Acute and chronic pain syndromes are commonly reported and historically under treated among persons living with HIV/AIDS.1-5 HIV-infected patients have reported persistent pain, fatigue, myalgias, and poor concentration even after successful immune reconstitution on long-term antiretroviral treatment (ART).6,7 Greater pain severity also has been observed in patients with concurrent HIV/AIDS and mental health disorders.7,8 Opioid analgesics frequently are prescribed to treat pain in persons with HIV/AIDS and were a mainstay of palliative AIDS care in the pre-highly active antiretroviral therapy era. Many persons with HIV/AIDS, however, are affected by opioid-use disorders. More than 327,000 AIDS cases in the United States occurred by injecting heroin and other illicit drugs.9 In addition, abuse of prescription opioids in the general US population has climbed steadily over the last decade, with an estimated 11.4 million persons reporting nonmedical use of a prescription opioid in the past year.10,11 Between 2004 and 2008, emergency department visits involving oxycodone, hydrocodone, and methadone increased 152%, 123%, and 73%, respectively, and the number of fatal overdoses due to opioid analgesics now exceeds those due to heroin and cocaine combined.12,13 Finally, HIV-infected patients with problem drug-use histories are more likely to have higher levels of pain and symptom distress than those without drug-use histories.14-16 Thus, although opioids can treat pain effectively,17 prescribers must consider the potential adverse consequences of iatrogenic or missed addiction diagnoses.
HIV primary care providers are well positioned not only to screen and conduct brief interventions for addictive behaviors but also to provide office-based treatment for opioid dependence and alcohol and nicotine use disorders. Most clinicians, however, receive little training in the detection and management of substance use disorders,18,19 and many primary care physicians inadequately screen for or intervene in diagnosed cases of addiction.20 Providers have reported that they do not feel competent treating patients with substance use disorders and that working with drug users is unrewarding.21 Among 462 HIV providers surveyed in the United States at continuing education symposia on pain management in HIV/AIDS patients, the most common provider-related barriers to managing pain was a lack of knowledge about pain management, lack of access to pain management experts, and concerns about potential substance abuse or addiction.22 Provider confidence in substance use assessment and intervention is one of several factors associated with greater professional satisfaction caring for drug-using patients.23 Identifying opioid analgesic abuse and other aberrant behaviors (eg, diversion) is an area of growing interest in the management of nonmalignant chronic pain, which has led to the development of numerous screening and assessment tools24-28 and recent publication of opioid treatment guidelines by the American Pain Society and the American Academy of Pain Medicine17 and the American Society of Interventional Pain Physicians.29 These guidelines recommend clinical practices, such as routine assessments for risk of substance abuse, misuse or addiction, and monitoring high risk patients with periodic urine drug screening. The AIDS Education and Training Centers National Resource Center also released a Chronic Pain Toolkit, which offers algorithms and general guidelines for the management of chronic pain in patients with HIV/AIDS.30 To our knowledge, no other clinical guidelines have been recommended by professional HIV/AIDS organizations specifically for providers managing chronic pain in patients with HIV/AIDS.
To better understand the training, attitudes, and practices of medical providers that prescribe chronic opioid therapy (COT) to their HIV/AIDS patients, we conducted a survey of HIV providers to examine factors that may be associated with provider confidence in recognizing opioid analgesic abuse. We measured providers' perceptions and clinical practices when prescribing COT in HIV care settings. We hypothesized that confidence recognizing the abuse of prescription pain medications is associated with higher levels of training and practice support, more experience providing treatment for substance use disorders, and greater utilization of standardized approaches to opioid prescribing.
