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Opioid prescribing among HIV-infected and uninfected patients
S82
The Journal of Pain
(424) Opioid prescribing among HIV-infected and uninfected patients K Gordon, E Edelman, M Skanderson, J Gaither, J Goulet, W Becker, A Gordon, J Brennan Braden, R Kerns, A Justice, and D Fiellin; West Haven VA, West Haven, CT As patients with HIV live longer, pain conditions increasingly impact their quality of life. We sought to characterize opioid prescribing in HIV-infected individuals and determine whether opioid prescribing varied by HIV status. We used the Veterans Aging Cohort Study - Virtual Cohort, with HIV-infected (n=23,651) and age/race/ethnicity/site-matched uninfected (n=55,097) U.S. Veterans in care during fiscal year 2006 to assess the relationship between HIV status and being prescribed any opioids, high doses of opioids (at least 120 mg morphine equivalents daily) and long term opioids (at least 90 days supplied). Models were adjusted for patient characteristics, including pain diagnoses (none, acute, chronic), mental health and substance use disorders. Opioids were prescribed in 30.9% of HIV-infected and 27.6% of uninfected patients (p<.0001), with 6.1% vs. 4.9% (p<.0001) receiving high doses and 37.7% vs. 42.4% (p<.0001) receiving long term opioids, respectively. Among patients prescribed opioids, HIV-infected patients were more likely to have no pain diagnosis recorded (39.3% vs. 26.2%), more likely to have an acute pain diagnosis (7.5% vs. 4.4%), and less likely to have a chronic pain diagnosis (53.2% vs. 69.4%) compared to uninfected patients (p<.0001). Among patients prescribed opioids, HIV-infected patients consistently had more comorbid mental health and substance use disorders, including depression (8.7% vs. 7.6%, p<.0001), alcohol (13.0% vs. 11.2%, p<.0001) and drug use disorders (17.3% vs. 10.4%, p<.0001) than uninfected patients. Only PTSD (8.5% vs. 15.2%, p<.0001) was less common in HIV-infected patients. HIV status was associated with any prescribed opioids in both unadjusted (OR 1.17, 95% CI 1.13, 1.21) and adjusted (OR 1.40, 95% CI 1.35, 1.46) models. Given that HIV-infected patients prescribed opioids have high rates of comorbid disease, such as mental health and substance use disorders, but are less likely to have a documented pain diagnosis, efforts to promote guideline-consistent care are needed.
Abstracts (426) Sleep and depression assessment in patients with nonmalignant chronic pain with extended release hydromorphone treatment n, I Vazquez Naville, L Perez Garcia, S Hernandez Gonzalez, R Calvo Falco M Perez Mendez, I Cabrera Diaz, A Sancho De Avila, and J Arranz Duran; ~ora de Candelaria, Santa Cruz de Tenerife, University Hospital Nuestra Sen Tenerife, Spain Chronic benign pain has been correlated with sleep disorders and depression. The objective of this study is to describe the relationship between sleep disorders, doses of OROS hydromorphone and depression symptoms in the management of patients with non malignant severe chronic pain. A descriptive retrospective study of 32 patients. Pittsburgh Sleep Quality Index (PSQI), Beck depression questionnaire (DBI) and VAS before and 1 month after inclusion in the treatment with OROS hydromorphome was accomplished through medical record review. Patients were divided into 2 groups: moderate to severe depression (19-63 points) and mild depression (<19 points). There were 6 dropouts due to adverse effects. The remaining 26 patients started from a baseline VAS of 7.9 6 1.3 to 2.1 6 1.7 after a month of treatment. The mean daily dose of hydromorphone in relation with the degree of depression after a month of treatment showed a high correlation coefficient of 0.74. Sleep disorders were significantly decreased in both groups 14.6 6 4.7 vs. 6.7 6 3.6, without significant correlation with the degree of depression. Regarding the PSQI score: 21 (80.76 %) patients obtained scores > 5 (poor sleep quality) of which only 6 subjectively rated it as poor or very poor. Opioids produce impaired sleep quality, by disruption of its architecture. However, in our sample, patients rested more and better. We observed that subjective perception of sleep assessment was much better than scores obtained with more objective questionnaires, as the PSQI. Relationship between sleep disorders and severity of mood disorders associated with it wasn’t observed. These results suggest that it is important to actively investigate through questionnaires as subjective as possible, sleep disorders, presence of depression and chronic pain, as well as changes in them with the opioids. In our sample OROS hydromorphone improved pain degree, mood disturbances and sleep disorders.
