High-Risk Prescription Opioid Use Among People Living With HIV

Chelsea E. Canan, PhD, MPH; Geetanjali Chander, MD, MPH; Anne K. Monroe, MD; Kelly A. Gebo, MD, MPH; Richard D. Moore, MD; Allison L. Agwu, MD; G. Caleb Alexander, MD, MS; Bryan Lau, PhD


J Acquir Immune Defic Syndr. 2018;78(3):283-290. 

In This Article

Abstract and Introduction


Background: Prescription opioid use is greater among people living with HIV (PLWH), yet little is known about the prevalence of specific types of high-risk use among these individuals.

Setting: We analyzed clinical and demographic data from the HIV Research Network and prescribing data from Medicaid for noncancer patients seeking HIV treatment at 4 urban clinics between 2006 and 2010.

Methods: HIV Research Network patients were included in the analytic sample if they received at least one incident opioid prescription. We examined 4 measures of high-risk opioid use: (1) high daily dosage; (2) early refills; (3) overlapping prescriptions; and (4) multiple prescribers.

Results: Of 4605 eligible PLWH, 1814 (39.4%) received at least one incident opioid prescription during follow-up. The sample was 61% men and 62% African American with a median age of 44.5 years. High-risk opioid use occurred among 30% of incident opioid users (high daily dosage: 7.9%; early refills: 15.9%; overlapping prescriptions: 16.4%; and multiple prescribers: 19.7%). About half of the cumulative incidence of high-risk use occurred within 1 year of receiving an opioid prescription. After adjusting for study site, high-risk opioid use was greater among patients with injection drug use as an HIV risk factor [adjusted hazard ratio (aHR) = 1.39, 95% confidence interval: 1.11 to 1.74], non-Hispanic whites [aHR = 1.61, (1.21 to 2.14)], patients age 35–45 [aHR = 1.94, (1.33 to 2.80)] and 45–55 [aHR = 1.84, (1.27 to 2.67)], and patients with a diagnosis of chronic pain [aHR = 1.32, (1.03 to 1.70)].

Conclusions: A large proportion of PLWH received opioid prescriptions, and among these opioid recipients, high-risk opioid use was common. High-risk use patterns often occurred within the first year, suggesting this is a critical time for intervention.


Opioid use and opioid misuse have increased dramatically during the past 2 decades.[1–8] Unintentional poisoning, such as drug overdose, is now the leading cause of accidental death in the United States, surpassing motor vehicle accidents as the leading cause of unintentional injury deaths in 2011.[9] Nearly 60% of overdose deaths in the United States involve an opioid,[1] leading to a concerted effort by care providers across the country to carefully monitor the use of prescription opioids.[10,11]

Growing concern surrounding the increase of opioid use disorders has led to attempts to identify precursors to opioid misuse, with the intent of allowing health providers the opportunity to intervene before patients experience adverse consequences. Some such attempts include identifying patterns of high-risk use, such as the use of multiple prescribers and/or pharmacies, receiving overlapping opioid prescriptions, and high daily dosage. These use patterns have been used in both research and clinical settings to identify possible or probable opioid use disorders; although it is not possible to determine opioid misuse based on utilization patterns alone, a large body of evidence suggests that individuals with high-risk use patterns are at increased risk of injury or death.[12–21]

One particularly vulnerable population at risk for morbidity and mortality associated with opioid use is people living with HIV (PLWH). The prevalence of chronic pain is high among PLWH, with prevalence estimates ranging from 25% to 80%.[22–25] In addition, the prevalence of opioid use disorders is higher among PLWH than in the general population.[26–28] In this study, we characterized utilization patterns of high-risk opioid use among PLWH and identified risk factors for high-risk opioid use.