High prevalence of high-risk opioid prescribing among HIV-positive adults in the US

There is a high prevalence of prescription opioid use among HIV-positive people, with many individuals having prescribing patterns associated with a high risk of dependence, investigators from the United States report in the Journal of Acquired Immune Deficiency Syndromes. Approximately 40% of people living with HIV received an opioid prescription, with high-risk use occurring in a third of these individuals. A history of injecting drug use and chronic pain were both among the risk factors for high-risk prescribing.

“High-risk opioid use was common…with 30% of patients exhibiting at least one of the four high-risk outcomes,” comment the authors. “Of note, approximately half the total cumulative incidence of high-risk use occurred within the first year after a patient received an incident opioid prescription. The first year of opioid use likely represents a critical period, as addiction and development of opioid disorders often occur early in treatment.”

The past two decades have witnessed a dramatic increase in use and misuse of prescription opioids in the United States, Canada, Australia and New Zealand. Opioid painkiller use and misuse is much less frequent in Europe, partly due to tighter regulation but also because heroin is cheaper and more freely available, according to the European Monitoring Centre for Drugs and Drug Addiction.


person years

In a study “100 person years of follow-up” could mean that information was collected on 100 people for one year, or on 50 people for two years each, or on ten people over ten years. In practice, each person’s duration of follow-up is likely to be different.


Short for people living with HIV.

virological suppression

Halting of the function or replication of a virus. In HIV, optimal viral suppression is measured as the reduction of viral load (HIV RNA) to undetectable levels and is the goal of antiretroviral therapy.

exclusion criteria

Defines who cannot take part in a research study. Eligibility criteria may include disease type and stage, other medical conditions, previous treatment history, age, and gender. For example, many trials exclude women who are pregnant, to avoid any possible danger to a baby, or people who are taking a drug that might interact with the treatment being studied.

opioid substitution therapy (OST)

Providing users of an illegal drug (such as heroin) with a replacement drug (such as methadone, buprenorphine or naltrexone) under medical supervision. This helps the person reduce the frequency of injections and their dependency on illegal drugs. It is part of a harm reduction approach.



The most commonly prescribed opioid products are oxycodone and hydrocodone. Over-prescription of these products, coupled with opportunities within the US health system to obtain multiple prescriptions, has led to dependence and abuse.

People with HIV often have conditions that warrant the use of opioids – such as chronic pain – but little is known about patterns of opioid prescribing in this population. The investigators undertook the study to better characterise patterns of opioid prescribing among HIV-positive adults.

Researchers examined the medical and prescribing records of 4605 HIV-positive adults who received care between 2006 and 2010 at four urban treatment centres. Data were gathered on the overall prevalence of opioid prescribing and four types of prescribing associated with a high risk of dependence: high daily dose; overlapping prescriptions; multiple prescribers (three different prescribers within 90 days); and early prescription refills.The study excluded prescriptions for opioid substitution therapy with methadone or buprenorphine.

Approximately two-thirds of the study participants were male, 62% were African American and 31% had a history of injecting drug use. The median age was 45 years.

During the four years of the study, 39% of people received an opioid prescription, these individuals receiving a median of two prescriptions per year. The most commonly prescribed opioid was short-acting oxycodone.

Just under a third of people receiving an opioid prescription met at least one of the criteria for high-risk use. A fifth had multiple prescribers (incidence rate [IR] = 10.4 per 100 person-years); 16% had overlapping prescriptions (IR = 8.1 per 100 person-years); 16% received early refills (IR = 7.9 per 100 person-years) and 8% had a high daily dose (IR = 3.6 per 100 person-years).

Incidence of any high-risk opioid prescribing was 17.4 events per 100 person-years. Approximately half the high-risk use occurred within a year of opioids first being prescribed, the investigators suggesting this is a critical time for intervention to prevent the development of dependence.

Risk factors for high-risk opioid use were injecting drug use (aHR = 1.39; 95% CI, 1.11-1.74) compared to other HIV risk groups, age 35-45 years (aHR = 1.94, 95% CI, 1.33-2.80) and 45-55 years (aHR = 1.84, 95% CI, 1.27-2.67) versus other age groups, white ethnicity (aHR = 1.61; 95% CI, 1.21-2.14) and a chronic pain diagnosis (aHR = 1.32; 95% CI, 1.03-1.70).

Baseline factors associated with a lower risk of high-risk prescribing patterns included viral suppression (aHR = 0.91; 95% CI, 0.73-1.13) and antiretroviral therapy (aHR = 0.83; 95% CI, 0.67-1.02).

“This study extends existing knowledge about characteristics associated with high-risk opioid use to PLWH [people living with HIV] and expands on prior studies examining utilization patterns indicative of opioid misuse,” conclude the authors. “Our results can be used to help identify patients who may benefit most from additional opioid screening and counseling.”


Cana CE et al. High-risk prescription opioid use among people living with HIV. J Acquir Immune Defic Syndr, online edition. DOI: 10.1097/QAI.0000000000001690 (2018).