Clinicians prescribing COT to their HIV-infected patients were invited to participate in a survey developed as part of the Integrated Buprenorphine and HIV Care Evaluation (BHIVES), a Special Project of National Significance comprised of 10 national sites funded by the HIV/AIDS Bureau of the Health Resources and Services Administration to develop and evaluate integrated models of office-based buprenorphine treatment in HIV primary care settings. Details of the parent study are described in this journal issue31,32 and elsewhere.33 A supplemental survey was developed by a BHIVES workgroup, which convened to address the quality of opioid prescribing in HIV/AIDS clinics when it was noted that a significant number of opioid-dependent patients were not considered or referred for buprenorphine treatment and were prescribed high doses of opioid analgesics for chronic pain by their HIV providers. Eligible participants for the supplemental survey included physicians, nurse practitioners, and physician assistants who prescribed COT to their primary care patients with HIV/AIDS.
E-mail invitations were sent by individual BHIVES sites to their HIV medical providers. The solicitation requested providers' anonymous participation in a 20-minute on-line survey. Those that responded “yes” to the question, “Do you provide prescription opioids to HIV-positive patients in the treatment of chronic pain?” and agreed to participate in the study completed an on-line consent form and were directed by a web link to the survey. The web link remained open from October 2007 to April 2008. Hard copy versions of the consent form and survey also were made available for completion by medical providers during the same period. The respondents received no study payments for their participation. All study procedures were reviewed and approved by the institutional review boards of The New York Academy of Medicine and each of the participating sites.
The 55-item survey contained questions about provider demographics, training, certification, and clinical experience. We also asked providers to describe their patients, including: the number of patients seen each month, and proportions of patients with HIV/AIDS, patients on ART, patients in behavioral risk groups, patients with a chronic pain condition, and patients receiving COT for pain. We asked about clinical practices that providers may have utilized in the management of patients receiving prescription opioid analgesics for the treatment of chronic pain. For each practice, providers were asked to indicate how often they used it: never = I never do this; routinely = I do this with most or all my patients when I prescribe opioid analgesics; and selectively = I only do this when I suspect substance abuse. We also asked providers to rate their concern about substance use and the possible misuse of prescription opioids in their HIV/AIDS patients and to provide estimates of the proportion of their patients misusing prescriptions and with addictive disorders. Misuse was defined as “the use of a medication for an indication other than that intended at the time of prescription, for euphoria, for diversion, or only to prevent opioid withdrawal.” Addiction was defined as “both a physical dependence (eg, tolerance, withdrawal) and loss of control over use.”34 In addition, we asked questions about providers' comfort and confidence in assessing and treating their patients' pain. The main outcome variable was “confidence in your ability to recognize abuse of prescription pain medications in your patients with HIV,” which we measured using a 10-point visual analog scale, where 0 = not at all confident and 10 = extremely confident.
Statistical analysis was performed using SPSS (SPSS Inc, Chicago, IL). We used descriptive statistics to analyze provider and patient variables. We estimated the mean confidence score of providers' ability to recognize prescription pain medication abuse by their patients with HIV. We examined the associations between this main outcome variable and predictor variables, including provider and patient characteristics, provider attitudes, and clinical practices with chronic pain management and addiction. Analysis of variance procedures were used to test the differences in mean confidence scores by categorical variables and the Pearson product-moment correlation coefficient to test continuous variables and to test the independence of provider attitude scales. We used an ordinal regression model to test ordinal responses (eg, never, routinely, selectively) and Generalized Linear Model techniques to examine factors associated with the main outcome variable. A general hieratical approach was taken to build multivariate models that assess factors associated with provider confidence. First, predictors were categorized into a series of conceptually distinct domains including demographic, socioeconomic, social supportive, HIV history and treatment status, HIV risk factors, substance use and treatment history, mental and physical health status, quality of life indicators, and historic and contemporaneous service utilization. Second, within domains, each predictor's independent effect on the dependent variable of interest was calculated using Least Squares Regression. Domain-specific full models were then generated using variables found to have a significant effect (P ≤ 0.100) when analyzed independently. Third, variables found to be significant in the domain specific models were included in a full model. Finally, a fully parsimonious model was constructed from variables that remained significant in the full Least Squares model.
