heroin, and illegally made fentanyl. (2) Although US providers began prescribing fewer opioids starting in 2010, in 2015 the amount of opioids prescribed in the United States was still 3 times higher than in 19997 and almost 4 times higher than the prescribing rate in Europe. (8) The Centers for Disease Control and Prevention (CDC) has guidelines for providers on proper opioid prescribing. (5)

If your provider prescribes an opioid like OxyContin or Vicodin, it is critical to take the drug exactly as your provider directs and not to continue using it longer than directed. If you are misusing prescription opioids or started using illegal opioids, get help to stop from your provider or from a drug treatment center. Several drugs--methadone, buprenorphine, and naltrexone--can help people recover from opioid addiction. (9)

A hopeful finding emerged from the study of opioid use in people with HIV:1 Episodic and chronic opioid users proved less likely to get an opioid prescription with longer time in HIV care. That encouraging trend could reflect the overall benefits of maintaining steady HIV care, such as prevention or treatment of serious nonHIV diseases that may call for an opioid prescription.

References

(1.) Brunet L, Napravnik S, Heine AD, Leone PA, Eron JJ. Longitudinal opioid use among HIV-infected patients, 2000 to 2014. J Acquir Immune Defic Syndr. 2017; 75:77-80.

(2.) National Institutes of Health. National Institute of Drug Addiction. Opioid crisis. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-crisis

(3.) National Institutes of Health. National Institute of Drug Addiction. Opioids. https://www.drugabuse.gov/ drugs-abuse/opioids

(4.) Silverberg MJ, Ray GT, Saunders K, et al. Prescription long-term opioid use in HIV-infected patients. Clin J Pain. 2012; 28:3-46.

(5.) Centers for Disease Control and Prevention. CDC Guideline for Prescribing Opioids for Chronic Pain--United States 2016. Recommendations and Reports/March 18, 2016; 65(1):1-49. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

(6.) Gaither JR, Goulet JL, Becker WC, et al. Guideline-concordant management of opioid therapy among human immunodeficiency virus (HIV)-infected and uninfected veterans. J Pain. 2014; 15:1130-1140.

(7.) Guy GP Jr, Zhang K, Bohm MK, et al. Vital Signs: Changes in opioid prescribing in the United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017; 66(26). https://www.cdc.gov/mmwr/volumes/66/wr/mm6626a4.htm?s_cid=mm6626a4_w

(8.) Schuchat A, Houry D, Guy GP Jr. New data on opioid use and prescribing in the United States. JAMA. Published online July 6, 2017. doi:10.1001/jama.2017.8913.

(9.) National Institutes of Health. National Institute of Drug Addiction. Medications to treat opioid addiction. https://www.drugabuse.gov/publications/research-reports/medications-to-treat-opioid-addiction/overview

* Words in bold are defined in the Technical Word List at the end of this issue of HIV Treatment Alerts.
What you should know about opioid painkillers

> Opioids are strong pain medications that a provider can prescribe
  or that can be obtained illegally.

> Opioids include (1) prescription medicines like oxycodone
  (OxyContin), hydrocodone (Vicodin), fentanyl, codeine, and
  morphine, and (2) illegal drugs like heroin.

> Besides relieving pain, opioids can cause euphoria--a strong
  sensation of excitement and well-being.

> Opioids are usually safe when taken as a provider directs. But if
  opioids are misused (taken too often or without a prescription),
  they can cause addiction, overdose, and death.

> There are medications that successfully treat opioid
  misuse--methadone, buprenorphine, and naltrexone. Naloxone can
  reverse opioid overdose.

> In 2015 opioid overdoses killed 33,000 people in the United States.

> In 2015 an estimated 2 million people in the United States had
  substance use disorders related to prescription opioid pain
  relievers.

> About 80% of people who use heroin first misused prescription
  opioids.

Sources: National Institutes of Health. National Institute of Drug
Addiction. Opioid crisis. (2) National Institute of Drug Addiction.
Opioids. (3)

Figure 1. In a large group of people with HIV, probability of
having an opioid prescription fell through 15 years of HIV care in
people with chronic use (an opioid prescription during at least
half of the years in care) and in people with episodic use (at
least 1 opioid prescription in at least 2 consecutive years).

Probability of opioid prescribing
through 15 years of HIV care

       Chronic  Episodic

1 y    64%      7%
5 y    69%      22%
10 y   60%      51%
15 y   35%      14%

Note: Table made from bar graph.
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Publication:HIV Treatment: ALERTS!
Date:Sep 1, 2017
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