A qualitative exploration of chronic pain and opioid treatment among HIV patients with drug use disorders

Sarina R. Isenberg, MA; Allysha C. Maragh-Bass, MPH, PhD; Kathleen Ridgeway, MSPH; Mary Catherine Beach, MD, MPH; Amy R. Knowlton, MPH, ScD

doi:10.5055/jom.2017.0363

Authors

Sarina R. Isenberg, MA
Allysha C. Maragh-Bass, MPH, PhD
Kathleen Ridgeway, MSPH
Mary Catherine Beach, MD, MPH
Amy R. Knowlton, MPH, ScD

DOI:

https://doi.org/10.5055/jom.2017.0363

Keywords:

chronic pain management, HIV/AIDS, patient-provider communication/conflict, patient engagement in healthcare, drug/substance abuse, palliative care

Abstract

Objective: The study explored high-risk participants' experiences with pain management regarding clinical access to and use of prescription opioids.

Design: Qualitative semistructured interviews and focus groups.

Setting: Data were collected August 2014 to May 2015 at an urban community-based research facility in Baltimore City, MD.

Participants: HIV participants with chronic pain and a history of illicit drug use.

Methods: Qualitative coding and analysis used an iterative, inductive, and thematic approach and coders achieved inter-coder consistency.

Results: The authors identified two major themes. First, participants had positive and negative interactions with healthcare providers regarding chronic pain treatment. Participants perceived that providers lacked empathy for their pain and/or were not adequately managing their pain. These interactions resulted in participants seeking new providers or mistrusting the medical system. Further, providers’ surveillance of participants’ pain treatment regimen contributed to distress surrounding pain management. The second theme centered on participants’ pain management experiences with prescribed opioid analgesics. Participants felt they were receiving dosages and classes of analgesics that did not sufficiently address their pain, and consequently modified their dosages or rationed prescription opioids. Other participants were reluctant to take analgesics due to their history of illicit drug use. Some participants relapsed to illicit drug use when they felt their prescription opioids did not adequately address their pain needs.

Conclusions: Participant struggles with receiving and managing prescribed opioid analgesics suggest a need for: therapies beyond these medications; guidelines for providers specific to this population; and harm reduction trainings for providers.

Author Biographies

Sarina R. Isenberg, MA

Doctoral Candidate, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

Allysha C. Maragh-Bass, MPH, PhD

Doctoral Candidate, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

Kathleen Ridgeway, MSPH

Graduate of the MSPH program, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

Mary Catherine Beach, MD, MPH

Professor of Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland

Amy R. Knowlton, MPH, ScD

Associate Professor, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

References

Merlin JS, Westfall AO, Chamot E, et al.: Pain is independently associated with impaired physical function in HIV-infected patients. Pain Med. 2013; 14: 1985-1993.

Merlin JS, Cen L, Praestgaard A, et al.: Pain and physical and psychological symptoms in ambulatory HIV patients in the current treatment era. J Pain Symptom Manage. 2012; 43: 638-645.

Miaskowski C, Penko JM, Guzman D, et al.: Occurrence and characteristics of chronic pain in a community-based cohort of indigent adults living with HIV infection. J Pain. 2011; 12: 1004-1016.

Merlin JS, Westfall AO, Raper JL, et al.: Pain, mood, and substance abuse in HIV: Implications for clinic visit utilization, antiretroviral therapy adherence, and virologic failure. J Acquir Immune Defic Syndr. 2012; 61: 164-170.

Merlin J, Zinski A, Norton W, et al.: A conceptual framework for understanding chronic pain in patients with HIV. Pain Pract. 2014; 14: 207-216.

Surratt HL, Kurtz SP, Levi-Minzi MA, et al.: Pain treatment and antiretroviral medication adherence among vulnerable HIV-positive patients. AIDS Patient Care STDS. 2015; 29(4): 186-192.

Lucey BP, Clifford DB, Creighton J, et al.: Relationship of depression and catastrophizing to pain, disability, and medication adherence in patients with HIV-associated sensory neuropathy. AIDS Care. 2011; 23(8): 921-928.

Malvar J, Vaida F, Sanders CF, et al.: Predictors of new onset distal neuropathic pain in HIV-infected individuals in the era of combination antiretroviral therapy. Pain. 2015; 156(4): 731-739.

Evans SR, Ellis RJ, Chen H, et al.: Peripheral neuropathy in HIV: Prevalence and risk factors. AIDS. 2011; 25(7): 919-928.

Chen H, Clifford DB, Deng L, et al.: Peripheral neuropathy in ART-experienced patients: Prevalence and risk factors. J Neurovirol. 2013; 19(6): 557-564.

Stavros K, Simpson DM: Understanding the etiology and management of HIV-associated peripheral neuropathy. Curr HIV/AIDS Rep. 2014; 11(3): 195-201.

Cherry C, Wadley A, Kamerman P: Diagnosing and treating HIV-associated sensory neuropathy: A global perspective. Pain Manage. 2016; 6(2): 191-199.

Finnerup NB, Attal N, Haroutounian S, et al.: Pharmacotherapy for neuropathic pain in adults: A systematic review and meta-analysis. Lancet Neurol. 2015; 14(2): 162-173.

