Prescription opioid use, misuse, disorders and HIV outcomes

 描述（由申请人提供）：处方阿片类药物（PO）使用、误用、疾病和过量用药急剧增加。这种增长在很大程度上归因于供应商为慢性疼痛开出PO。与HIV-患者相比，HIV+患者的风险特别高，因为他们不成比例地遭受慢性疼痛，PO使用量更大，PO剂量更高，并且经常使用物质和精神健康障碍，这增加了PO滥用的风险。尽管HIV+患者中PO使用和风险较高，但PO使用与HIV结局之间的关系知之甚少。某些类型的PO使用（“PO使用条件”）可能与不良的HIV结局相关，类似于非法药物使用。也有可能一些PO使用条件不是，例如，PO使用而不误用可以改善患者的疼痛，身体功能和HIV护理的保留。很少有研究检查PO使用和HIV结果，此外，尚不清楚患者的心理社会功能、疼痛/残疾和生物医学因素以及提供者因素（例如，阿片类药物处方实践）影响PO使用和HIV结果之间的关系。缺乏证据来指导临床实践或制定指南或有效的干预措施。我们 总体目标是推进必要的证据基础，以指导慢性疼痛的HIV+患者的临床管理。慢性疼痛的HIV+患者中（腰痛、骨关节炎或神经病）在大型城市医疗中心接受治疗时，我们将使用三种不同的结构来检查PO的使用：1）基于疼痛管理框架的有序PO使用条件; 2）PO剂量、误用和成瘾的连续PO使用条件;（3）PO使用的类型学，我们将通过PO使用特征的潜在类别分析来识别PO使用。具体目标是：1）描述慢性疼痛HIV+患者队列中PO使用的特征; 2）检查PO使用条件与HIV结局之间的关联; 3）使用结构方程模型检查患者和提供者因素在PO使用条件与HIV结局之间的关系中的作用。我们假设：a）顺序PO使用量表上的较高值将与不良HIV结局相关; B）连续PO使用条件下的较高值（PO剂量，阿片类药物滥用和成瘾）将与不良的HIV结局相关; c）PO使用的不同类型与HIV结局的相关性不同;以及d）患者和提供者因素影响PO使用条件、HIV结果以及PO使用条件与HIV结果之间的关系。采用纵向队列设计，随访12个月，我们将在250名患有慢性疼痛的HIV+患者中进行访谈，身体功能评估，尿液毒理学测试，HIV病毒载量（VL）测试，并提取病历数据。主要HIV结局是VL;次要结局是CD 4计数、ART使用和依从性以及护理保留。研究结果将大大推进这一新兴和关键的研究领域，提供急需的证据来指导临床实践，并确定干预措施的目标，以改善慢性疼痛的HIV+患者的结局。

 DESCRIPTION (provided by applicant): Prescription opioid (PO) use, misuse, disorders, and overdose have dramatically increased. Much of this increase is attributed to providers prescribing POs for chronic pain. Compared to HIV- patients, HIV+ patients are particularly at risk because they suffer disproportionately from chronic pain, have greater PO use and higher PO dose, and often have substance use and mental health disorders that increase the risk for PO misuse. Despite high PO use and risk among HIV+ patients, little is known about the relationship between PO use and HIV outcomes. It is possible that some types of PO use ("PO use conditions") are associated with poor HIV outcomes, similar to illicit drug use. It is also possible that some PO use conditions are not, for example, PO use without misuse could improve patients' pain, physical function, and retention in HIV care. Very few studies have examined PO use and HIV outcomes, and further, it is unknown how patients' psychosocial functioning, pain/disability, and biomedical factors, as well as provider factors (e.g., opioid prescribing practices) influence the relationships between PO use and HIV outcomes. A lack of evidence exists to guide clinical practice or to develop guidelines or effective interventions. Our overarching goal is to advance the evidence base necessary to guide clinical management of HIV+ patients with chronic pain. Among HIV+ patients with chronic pain (low back pain, osteoarthritis, or neuropathy) receiving care in a large urban medical center, we will examine PO use using three distinct constructs: 1) an ordinal PO use condition based on a pain management framework; 2) continuous PO use conditions of PO dose, misuse, and addiction; and 3) typologies of PO use which we will identify using latent class analysis of PO use characteristics. The specific aims are: 1) to characterize PO use in a cohort of HIV+ patients with chronic pain; 2) to examine the association between PO use conditions and HIV outcomes; and 3) to examine the roles of patient and provider factors in the relationship between PO use conditions and HIV outcomes using structural equation modeling. We hypothesize that: a) a higher value on the ordinal PO use scale will be associated with poor HIV outcomes; b) higher values in the continuous PO use conditions (PO dose, opioid misuse, and addiction) will be associated with poor HIV outcomes; c) distinct typologies of PO use will differ in their association with HIV outcomes; and d) patient and provider factors influence PO use conditions, HIV outcomes, and the relationship between PO use conditions and HIV outcomes. Using a longitudinal cohort design with 12-month follow-up, we will conduct interviews, physical function assessments, urine toxicology tests, HIV viral load (VL) tests, and extract medical record data among 250 HIV+ patients with chronic pain. The primary HIV outcome is VL; secondary outcomes are CD4 count, ART utilization and adherence, and retention in care. Study findings will substantially advance this nascent and critical area of research, provide much needed evidence to guide clinical practice, and identify targets for interventions to improve outcomes in HIV+ patients with chronic pain.