Objective

Pain medicine agreements are frequently recommended for use with high-risk patients on chronic opioid therapy. We assessed how consistently pain medicine agreements were used and whether patients were aware that they had signed a pain medicine agreement in a sample of HIV-infected adults prescribed chronic opioid treatment.

Design

We recruited patients from a longitudinal cohort of community-based HIV-infected adults and recruited the patients' primary care providers (PCPs). The patients completed in-person interviews and PCPs completed mail-based questionnaires about the patients' use of pain medicine agreements. Among patients prescribed chronic opioid therapy, we analyzed the prevalence of pain medicine agreement use, patient factors associated with their use, and agreement between patient and clinician reports of pain agreements.

Results

We had 84 patient-clinician dyads, representing 38 PCPs. A total of 72.8% of patients fit the diagnostic criteria for a lifetime substance use disorder. PCPs reported using pain medicine agreements with 42.9% of patients. Patients with pain medicine agreements were more likely to be smokers (91.7% vs 58.3%; P = 0.001) and had higher mean scores on the Screener and Opioid Assessment for Patients with Pain (µ = 26.0 [standard deviation, SD] = 9.7) vs µ = 19.5 [SD = 9.3]; P = 0.003). Patients reported having a pain medicine agreement with a sensitivity of 61.1% and a specificity of 64.6%.

Conclusions

In a high-risk sample, clinicians were using agreements at a low rate, but were more likely to use them with patients at highest risk of misuse. Patients exhibited low awareness of whether they signed a pain medicine agreement.

We conducted a longitudinal study of a community-based cohort of HIV-infected indigent adults to examine smoking behaviors and factors associated with quitting. We assessed "hardcore" smoking behaviors associated with a low probability of quitting. Of the 296 participants, 218 were current smokers (73.6 %). The prevalence of "hardcore" smoking was high: 59.6 % smoked ≥15 cigarettes per day, and 67.3 % were daily smokers. During the study interval, 20.6 % made at least one quit attempt. Of these, 53.3 % were abstinent at 6 months. The successful quit rate over 2 years was 4.6 %. Illegal substance use (adjusted odds ratio, AOR 0.2, 95 % CI 0.1-0.6) and smoking within 30 min of waking (AOR 0.2, 95 % CI 0.1-0.7) were associated with lower likelihood of making a quit attempt. Interventions that reduce nicotine dependence prior to smoking cessation and those that are integrated with substance use treatment may be effective for this population.

Objective

We examined chronic pain management practices and confidence and satisfaction levels in treating chronic pain among primary care providers (PCPs) who cared for high-risk patients in safety net health settings.

Design

We recruited PCPs (N = 61) through their HIV-infected patients who were enrolled in a longitudinal study on pain, use, and misuse of opioid analgesics (Pain Study). We asked PCPs to complete a questionnaire about all of their patients in their practice on the prevalence of chronic pain and illicit substance use, use of opioid analgesics, confidence and satisfaction levels in treating chronic pain, and likelihood of prescribing opioid analgesics in response to clinical vignettes.

Results

All PCPs cared for at least some patients with chronic pain, and the majority prescribed opioid analgesics for its treatment. All PCPs cared for at least some patients who used illicit substances. PCPs reported low confidence and satisfaction levels in treating chronic pain. The majority (73.8%) of PCPs were highly likely to prescribe opioid analgesics to a patient without a history of substance use who had chronic pain. The majority (88.5%) were somewhat to highly likely to prescribe opioid analgesics to a patient with a prior history of substance use but not active use. Most (67.2%) were somewhat to highly likely to prescribe opioids to a patient with active substance use.

Conclusion

In order to improve PCPs' confidence and satisfaction in managing chronic pain, further work should explore the root causes of low confidence and satisfaction and also explore possible remedies.

Purpose

Mutual trust is an important aspect of the patient-physician relationship with positive consequences for both parties. Previous measures have been limited to patient trust in the physician. We set out to develop and validate a measure of physician trust in the patient.

Methods

We identified candidate items for the scale by content analysis of a previous qualitative study of patient-physician trust and developed and validated a scale among 61 primary care clinicians (50 physicians and 11 nonphysicians) with respect to 168 patients as part of a community-based study of prescription opioid use for chronic, nonmalignant pain in HIV-positive adults. Polychoric factor structure analysis using the Pratt D matrix was used to reduce the number of items and describe the factor structure. Construct validity was tested by comparing mean clinician trust scores for patients by clinician and patient behaviors expected to be associated with clinician trust using a generalized linear mixed model.

Results

The final 12-item scale had high internal reliability (Cronbach α =.93) and a distinct 2-factor pattern with the Pratt matrix D. Construct validity was demonstrated with respect to clinician-reported self-behaviors including toxicology screening (P <.001), and refusal to prescribe opioids (P <.001) and with patient behaviors including reporting opioids lost or stolen (P=.008), taking opioids to get high (P <.001), and selling opioids (P<.001).