Phillips TJ, Cherry CL, Cox S, et al.: Pharmacological treatment of painful HIV-associated sensory neuropathy: A systematic review and meta-analysis of randomised controlled trials. PLoS One. 2010; 5(12): e14433.

Schutz S, Robinson-Papp J: HIV-related neuropathy: Current perspectives. HIV AIDS (Auckl). 2013; 5: 243-251.

Roter D, Hall J: Doctors Talking with Patients/Patients Talking with Doctors: Improving Communication in Medical Visits. 2nd ed. Westport, CT: Praegar, 2011.

Dorflinger L, Kerns RD, Auerbach SM: Providers' roles in enhancing patients' adherence to pain self management. Transl Behav Med. 2013; 3(1): 39-46.

Hughes HK, Korthuis PT, Saha S, et al.: A mixed methods study of patient–provider communication about opioid analgesics. Patient Educ Counsel. 2015; 98: 453-461.

Vijayaraghavan M, Penko J, Guzman D, et al.: Primary care providers' judgments of opioid analgesic misuse in a community-based cohort of HIV-infected indigent adults. J Gen Intern Med. 2011; 26: 412-418.

Merlin JS, Walcott M, Ritchie C, et al.: ‘Two Pains Together’: Patient perspectives on psychological aspects of chronic pain while living with HIV. PLoS One. 2014; 9: e111765.

Merlin JS: Pain self-management in HIV-infected individuals with chronic pain: A qualitative study. Pain Med. 2015; 16: 706-714.

St Marie B: Health care experiences when pain and substance use disorder coexist: “Just because i'm an addict doesn't mean i don't have pain.” Pain Med. 2014; 15(12): 2075-2086.

Vlahov D, Anthony JC, Munoz A, et al.: The ALIVE study, a longitudinal study of HIV-1 infection in intravenous drug users: Description of methods and characteristics of participants. NIDA Res Monogr. 1991; 109: 75-100.

Cleeland CS, Ryan KM: Pain assessment: Global use of the Brief Pain Inventory. Ann Acad Med Singapore. 1994; 23(2): 129-138.

Knowlton AR, Mitchell MM, Robinson AC, et al.: Informal HIV caregiver proxy reports of care recipients' treatment adherence: Relationship factors associated with concordance with recipients' viral suppression. AIDS Behav. 2015; 19(11): 2123-2129.

MDoHM: HIV/AIDS in Baltimore City: An Epidemiological Profile. Baltimore, MD: Maryland Infectious Disease and Environmental Health Administration, 2012.

Reuter P, Hsu M, Petronis K, et al: Estimating the Need for Substance Abuse Treatment in Maryland. College Park, MD: Center for Substance Abuse Research, 1998.

Pope C: Qualitative research in health care: Analysing qualitative data. Br Med J. 2000; 320: 114-146.

Bradley EH, Curry LA, Devers KJ: Qualitative data analysis for health services research: Developing taxonomy, themes, and theory. Health Serv Res. 2007; 42: 1758-1772.

Software: ATLAS.ti Qualitative Data Analysis and Research Software for Macs, Version 1.0.29 (110). Berlin, Germany, 2012.

Noble M, Treadwell JR, Tregear SJ, et al: Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev [online]. 2010; CD006605.

Koeppe J, Armon C, Lyda K, et al.: Ongoing pain despite aggressive opioid pain management among persons with HIV. Clin J Pain. 2010; 26(3): 190-198.

Lum PJ, Little S, Botsko M, et al.: Opioid-prescribing practices and provider confidence recognizing opioid analgesic abuse in HIV primary care settings. J Acquir Immune Defic Syndr. 2011; 56(suppl 1): S91-S97.

Krashin D, Merrill J, Trescot A: Opioids in the management of HIV-related pain. Pain Physician. 2012; 15: ES157-ES168.

Korthuis PT, Saha S, Chander G, et al.: Substance use and the quality of patient-provider communication in HIV clinics. AIDS Behav. 2011; 15(4): 832-841.

Institute of Medicine: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academies Press, 2011.

Keltner JR, Vaida F, Ellis RJ, et al.: Health-related quality of life ‘well-being’ in HIV distal neuropathic pain is more strongly associated with depression severity than with pain intensity. Psychosomatics. 2012; 53(4): 380-386.

Williams AC, Eccleston C, Morley S: Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2012; 11: CD007407.

Turk D, Melzack R (eds.): Handbook of Pain Assessment. 3rd ed. New York: Guilford Press, 2010.

Henschke N, Ostelo RW, van Tulder MW, et al.: Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev. 2010; 7: CD002014.

Hilton BA, Thompson R, Moore-Dempsey L, et al.: Harm reduction theories and strategies for control of human immunodeficiency virus: a review of the literature. J Adv Nurs. 2001; 33(3): 357-370.

Swendeman D, Ingram BL, Rotheram-Borus MJ: Common elements in self-management of HIV and other chronic illnesses: An integrative framework. AIDS Care. 2009; 21(10): 1321-1334.

Nicholas PK, Voss JG, Corless IB, et al.: Unhealthy behaviours for self-management of HIV-related peripheral neuropathy. AIDS Care. 2007; 19(10): 1266-1273.

Dowell D, Haegerich TM, Chou R: CDC guideline for prescribing opioids for chronic pain - United States, 2016. MMWR Recomm Rep. 2016; 65(1): 1-49.