Responses from 106 providers (80 were physicians, 19 nurse practitioners, and 7 physician assistants) were included in the analysis. Their characteristics and results of scores of confidence in recognizing opioid analgesic abuse and measures of significance comparisons are shown in Table 1. The mean age range was between 45 and 54 years, 53% were female, and 71% were white. These providers reported an average of 12 years practicing HIV medicine and many (58%) listed HIV medicine as their clinical area of specialization. Almost half (46%) were internists or family practitioners and 40% were trained in infectious diseases. Nearly all (94%) had Drug Enforcement Agency (DEA) registrations, few (12%) were certified in treating addictive disorders, and 1 provider was certified in pain medicine. Thirty-nine (38%) providers reported having prescribed buprenorphine to their HIV-infected patients for the treatment of opioid addiction. Sixteen (15%) respondents reported no direct clinical experience treating patients with HIV/AIDS and opioid addiction.
Patient characteristics were described by 104 providers and are shown in Table 2, which also shows associations between patient characteristics and provider scores of confidence recognizing opioid analgesic abuse. Providers reported caring for an average of 92 patients monthly, of which 70 had HIV/AIDS. Of their HIV-infected patients, most (75%) were receiving ART and the most common exposure categories were men who have sex with men (38%) and injection drug users (37%). Providers reported that 28% of their HIV-infected patients had chronic pain, 23% had neuropathic pain, and 21% received opioids for the treatment of chronic pain. Twenty percent of their HIV-infected patients were felt to be addicted to any opioid, 12% to prescription opioids, and 13% to heroin alone (data not shown). The opioids most commonly thought to be misused by their patients were oxycodone (71%), hydrocodone (65%), and clinician-prescribed methadone (43%). Other substances and the proportion of patients addicted were stimulants (22%), alcohol (18%), and benzodiazepines (9%).
The frequency of clinical practices that providers used in their management of patients taking opioid analgesics for the treatment of chronic pain are described in Table 3. The most common practices used routinely were discussing substance use issues with patients (76%), refusing early refills for lost, stolen, or overused medications (61%), and prescribing longer acting opioids instead of shorter acting opioids (56%). Urine toxicology screening (81%), discussing medication diversion (60%), and screening for substance abuse (59%) were the 3 most common practices employed selectively (I only do this when I suspect substance abuse). Most providers (68%) never employed random medication call backs or medication checks (eg, pill counts) or prescription monitoring programs (eg, state or managed care computer database of controlled substances prescribed to a patient). Written controlled substance contracts or agreements were routinely, selectively, and never used by 37%, 42%, and 21% of providers, respectively. Referrals to treatment programs that offer specialty addiction services (eg, methadone, residential, outpatient) were made by all providers (56% selectively, 44% routinely).
Mean provider confidence in recognizing prescription pain medication abuse in HIV-infected patients was 6.3 of 10 (Table 1). Confidence correlated highly and was collinear with other provider attitudes, such as comfort treating chronic pain, confidence in diagnosing or treating chronic pain, comfort prescribing opioid analgesics, and comfort prescribing opioid analgesics to patients with a history of prescription pain medication abuse independent of whether those patients were receiving substance abuse treatment.
Provider characteristics that were statistically associated with higher confidence are shown in Table 1 and include male provider sex (P = 0.04), specialty training in addiction medicine or addiction psychiatry (P = 0.01), and having prescribed buprenorphine for opioid dependence to HIV-infected patients (P = 0.009). Providers with no direct clinical experience treating their HIV-infected patients for opioid addiction reported significantly lower confidence (P = 0.001). Patient characteristics associated with provider confidence recognizing opioid analgesic abuse are shown in Table 2. Larger patient caseloads were associated with higher mean confidence (P = 0.027). Specifically, confidence was higher among providers, who cared for more patients with injecting drug use as their primary exposure group (P = 0.012), more patients with chronic pain syndromes (P = 0.026), more patients with chronic neuropathic pain (P = 0.047), and more patients receiving COT (P = 0.007). In addition, significantly higher provider confidence was reported by respondents, who more often discussed substance abuse issues with their patients (P = 0.03), conducted urine drug testing (P = 0.008), and prescribed longer acting opioid medications (P = 0.005) (Table 3).