(425) Attitudes and beliefs associated with opioid use – differences among working and work disabled chronic noncancer pain patients not known to misuse or abuse
(427) Understanding adherence to prescribed opioids in sickle cell disease: a qualitative study
H Wilson, M Skinner, J Robinson, and D Turk; University of Washington, Seattle, WA
Opioid nonadherence may be a frequent problem in acute and chronic pain conditions but little has been published about patterns of opioid adherence. We studied opioid adherence for sickle cell disease (SCD) pain, both over time and at particular times in adults with SCD, to identify patterns of opioid use, and to describe attitudes, beliefs, and contextual factors related to opioid adherence and patterns of opioid use. Semi-structured, qualitative interviews were conducted with a purposive sample of SCD outpatients. The final sample consisted of 6 adults: 3 women and 3 men, who were currently receiving an opioid prescription. The mean age of the sample was 36 years (range 28–57), and all participants were African American and well educated (had at least some college). Participants were prescribed a wide range of opioids. Descriptive review of transcripts revealed that SCD patients exhibited various use patterns including overuse, underuse, and arbitrary use (both underuse and overuse). Patients used opioids differently based on the time of day, and also based on the context or location of participants at time of dose. Several biopsychosocial factors hindered or motivated opioid use: severe pain intensity, side effects, stress, family gatherings, unplanned meetings, church attendance, and anticipatory fear of pain. In summary, findings of this qualitative study raise hypotheses that in SCD, various patterns of use of prescribed opioids occur, and these patterns may be associated with various attitudes, beliefs, and contextual factors. Recognizing and quantifying such patterns and associations may help clinicians find solutions for improving opioid adherence, and may better identify patients at risk for inappropriate opioid use.
Despite patient convictions regarding the benefits of long-term opioid therapy (LOT), there is question about the magnitude and duration of the effects of opioids for pain management in chronic non-cancer pain (CNCP). Patients often report significant benefit and desire to continue LOT even when amount of pain reduction and functional improvement are not apparent. The present study evaluated patients’ beliefs about benefits and adverse effects attributed to opioids. Although issues related to LOT have generated a great deal of negative attention, a majority of research has been devoted to understanding the minority of CNCP patients that abuse and/or misuse opioids. This study was designed to learn about perceptions and responses of patients who are not known to be abusers or misusers. CNCP patients (N=88) prescribed and not misusing LOT were divided into ‘‘working’’ (WRK; n=29) and ‘‘work disabled’’ (WRK-D; n=53) groups, and were asked to answer a set of demographic questions, in addition to a series of questions aimed at assessing their beliefs, practices, and patterns of opioid use. Overall, patients’ responses indicated that they perceive the medications as reducing and giving them control over their pain allowing them to function better, and believe that pain would become overwhelming if they did not take opioids. Patients’ perceptions seem inconsistent with their reports of continued high pain (WRK=4.91+/-1.4, WRKD=5.62+/-1.8) and functional limitations (WRK BPI Interference=5.8+/-1.9; WRK-D BPI Interference=6.05+/-1.89). Pain duration (WRK=22+/-16.6, WRKD=18.9+/-12.3) and average pain (WRK=4.91+/-1.4, WRK-D=5.62+/-1.8) were not significantly different between WRK and WRK-D groups. Logistic regression revealed the most sensitive predictors of work status were perceived pain interference (b=-.53, p<.01) and catastrophizing (b=-.98, p<.01) contribute significantly to work status (total R2 = 26.72%). Results suggest that reductions in pain may not be sufficient to promote return to work without addressing patient perceptions of abilities and reductions in catastrophic thoughts.
