Prescription opioid use, misuse, disorders and HIV outcomes

 描述(由申请人提供)：处方阿片类药物(PO)的使用、误用、紊乱和过量显著增加。这一增长在很大程度上归因于提供者为慢性疼痛开了POS处方。与HIV患者相比，HIV+患者尤其危险，因为他们遭受不成比例的慢性疼痛，PO使用量更大，PO剂量更高，而且经常有药物使用和精神健康障碍，这增加了PO滥用的风险。尽管在HIV+患者中PO的使用率和风险很高，但对PO的使用和HIV结局之间的关系知之甚少。可能某些类型的PO使用(“PO使用条件”)与艾滋病毒不良结局有关，类似于非法药物使用。也有可能一些PO的使用条件不是，例如，在不滥用PO的情况下使用PO可以改善患者的疼痛、身体功能和在HIV护理中的滞留。很少有研究研究PO的使用和艾滋病毒的结果，此外，尚不清楚患者的心理社会功能、疼痛/残疾、生物医学因素以及提供者因素(例如阿片类药物处方做法)如何影响PO的使用和艾滋病毒的结果之间的关系。缺乏指导临床实践或制定指南或有效干预措施的证据。我们的 总体目标是推进必要的证据基础，以指导HIV+慢性疼痛患者的临床治疗。在大型城市医疗中心接受护理的HIV+慢性疼痛(下腰痛、骨关节炎或神经病)患者中，我们将使用三个不同的结构来检查PO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；以及3)PO使用的类型，我们将使用PO使用特征的潜在类别分析来确定PO使用类型。具体目标是：1)确定一组HIV+慢性疼痛患者使用PO的特征；2)检验PO使用条件与HIV结局之间的关系；3)使用结构方程模型检验患者和提供者因素在PO使用状况与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较差的HIV结果相关；b)连续PO使用条件(PO剂量、阿片类药物滥用和成瘾)的较高值将与较差的HIV结果相关；c)PO使用的不同类型与HIV结果的关联将不同；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，我们将对250名HIV+慢性疼痛患者进行访谈、身体功能评估、尿毒学测试、HIV病毒载量(VL)测试，并提取病历数据。HIV的主要结果是VL；次要结果是CD4计数、抗逆转录病毒药物的使用和依从性以及在护理中的保留。研究结果将极大地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，并确定干预目标，以改善HIV+慢性疼痛患者的预后。

 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.