The HIV population is aging and approximately 50% of HIV patients report chronic pain. Up to 20% receive prescriptions for chronic opioid therapy, and misuse of these medications is common. There is thus bilateral dissatisfaction with chronic pain treatment: many patients do not report full symptom relief and HIV primary care providers (HIV-PCPs) express concern about opioid misuse. A problematic cycle frequently arises: HIV patients with more severe pain are more likely to misuse opioids, and PCPs' reluctance to prescribe adequate doses of analgesics may lead patients to seek pain relief by such misuse or by use of illicit drugs. Further, this dissatisfaction can lead to poor patient-provider alliance, which is important in HIV treatment and antiretroviral adherence. Despite these concerns, few interventions have been studied to decrease misuse of prescribed opioids; none have been developed specifically for HIV patients. This project will develop a collaborative, brief, behavioral consultation intervention targeting misuse of prescribed opioids in older HIV+ adults. The intervention, CHOACOT (Consultation for HIV+ Older Adults on Chronic Opioid Therapy), will likely consist of: 1) three meetings between the Behavioral Health Consultant (BHC) and the patient, 2) two brief consultations between the BHC and the HIV-PCP, and 3) a joint meeting of the patient, BHC, and HIV-PCP. CHOACOT will be based on the primary care behavioral consultation model and behavior therapy techniques including motivational interviewing and functional assessment. To achieve our aims, we will develop CHOACOT beginning with an iterative open trial (n=10). Next, we will conduct a pilot randomized clinical trial (n=30) of CHOACOT versus enhanced Treatment-As-Usual. Opioid misuse will be the primary outcome variable. Quality of the patient-provider relationship, pain, problematic use of other substances, antiretroviral adherence, and psychosocial functioning will be secondary outcomes.
The specific aims are:
Aim 1. Develop and refine CHOACOT so that it meets standards of feasibility and acceptability for HIV PCPs, BHCs, and participants; 1a. To develop and field test a CHOACOT BHC manual; 1b. To develop a reliable measure of BHC manual adherence; 1c. To develop and field-test BHC training and supervision procedures.
Aim 2. Refine research procedures (e.g., consent and randomization processes, assessment procedures), and establish their feasibility and acceptability to participants while confirming recruitment goal targets. This lineof work could lead to the incorporation into HIV care of a theoretically-driven and empirically- tested brief intervention for older HIV patients who are prescribed opioids for chronic pain and for whom there is concern about opioid misuse.
Up to 20% of HIV patients receives prescriptions for chronic opioid therapy (COT) to treat chronic pain. This project will develop a novel collaborative treatment, based on the primary care behavioral consultation model and behavior therapy techniques including motivational interviewing and functional assessment, in which a patient, a behavioral health consultant and a HIV primary care provider share a unified plan targeting misuse of prescribed opioid analgesics in older HIV+ adults. This would be the first theoretically-driven, empirically- tested intervention that specifically attends to the difficult issues around chronic pain and opioid prescription in HIV clinical practice.
