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Pain, Mood, and Substance Abuse in HIV: Implications for Clinic Visit Utilization, Antiretroviral Therapy Adherence, and Virologic Failure

Merlin, Jessica S. MD, MBA*,†; Westfall, Andrew O. MS*,‡; Raper, James L. DSN, CRNP, JD*; Zinski, Anne PhD*; Norton, Wynne E. PhD§; Willig, James H. MD, MSPH*; Gross, Robert MD, MSCE; Ritchie, Christine S. MD, MSPH; Saag, Michael S. MD*; Mugavero, Michael J. MD, MHSc*

JAIDS Journal of Acquired Immune Deficiency Syndromes: October 1st, 2012 - Volume 61 - Issue 2 - p 164–170
doi: 10.1097/QAI.0b013e3182662215
Clinical Science

Background: Cooccurring pain, mood disorders, and substance abuse are common in HIV-infected patients. Our objective was to investigate the relationship between pain, alone and in the context of mood disorders and substance abuse, on clinic utilization, antiretroviral therapy adherence, and virologic suppression.

Methods: Pain, mood disorders, and substance abuse were assessed at the first visit. No-show and urgent visits were measured over a 1-year period. Models were adjusted for age, race, sex, insurance status, CD4+ T-lymphocyte count, and HIV risk factor.

Results: Among 1521 participants, 509 (34%) reported pain, 239 (16%) had pain alone, 189 (13%) had pain and a mood disorder, and 30 (2%) had pain and substance abuse. In univariate models, participants with pain, mood disorders, and substance abuse had higher odds of a no-show visit than those without these conditions [odds ratio (OR), 1.4; 95% confidence interval (CI), 1.1–1.8; OR, 1.5; 95% CI, 1.2–1.9; OR, 2.0; 95% CI, 1.4–2.8, respectively]. In the multivariable model, pain increased the odds of a no-show visit only in participants without substance abuse (OR, 1.5; 95% CI, 1.1–1.9) and pain reduced the odds of a no-show visit in participants with substance abuse (OR, 0.5; 95% CI, 0.2–0.9; P for interaction = 0.0022).

Conclusions: In this study, pain increased the odds of no-show visits but only for participants without substance abuse. Because pain, mood disorders, and substance abuse are highly prevalent in HIV-infected patients, our findings have implications for HIV treatment success. Interventions that incorporate pain management may be important for improving health outcomes in patients living with HIV infection.

*Division of Infectious Diseases, Department of Medicine

Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine

Departments of Biostatistics; and

§Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, AL

Division of Infectious Diseases, Department of Medicine, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, and Philadelphia Veterans Affairs Medical Center, Philadelphia, PA

Division of Geriatrics, Department of Medicine, University of California at San Francisco, Jewish Home of San Francisco Center for Research on Aging, San Francisco, CA.

Correspondence to: Jessica S. Merlin, MD, MBA, BBRB 222, 1530 3rd Avenue S, Birmingham, AL 35294-2170 (e-mail

A. O. Westfall has received consulting fees from Definicaire LLC. R. Gross is supported by the Penn Center for AIDS Research (CFAR) (P30 AI 045008). C. S. Ritchie is supported by 7K07AG031779 (NIA). M. J. Mugavero is supported by K23MH082641 and has received consulting fees (advisory board) from Merck Foundation, Bristol-Myers Squibb, and Gilead Sciences, and grant support to UAB from Tibotec Therapeutics, Pfizer, Inc, Bristol-Myers Squibb, and Definicare, LLC. For the remaining authors, no conflicts of interest were disclosed.

Received March 22, 2012

Accepted June 22, 2012

© 2012 by Lippincott Williams & Wilkins