In a multiple linear regression model, provider confidence recognizing opioid analgesic abuse among their HIV-infected patients was independently associated with caring for more patients with chronic pain syndromes (β = 2.268, P = 0.026) and conducting urine toxicology screening in patients suspected of misuse (β = 2.070, P = 0.041). Confidence was inversely associated with no direct clinical experience treating patients with HIV/AIDS and opioid addiction (β = −2.238, P = 0.020).
Opioid analgesics can be effective components for the treatment of moderate to severe pain in patients with HIV/AIDS,35-37 but opioids also can be associated with physiologic dependence, misuse, and life-threatening adverse consequences with which prescribers must contend. Fear of causing addiction is a major provider barrier to prescribing opioid analgesics, and there is unfortunately no single test or pathognomonic sign that helps providers predict which patients will respond well when prescribed opioid analgesics.38 In an anonymous survey of 106 clinicians that provide prescription pain medications to their HIV-infected patients for the treatment of chronic pain, we detected infrequent use of guideline-recommended practices (eg, screening for substance use risk)17 and limited provider confidence in recognizing opioid analgesic abuse. Confidence was unexpectedly low, given providers' high estimates of the prevalence of chronic pain in their patients, the proportion of their patients receiving COT, and the proportion of their patients thought to be addicted to opioids.
In this study, we also found that providers who prescribe buprenorphine to their HIV-infected patients for the treatment of opioid dependence report significantly greater confidence in recognizing opioid analgesic abuse. One reason that buprenorphine prescribers may be more confident is they have something tangible and medically effective to offer their addicted patients. Providers who do not feel comfortable or empowered to treat addiction may not feel as comfortable or confident diagnosing it. In addition, respondents to this survey practiced at clinics participating in the BHIVES initiative where buprenorphine-prescribing providers may have received more provider education, support, and mentoring opportunities on detecting and managing opioid dependence in their HIV practice than nonprescribers.
Provider confidence recognizing opioid analgesic abuse also is associated in this study with caring for a higher number of patients per month; specifically, patients that are injection drug users, have chronic pain, or receive opioid analgesic prescriptions for pain. Although tempting at first to apply the old adage “practice makes perfect” to this association, we observe that few of the clinical guidelines recommended by professional pain organizations for prescribing COT17,29 are practiced by HIV providers routinely (ie, “I do this with most or all my patients when I prescribe opioid analgesics”). When used routinely, however, clinical practices such as urine toxicology and prescribing longer acting opioids are associated with higher provider confidence in this study. Based on these findings, we suggest that the routine practice of clinical guidelines as recommended by pain experts may be applied to HIV care settings. In favor of a more standardized approach to pain management among HIV-infected patients are opportunities to reduce stigma that is reinforced by selective monitoring of misuse suspects in an already highly stigmatized patient population, and clear evidence that most providers are unable to predict with certainty which of their patients will develop problematic use, abuse, or dependence.39,40 Indeed, Katz et al41 have shown that reliance on aberrant behavior to trigger urine drug testing misses about half of COT patients using unprescribed or illicit drugs. In our study, urine drug testing was conducted selectively (ie, “I only do this when I suspect substance abuse”) by the majority (81%) of providers and routinely by only 9% of providers. We suggest that selective behavior is ineffective and contributes instead to a dynamic of “mutual mistrust” in provider-patient relationships, especially concerning opioid prescribing.42 A rational alternative to selective monitoring of patients receiving opioid analgesics may be the “universal precautions” approach recommended by Gourlay et al,38 which applies an appropriate minimum level of precaution and care to all patients presenting with chronic pain. This standardized biopsychosocial approach includes screening all patients for substance use and a framework for stratifying addiction risk. Future research can help delineate if the application of these kinds of standardized clinical guidelines results in better patient care, higher provider confidence in substance use detection and intervention, and greater professional satisfaction working with HIV-infected patients who have chronic pain.
