Prescription opioids are the second most commonly abused substances in the U.S. (after marijuana), and overdose deaths related to prescription opioids now exceed deaths from motor vehicle crashes. Prescription opioid abuse appears to be even more common among HIV-infected patients, presumably a consequence of the known co-morbidity between HIV and substance use. Studies suggest that one-fifth of all HIV-infected patients are prescribed chronic opioid therapy (COT) for pain and that HIV-infected patients are more likely to be prescribed opioids for pain than HIV-uninfected patients. Given the high prevalence of pain (~50%) among HIV-infected patients, pain management is by necessity a major responsibility of physicians treating patients with HIV. However, most physicians and advanced practice providers providing primary care for HIV-infected patients (henceforth referred to as HIV physicians) have little training in the management of chronic pain. Therefore, HIV physicians frequently do not follow existing guidelines for prescribing opioids and report low satisfaction and limited confidence with this important and at times vexing aspect of clinical care. The proposed "Targeting Effective Analgesia in Clinics for HIV" (TEACH) Study will test the effectiveness of a collaborative care intervention directed toward HIV physicians to improve the management of COT and reduce the misuse of prescription opioids among HIV-infected persons. The intervention is composed of the following elements: 1) collaboration with a nurse care manager (NCM);2) physician education and academic detailing;and 3) facilitated access to a specialist in addictions to help manage the most challenging HIV-infected patients on COT. The NCM will utilize an electronic registry to assist physicians in implementing guideline-driven care including opioid treatment agreements, urine drug testing (UDT), random pill counts and checking of online Prescription Monitoring Programs (PMPs). Physicians in the control group will receive information summarizing guidelines for COT but will not have access to the support of the TEACH intervention. This 3-site study will use a cluster randomized trial design, randomized at the level of the physician, and compare primary outcomes over one year.
The Specific Aims are to test the effectiveness of the TEACH collaborative care program to achieve the following:
Aim 1 - Improve HIV physicians'adherence to guidelines for COT compared to standard practice;
Aim 2 - Increase HIV physicians'satisfaction and confidence in prescribing COT;
Aim 3 - Reduce aberrant use of prescription opioids among HIV-infected patients who are on COT;
and Aim 4 - Improve virologic control among HIV-infected patients who are on COT. If effective, implementation of the intervention in HIV clinics will enable physicians in clinical teas to deliver chronic opioid therapy according to established guidelines with more confidence, potentially resulting in less prescription drug abuse and improved HIV outcomes.
This is a novel randomized controlled trial of a chronic disease management intervention to improve the delivery of chronic opioid therapy and reduce prescription opioid misuse among HIV-infected persons. If demonstrated to be effective, this model could be adopted by clinics nationwide, may improve physician satisfaction and confidence with this challenging aspect of patient care, and has the potential to improve the health and well-being of persons with HIV.