Study: Rate of Opioid-Related Deaths Increasing in Patients With HIV

Concomitant HIV infection and opioid use is common throughout the United States.^1-4 Patients with HIV are more likely to have chronic pain, be prescribed opioid therapy, and receive higher doses of opioids.¹ While not every patient who is prescribed opioids becomes addicted, these characteristics increase the likelihood of opioid use disorder (OUD) and the potential for opioid-related death among this patient population.

OUD has a negative impact on HIV care, adherence and outcomes, and is cited as a potential risk for increased transmission.² It also appears that OUD may be a notable risk factor for mortality in HIV patients.

A study presented at the 2019 Conference on Retroviruses and Opportunistic Infections (CROI) revealed data that, while the overall number of deaths in patients with HIV in the United States is declining, the number of number of opioid overdose deaths in HIV patients is on the rise.³ Using data from the National HIV Surveillance System, the retrospective study showed a 12.7% decline [1630.6 vs. 1,868.8 per 100,000] in overall deaths in HIV patients from 2011 to 2015. In that same period, the amount of opioid-related deaths in patients with HIV rose by 47% [33.1 vs. 23.2 per 100,000].

The highest rate of deaths occurred in injection drug users [137.4/100,000], Caucasians [49.1/100,000], patients aged 50-59 years [41.9/100,000] and women [35.2/100,000]. However, the increase of opioid deaths was consistent across all ages, genders, ethnicities, and transmission categories. Several demographics saw increases in opioid-related deaths in excess of 50%. These include injectable drug users (80%), heterosexual transmission (74%), and African Americans (74%). Though patients in the fifth decade had the highest consistent overall rates of opioid deaths, the sharpest increases in mortality were seen in patients over the age of 60 years (202%), those 20-29 years (113%), and those 40-49 years (51%).

The West US Census region was the only geographic location in the US where an increase in opioid-related deaths was not seen (2% decline). In contrast, large increases were seen in the South (65%), the Northeast (59%), the Midwest (32%).The authors concluded that prevention efforts could specifically focus or target those groups with the highest overall rates or greatest increases in opioid-related deaths.

While this study suggests where prevention efforts can be focused, by whom prevention should be provided remains unclear. It is not uncommon for HIV patients to be prescribed opioids by the same clinician treating their HIV.^2,4-5 Several recent studies have highlighted the integration of HIV and OUD care.^2,4-5 While integration does increase antiviral receipt and patient satisfaction, it has not yet shown to improve HIV outcomes.⁵ Furthermore, the recommended and necessary vigilance for opioid prescribing may not always occur in this setting.

In a study published in AIDS and Behavior, HIV physicians acknowledged feeling undertrained in chronic pain management and opioid prescribing.² They also expressed hesitation for creating situations that might hamper the provider-patient relationship essential to optimal HIV-related outcomes or introducing the stress that opioid deprescribing could cause the patient. Subsequently, the task of monitoring patients on opioids often falls to other health care providers. Still, the recognition and treatment of OUD is vital for any patient population; HIV patients in particular may experience benefits beyond sobriety.

The treatment of OUD has been shown to reduce HIV transmission, increase antiviral adherence, improve viral suppression, and decrease mortality.⁶ One meta-analysis revealed that providing medications for OUD reduced HIV transmissions by 54%.⁶

Selecting an agent can be cumbersome. Of the available options, buprenorphine appears to be the best suited for HIV patients in terms of minimal pertinent drug-interactions and easier administration burden. In addition to traditional oral routes, it come as a monthly injection or 6-month implant which can be administered in the clinic.⁶ Methadone metabolism is highly dependent on cytochrome P450 (CYP) enzymes which are known to be induced by several antivirals. Subsequently, HIV patients may require higher methadone doses for effective treatment.⁶ Logistic and dosing barriers can be proactively addressed if appropriately identified. Inclusion of and input from a pharmacist could positively affect these treatment decisions.

The opioid epidemic has raged in almost every demographic and segment of society in the US. This new data indicating that opioid overdoses in HIV patients are threatening to circumvent the enormous strides in HIV treatment and mortality over several decades must be addressed.

Identification and treatment of HIV patients with OUD can help mitigate the rising mortality rates while subsequently improving overall HIV care and outcomes. However, successful treatment for many HIV patients will require a collaborative, interprofessional approach.

References

• Cunningham CO. Opioids and HIV infection: from pain management to addiction treatment. Top Antivir Med. 2018;25:143-146
• Carrol JJ, Colasanti J, Lira MC et al. HIV Physicians and chronic opioid therapy: it’s time to raise the bar. AIDS Behav. 2018. Doi: doi: 10.1007/s10461-018-2356-2. [Epub ahead of print]
• Bosh KA, Crepaz N, Dong X et al. Opioid overdose deaths among persons with HIV Infection, United States, 2011-2015. [Abstract number 147]. Abstract presented at the 2019 Conference on Retroviruses and Opportunistic Infections; March 7, 2019; Seattle, Washington
• Oldfield BJ, Munoz, N, Boshnack N, et al. “No more falling through the cracks”: A qualitative study to inform measurement of integration of care of HIV and opioid use disorder. J Subst Abuse Treat. 2019;97:28-40
• Oldfield BJ, Munoz N, Mcgovern MP, et al. Integration of care for HIV and opioid use disorder: a systematic review of interventions in clinical and community-based settings. AIDS. 2018.doi: 10.1097/QAD.0000000000002125. [Epub ahead of print]
• Fanucchi L, Springer SA, Korthuis PT. Medications for the treatment of opioid use disorder among persons living with HIV. Curr HIV/AIDS/ Rep. 2019. doi: 10.1007/s11904-019-00436-7. [Epub ahead of print]