This report has a number of limitations. First, we recruited participants using convenience sampling. Therefore, our findings may not be generalizable to all medical providers caring for HIV-infected patients with chronic pain. In addition, although web links were set up to receive survey responses from nine BHIVES clinical sites and all 9 sites delivered responses, the majority (71%) were submitted by 3 sites. Our findings, therefore, also may not be representative of clinicians practicing at all BHIVES sites. Similarly, BHIVES sites may not be representative of other HIV clinical settings, in particular, those in rural areas, which were not represented in the parent study. Nonetheless, our sample was geographically and professionally diverse and included allied health providers who often provide a substantial amount of follow-up care, including opioid prescribing in large HIV primary care clinics. A second limitation is that all data were collected by self-report and may reflect social desirability bias, although the anonymous nature of the survey should help minimize this concern. Third, we detected high levels of multicollinearity among many independent variables, including providers' attitudes about their comfort and confidence managing patients with pain or substance use and the clinical practices they employed to manage patients receiving COT. For example, if a provider or providers from one clinical site used a particular method (ie, routine urine toxicology) for managing COT patients, then these providers were likely to employ other pain management practices as well. The high correlation among the independent variables limited the number that could enter the model. Thus, although the 3 variables in our multivariate model are conceptually independent and explain much of the variance in providers' confidence, many other variables also could predict the main outcome and should be examined in a future larger study. Finally, cross-sectional studies such as this one can identify associations but are unable to determine causality or the direction of these associations.
Twenty years ago, HIV infection was a uniformly fatal disease. Many medical providers prescribed large doses and quantities of opioids for palliative care and without grave concern for drug dependence or functional status. Today, with reductions in AIDS-related mortality due to effective combination ART, HIV-infected patients are now often told they can expect to live long lives. Indeed, HIV/AIDS care has evolved from a hospice model to one of chronic disease management,43,44 yet many more patients with HIV/AIDS may struggle with residual chronic inflammation and functional disability exacerbated by the adverse sequelae of pain and/or its treatment. Clinicians who care for HIV-infected patients are challenged not only to keep pace with the skills and knowledge to prescribe opioid analgesics safely and effectively but also to balance the potential risks and benefits along what may be a continuum between pain and addiction. Increased awareness and provider training are sorely needed in this field. HIV clinicians will benefit greatly by the following: (1) knowledge about chronic pain and its treatment; (2) rational guidelines to assess and monitor patients on COT; (3) tools and strategies for working with patients around pain and addiction; and (4) structures at a clinic systems level that allow them to be successful. Office-based treatment of opioid dependence with buprenorphine is an additional skill that HIV clinicians managing pain patients should consider for their practice. Improvements in provider confidence recognizing opioid analgesic abuse and professional satisfaction working with chronic pain patients living with HIV/AIDS are essential for both clinician training and patient care. A thoughtful, standardized approach to addressing chronic pain and substance use disorders in HIV-infected patients would be a welcome addition to national HIV/AIDS clinical care guidelines to assist providers from missing treatable addiction diagnoses and to enhance overall patient quality of life.
The authors wish to thank Dr Yong Song, who drafted earlier versions of the survey and who contributed greatly to the success of this project. The authors also wish to thank the Health Resources and Services Administration, which supported this work through an HIV/AIDS Bureau's Special Project of National Significance, Grant No. H97HA03799.
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APPENDIX I: The BHIVES Collaborative
The CORE Center (Chicago, IL), El Rio Santa Cruz Neighborhood Health Center (Tucson, AZ), Johns Hopkins University (Baltimore, MD), Miriam Hospital (Providence, RI), Montefiore Medical Center (Bronx, NY), OASIS (Oakland, CA), Oregon Health Sciences University (Portland, OR), University of California San Francisco Positive Health Program at San Francisco General Hospital (San Francisco, CA), University of Miami Medical School (Miami, FL), Yale University School of Medicine (New Haven, CT) and The New York Academy of Medicine (New York, NY). Cited Here...