A Alsalman and W Smith; Virginia Commonwealth University, Richmond, VA
The Journal of Pain
(424) Opioid prescribing among HIV-infected and uninfected patients K Gordon, E Edelman, M Skanderson, J Gaither, J Goulet, W Becker, A Gordon, J Brennan Braden, R Kerns, A Justice, and D Fiellin; West Haven VA, West Haven, CT As patients with HIV live longer, pain conditions increasingly impact their quality of life. We sought to characterize opioid prescribing in HIV-infected individuals and determine whether opioid prescribing varied by HIV status. We used the Veterans Aging Cohort Study - Virtual Cohort, with HIV-infected (n=23,651) and age/race/ethnicity/site-matched uninfected (n=55,097) U.S. Veterans in care during fiscal year 2006 to assess the relationship between HIV status and being prescribed any opioids, high doses of opioids (at least 120 mg morphine equivalents daily) and long term opioids (at least 90 days supplied). Models were adjusted for patient characteristics, including pain diagnoses (none, acute, chronic), mental health and substance use disorders. Opioids were prescribed in 30.9% of HIV-infected and 27.6% of uninfected patients (p<.0001), with 6.1% vs. 4.9% (p<.0001) receiving high doses and 37.7% vs. 42.4% (p<.0001) receiving long term opioids, respectively. Among patients prescribed opioids, HIV-infected patients were more likely to have no pain diagnosis recorded (39.3% vs. 26.2%), more likely to have an acute pain diagnosis (7.5% vs. 4.4%), and less likely to have a chronic pain diagnosis (53.2% vs. 69.4%) compared to uninfected patients (p<.0001). Among patients prescribed opioids, HIV-infected patients consistently had more comorbid mental health and substance use disorders, including depression (8.7% vs. 7.6%, p<.0001), alcohol (13.0% vs. 11.2%, p<.0001) and drug use disorders (17.3% vs. 10.4%, p<.0001) than uninfected patients. Only PTSD (8.5% vs. 15.2%, p<.0001) was less common in HIV-infected patients. HIV status was associated with any prescribed opioids in both unadjusted (OR 1.17, 95% CI 1.13, 1.21) and adjusted (OR 1.40, 95% CI 1.35, 1.46) models. Given that HIV-infected patients prescribed opioids have high rates of comorbid disease, such as mental health and substance use disorders, but are less likely to have a documented pain diagnosis, efforts to promote guideline-consistent care are needed.
Abstracts (426) Sleep and depression assessment in patients with nonmalignant chronic pain with extended release hydromorphone treatment n, I Vazquez Naville, L Perez Garcia, S Hernandez Gonzalez, R Calvo Falco M Perez Mendez, I Cabrera Diaz, A Sancho De Avila, and J Arranz Duran; ~ora de Candelaria, Santa Cruz de Tenerife, University Hospital Nuestra Sen Tenerife, Spain Chronic benign pain has been correlated with sleep disorders and depression. The objective of this study is to describe the relationship between sleep disorders, doses of OROS hydromorphone and depression symptoms in the management of patients with non malignant severe chronic pain. A descriptive retrospective study of 32 patients. Pittsburgh Sleep Quality Index (PSQI), Beck depression questionnaire (DBI) and VAS before and 1 month after inclusion in the treatment with OROS hydromorphome was accomplished through medical record review. Patients were divided into 2 groups: moderate to severe depression (19-63 points) and mild depression (<19 points). There were 6 dropouts due to adverse effects. The remaining 26 patients started from a baseline VAS of 7.9 6 1.3 to 2.1 6 1.7 after a month of treatment. The mean daily dose of hydromorphone in relation with the degree of depression after a month of treatment showed a high correlation coefficient of 0.74. Sleep disorders were significantly decreased in both groups 14.6 6 4.7 vs. 6.7 6 3.6, without significant correlation with the degree of depression. Regarding the PSQI score: 21 (80.76 %) patients obtained scores > 5 (poor sleep quality) of which only 6 subjectively rated it as poor or very poor. Opioids produce impaired sleep quality, by disruption of its architecture. However, in our sample, patients rested more and better. We observed that subjective perception of sleep assessment was much better than scores obtained with more objective questionnaires, as the PSQI. Relationship between sleep disorders and severity of mood disorders associated with it wasn’t observed. These results suggest that it is important to actively investigate through questionnaires as subjective as possible, sleep disorders, presence of depression and chronic pain, as well as changes in them with the opioids. In our sample OROS hydromorphone improved pain degree, mood disturbances and sleep disorders.
