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Prescribed Opioid Dose Increase Tied
to Future Heroin Use in HIV+ People

  AIDS 2020: 23rd International AIDS Conference Virtual, July 6-10, 2020
Mark Mascolini
Analysis of 598 San Francisco opioid users with or without HIV linked raising a prescription opioid dose to future heroin use in people with HIV [1]. Compared with HIV-negative people prescribed opioids, those with HIV were prescribed higher opioid doses despite reporting less pain and fewer sleep problems.
San Francisco Department of Public Health workers undertook this study because reduced prescribing of opioid pain relievers starting around 10 years ago led to an array of problems, including increased pain, worsened function, and psychological distress. To explore the impact of changes in opioids prescribed for chronic pain, the Public Health team studied 182 people with HIV and 416 without HIV who had follow-up after starting an opioid prescription.
This retrospective analysis involved publicly insured people prescribed an opioid pain reliever for noncancer pain for at least 3 consecutive months at San Francisco clinics in 2017-2018. The researchers used continuation-ratio models to assess associations between opioid discontinuation or a 30% dose change and subsequent frequency of heroin and nonprescribed opioid use. These models accounted for demographics, clinical and behavioral traits, and past use of heroin or nonprescribed opioids.
Compared with HIV-negative people, those with HIV were younger (median 50 versus 54 years, P < 0.001), more often white or Hispanic and less often black (P = 0.063), and more often male (71.4% versus 51.7%) or transgender (8.8% versus 2.4%) (P < 0.001). Average opioid dose was significantly higher in people with HIV in 2014, 2015, and 2016 (P = 0.007, 0.008, and 0.018), although people with HIV reported significantly less pain (average 7.1 versus 7.8 on 0-10 scale, P < 0.001). People with HIV also had significantly fewer sleep problems in the past 3 months (5.8 versus 6.5 on 0-10 scale, P = 0.017).
During follow-up, people with HIV reported using cocaine or methamphetamine significantly more often than people without HIV (51.1% versus 29.1%, P < 0.001) but were less likely to have a controlled substance agreement during follow-up (63.7% versus 83.4%, P < 0.001), have a controlled substance monitoring program check during follow-up (29.1% versus 77.4%, P < 0.001), or have a naloxone prescription during follow-up (31.3% versus 51.9%, P < 0.001).
In the whole study group, compared with people who had no prescribed opioid dose change, those whose prescribed dose increased had two-thirds higher odds of more frequent subsequent heroin use (adjusted odds ratio [aOR] 1.67, 95% confidence interval [CI] 1.32 to 2.12). An increasing dose more than tripled chances of subsequent heroin use in people with HIV (aOR 3.32, 95% CI 2.27 to 4.87) but did not affect chances of later heroin use in the HIV-negative group. Stopping an opioid prescription independently predicted heroin use in the whole study group and in HIV-negative people (aOR 2.05, 95% CI C1.60 to 2.84), but not in the HIV group.
Compared with people who had no change in prescribed opioid dose, decreasing the dose or stopping the prescription independently predicted more frequent subsequent nonprescribed opioid use in HIV-negative people (aOR 1.27 and 2.18) but not in people with HIV.
The Public Health team noted that most HIV-positive people in this study received care at a clinic that did not systematically employ opioid stewardship measures, such as a controlled substance agreement, naloxone prescriptions, or check-ins with a controlled substance monitoring program. In contrast, HIV-negative people went to clinics that usually did employ such measures. This difference, the researchers suggested, may contribute to greater subsequent illicit drug use in the HIV group.
The investigators urge clinicians to "be aware of the risks of both increasing and discontinuing opioid pain relievers" when modifying ongoing management of people taking prescription opioids.
1. Coffin PO, Rowe C, Oman N, et al. Illicit opioid use following changes in opioids prescribed for chronic non-cancer pain among persons living with and without HIV. AIDS 2020: 23rd International AIDS Conference Virtual. July 6-10, 2020. Abstract PEB0347.