Conclusions

If validated in other populations, this measure of physician trust in the patient will be useful in investigating the antecedents and consequences of mutual trust, and the relationship between mutual trust and processes of care, which can help improve the delivery of clinical care.

Background

Primary care providers (PCPs) must balance treatment of chronic non-cancer pain with opioid analgesics with concerns about opioid misuse.

Objective

We co-enrolled community-based indigent adults and their PCPs to determine PCPs’ accuracy of estimating opioid analgesic misuse and illicit substance use.

Design

Patient-provider dyad study.

Participants

HIV-infected, community-based indigent adults (‘patients’) and their PCPs.

Main measures

Using structured interviews, we queried patients on use and misuse of opioid analgesics and illicit substances. PCPs completed patient- and provider-specific questionnaires. We calculated the sensitivity, specificity, and measures of agreement between PCPs’ judgments and patients’ reports of opioid misuse and illicit substance use. We examined factors associated with PCPs’ thinking that their patients had misused opioid analgesics and determined factors associated with patients’ misuse.

Key results

We had 105 patient-provider dyads. Of the patients, 21 had misused opioids and 45 had used illicit substances in the past year. The sensitivity of PCPs’ judgments of opioid analgesic misuse was 61.9% and specificity, 53.6% (Kappa score 0.09, p = 0.10). The sensitivity of PCPs’ judgments of illicit substance use was 71.1% and specificity, 66.7% (Kappa score 0.37, p <0.001). PCPs were more likely to think that younger patients (Adjusted odds ratio (AOR) 0.89, 95% CI 0.84-0.97), African American patients (AOR 2.53, 95% CI 1.05-6.07) and those who had used illicit substances in the past year (AOR 3.33, 95% CI 1.35-8.20) had misused opioids. Younger (AOR 0.94, 95% CI 0.86-1.02) and African American (AOR 0.71, 95% CI 0.25-1.97) patients were not more likely to report misuse, whereas persons who had used illicit substances were (AOR 3.01, 95% CI 1.04-8.76).

Conclusion

PCPs’ impressions of misuse were discordant with patients’ self-reports of opioid analgesic misuse. PCPs incorrectly used age and race as predictors of misuse in this high-risk cohort.

Background

Interpersonal trust plays an important role in the clinic visit. Clinician trust in the patient may be especially important when prescribing opioid analgesics because of concerns about misuse. Previous studies have found that non-white patients are perceived negatively by clinicians.

Objective

To examine whether clinicians' trust in patients differed by patients' race/ethnicity in a socially marginalized cohort.

Design

Cross-sectional study of patient-clinician dyads.

Participants

169 HIV infected indigent patients recruited from the community and their 61 primary care providers (PCPs.)

Main measures

The Physician Trust in Patients Scale (PTPS), a validated scale that measures PCPs' trust in patients.

Key results

The mean PTPS score was 43.2 (SD 10.8) out of a possible 60. Reported current illicit drug use and prescription opioid misuse were similar across patients' race or ethnicity. However, both patient illicit drug use and patient non-white race/ethnicity were associated with lower PTPS scores. In a multivariate model, non-white race/ethnicity was independently associated with PTPS scores 6.3 points lower than whites (95% CI: -9.9, -2.7). Current illicit drug use was associated with PTSP scores 5.5 lower than no drug use (95% CI -8.5, -2.5).

Conclusion

In a socially marginalized cohort, non-white patients were trusted less than white patients by their PCPs, despite similar rates of illicit drug use and opioid analgesic misuse. The effect was independent of illicit drug use. This finding may reflect unconscious stereotypes by PCPs and may underlie disparities in chronic pain management.

Unlabelled

Pain is common among people living with HIV/AIDS (PLWHA), but little is known about chronic pain in socioeconomically disadvantaged HIV-infected populations with high rates of substance abuse in the postantiretroviral era. This cross-sectional study describes the occurrence and characteristics of pain in a community-based cohort of 296 indigent PLWHA. Participants completed questionnaires about sociodemographics, substance use, depression, and pain. Cut-point analysis was used to generate categories of pain severity. Of the 270 participants who reported pain or the use of a pain medication in the past week, 8.2% had mild pain, 38.1% had moderate pain, and 53.7% had severe pain. Female sex and less education were associated with more severe pain. Depression was more common among participants with severe pain than among those with mild pain. Increasing pain severity was associated with daily pain and with chronic pain. Over half of the participants reported having a prescription for an opioid analgesic. Findings from this study suggest that chronic pain is a significant problem in this high risk, socioeconomically disadvantaged group of patients with HIV disease and high rates of previous or concurrent use of illicit drugs.

Perspective

This article presents epidemiological data showing that unrelieved chronic pain is a significant problem for indigent people living with HIV. Participants reported pain severity similar to those with metastatic cancer. Despite high rates of substance use disorders, approximately half received prescriptions for opioid analgesics, although few for long-acting agents.