(425) Attitudes and beliefs associated with opioid use – differences among working and work disabled chronic noncancer pain patients not known to misuse or abuse
(427) Understanding adherence to prescribed opioids in sickle cell disease: a qualitative study
H Wilson, M Skinner, J Robinson, and D Turk; University of Washington, Seattle, WA
Opioid nonadherence may be a frequent problem in acute and chronic pain conditions but little has been published about patterns of opioid adherence. We studied opioid adherence for sickle cell disease (SCD) pain, both over time and at particular times in adults with SCD, to identify patterns of opioid use, and to describe attitudes, beliefs, and contextual factors related to opioid adherence and patterns of opioid use. Semi-structured, qualitative interviews were conducted with a purposive sample of SCD outpatients. The final sample consisted of 6 adults: 3 women and 3 men, who were currently receiving an opioid prescription. The mean age of the sample was 36 years (range 28–57), and all participants were African American and well educated (had at least some college). Participants were prescribed a wide range of opioids. Descriptive review of transcripts revealed that SCD patients exhibited various use patterns including overuse, underuse, and arbitrary use (both underuse and overuse). Patients used opioids differently based on the time of day, and also based on the context or location of participants at time of dose. Several biopsychosocial factors hindered or motivated opioid use: severe pain intensity, side effects, stress, family gatherings, unplanned meetings, church attendance, and anticipatory fear of pain. In summary, findings of this qualitative study raise hypotheses that in SCD, various patterns of use of prescribed opioids occur, and these patterns may be associated with various attitudes, beliefs, and contextual factors. Recognizing and quantifying such patterns and associations may help clinicians find solutions for improving opioid adherence, and may better identify patients at risk for inappropriate opioid use.
Despite patient convictions regarding the benefits of long-term opioid therapy (LOT), there is question about the magnitude and duration of the effects of opioids for pain management in chronic non-cancer pain (CNCP). Patients often report significant benefit and desire to continue LOT even when amount of pain reduction and functional improvement are not apparent. The present study evaluated patients’ beliefs about benefits and adverse effects attributed to opioids. Although issues related to LOT have generated a great deal of negative attention, a majority of research has been devoted to understanding the minority of CNCP patients that abuse and/or misuse opioids. This study was designed to learn about perceptions and responses of patients who are not known to be abusers or misusers. CNCP patients (N=88) prescribed and not misusing LOT were divided into ‘‘working’’ (WRK; n=29) and ‘‘work disabled’’ (WRK-D; n=53) groups, and were asked to answer a set of demographic questions, in addition to a series of questions aimed at assessing their beliefs, practices, and patterns of opioid use. Overall, patients’ responses indicated that they perceive the medications as reducing and giving them control over their pain allowing them to function better, and believe that pain would become overwhelming if they did not take opioids. Patients’ perceptions seem inconsistent with their reports of continued high pain (WRK=4.91+/-1.4, WRKD=5.62+/-1.8) and functional limitations (WRK BPI Interference=5.8+/-1.9; WRK-D BPI Interference=6.05+/-1.89). Pain duration (WRK=22+/-16.6, WRKD=18.9+/-12.3) and average pain (WRK=4.91+/-1.4, WRK-D=5.62+/-1.8) were not significantly different between WRK and WRK-D groups. Logistic regression revealed the most sensitive predictors of work status were perceived pain interference (b=-.53, p<.01) and catastrophizing (b=-.98, p<.01) contribute significantly to work status (total R2 = 26.72%). Results suggest that reductions in pain may not be sufficient to promote return to work without addressing patient perceptions of abilities and reductions in catastrophic thoughts.
A Alsalman and W Smith; Virginia Commonwealth University, Richmond, VA