Association Between Diagnoses of Chronic Noncancer Pain, Substance Use Disorder, and HIV-Related Outcomes in People Living With HIV

Abstract

Background: Chronic pain is common in people living with HIV (PLWH). Few studies have evaluated the association between the diagnoses of chronic pain, substance use disorder (SUD), and HIV-related outcomes in clinical settings over a 10-year period.

Methods: Using electronic medical records, the study described psychiatric diagnoses, pain medication, and HIV-related variables in PLWH and examined the factors associated with pain diagnosis and HIV-related outcomes.

Results: Among 3528 PLWH, more than one-third exhibited a chronic pain diagnosis and more than one-third a psychiatric disorder. Chronic pain diagnosis has been associated with SUD and mood and anxiety disorders and occurred before SUD or psychiatric disorders about half of the time. Opioids have been commonly prescribed for pain management, more often than nonopioid analgesic, without any change in prescription pattern over the 10-year period. A dual diagnosis of pain and SUD has been associated with more psychiatric disorders and had a negative impact on the pain management by requesting more health care utilization and higher frequency of both opioid and nonopioid medication prescriptions. Chronic pain and SUD had a negative impact on ART adherence. SUD but not chronic pain has been associated with an unsuppressed HIV viral load.

Conclusions: In the current intertwining opioid prescription and opioid epidemic, opioids are still commonly prescribed in PLWH in HIV care. A diagnosis of chronic pain and/or SUD worsened the HIV-related outcomes, emphasizing the potential risk of the HIV epidemic. These findings called for a better coordinated care program in HIV clinics.

FIGURE 1.

Diagnoses (ICD-9 or ICD-10) encounters for HIV-positive individuals engaged in HIV care at the University of Pennsylvania health system during the 2007–2017 period (n = 3528).

FIGURE 2.

Change in noncancer chronic pain diagnosis and prescribed medications for pain management by year of pain diagnosis (2007–2017). Prescription opioids included medications that content opiates, morphine, codeine, and buprenorphine excluding methadone, buprenorphine, and buprenorphine/naloxone prescribed for opiate use disorder purposes. NSAID included aspirin, diclofenac, ibuprofen, fenoprofen, flurbiprofen, ketoprofen, meloxicam, and naproxen. Muscle relaxant included diazepam, carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine, and tizanidine. Antidepressant included SNRI (venlafaxine, duloxetine, and milnacipran), SSRI (paroxetine, fluoxetine, and sertraline), and tricyclic (amitriptyline, imipramine, clomipramine, doxepin, nortriptyline, and desipramine). Antianxiety agents included clonazepam, lorazepam, and alprazolam. Antipsychotic agents included olanzapine and quetiapine. Rx for pain, number of individuals who received a prescription of at least one of these above medications. SNRI, Serotonine Norepinephrine Reuptake Inhibitor; SSRI, Selective Serotonine Reuptake Inhibitor.