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Michael S. Saag, MD: Hello. I'm Dr Michael Saag, professor of medicine and infectious diseases at The University of Alabama at Birmingham (UAB). Welcome to season two of Medscape's InDiscussion series on HIV. Today we'll discuss HIV and management of opioid use disorder, an ongoing crisis in the United States and around the world, which has had an impact especially among people with HIV. First, let me introduce my guest, Dr Ellen Eaton, an associate professor at UAB who is a rising star in academic medicine. Her research focuses on patient care and infectious consequences of substance use and mental illness. Her lab is developing and testing interventions to link patients to addiction treatment and prevention across the HIV care continuum in both acute care and community-based settings. Ellen is the director of the Office-Based Opioid Treatment Clinic at the UAB 1917 Clinic and a member of the leadership team of The UAB Center for Addiction and Pain Prevention and Intervention. She's also a member of the IDSA (Infectious Diseases Society of America) HIVMA (HIV Medicine Association) Opioid Working Group. Ellen, welcome to the program.
Ellen F. Eaton, MD: Thanks so much for having me, Mike. It's good to be here.
Saag: Let's start with something simple. Can you give us the definition of opioid use disorder? We hear that term a lot, and a lot of us may be confused about what it means. What is opioid use disorder?
Eaton: The rule I was taught and what I teach my learners is the role of C's — cravings, consequences, and a lack of control. This generally implies that patients are not just taking opioids, but when they go without opioids, they have a physical dependency. They will crave the opioids. They experience negative consequences, but they continue to use. Maybe they're stealing to support their habit. Maybe they're taking from friends and families. Maybe they have a car accident when they're intoxicated. There is a lack of control. And with that, it implies a physical tolerance to opioids. They can no longer quit cold turkey, if you will. They're going to need assistance to get off the nonmedical opioids in this case. That's the definition I use in my clinic.
Saag: This conversation is specific to opioids. We could talk about methamphetamine, or we could talk about cocaine, or we could talk about alcohol use disorders. But today we're going to focus mostly on opioids, which are heroin and related compounds, oxycodone, OxyContin, that type of thing. Those other topics could take up another 25 minutes each. What is the prevalence — in the United States at least — among people with HIV who have opioid use disorder as you just defined it?
Eaton: In the general population, it's thought that we have upward of 7-8 million Americans living with opioid use disorder. That could be 3%-5% of the general population. What we know about HIV is that opioid use disorder is more common in this population because of chronic pain and because of a lot of the mental health comorbidities that go along with substance use. We know it's more like 15% of patients with HIV who have opioid use disorder. I would argue that is an underdiagnosed condition. I think we are still learning the importance of screening all of our patients with HIV. I still see patients presenting late with opioid use disorder that we simply hadn't recognized earlier.
Saag: In a backhanded way, unfortunately, physicians have sort of contributed to this opioid use disorder crisis going back to the eighties and nineties and into the 2000s where we were managing chronic pain with chronic opioids. Can you give us a brief description of how that happened and what we're doing about it now?
Eaton: Absolutely. There is a lot of great literature and books out there. I strongly recommend Dreamland by Sam Quinones. It's the book that inspired me to get into this line of work. He describes how nonmedical opioids came to be so prevalent in America, coming across borders, and how they were used initially to treat chronic pain from a lot of different musculoskeletal injuries. Many of my patients were first exposed to opioids from an injury when they were younger. A lot of them received opioids from a friend or family member who said, "Hey, you have a headache, so try some of this." Because many prescribers and clinicians were very liberal in prescribing opioids — oxycodone and Percocet [oxycodone acetaminophen] — in the early 2000s, a lot of people became dependent. Then when state medical boards and other agencies began cracking down on prescription pills, we saw a conversion. People were going from pills they got from their doctor to illicit pills they were getting in the community. A lot of those substances were easier to get and cheaper. Unfortunately, a lot of that was heroin that people began injecting. We did not have the capacity to treat opioid use disorder around 2010 to 2012. I would argue we still don't. The ideal transition would be at the same time we're restricting inappropriate prescribing to refer patients down the street, hopefully somewhere accessible and close by, to treat their opioid use disorder. That did not happen. That's why we have seen the shift from pills to needles, heroin, and more recently, fentanyl. People are truly self-medicating because they have this dependence that I described earlier.
Saag: In defense of some of the prescribing doctors, in the nineties, the medical establishment started making pain a vital sign. It had to be assessed on every visit. Doctors who would encounter a patient who scored 11 out of ten on pain thought, "What are we going to do about it? Oh, here's a prescription. It's easy. Take this." We conditioned patients to treat their chronic pain disorders with opioids, and now we're trying to reverse this. Let me pause for a minute and segue to something we commonly encounter, which are patients who come in with a chronic pain disorder and demand an opioid from you. How do you manage that?
Eaton: This is a hard clinical encounter. It takes a lot of time, if done well, which is challenging for a busy primary care HIV clinic, right? I like to ask them specifically what hurts and where the pain is. I conduct an exam. I ask them what they have tried and what nonopioid interventions they have tried. I offer a lot of counseling around NSAIDs as a first-line treatment for many different musculoskeletal injuries. I offer counseling around topical things that are safe, like lidocaine jellies, and things patients can do like stretching. I talk a lot about weight loss, which a hard thing to do, but a lot of my patients' musculoskeletal pain is related to the fact that they're carrying 50 extra pounds. I try to take a more holistic approach to patients with chronic pain. I can't think of more than two patients in my general HIV clinic who are on opioids for pain at this time. But as you know, a lot of the treatments for opioid use disorder like buprenorphine and methadone can more safely be used for chronic pain. There are great tools out there to help us with patients with chronic pain and opioid dependency. They truly need to be on some sort of opioid agonist or partial agonist. Some of the medications we're using for opioid use disorder can also safely be used for chronic pain. So this is an important thing to note with pharmacotherapy.
Saag: I recently had a patient who stormed out of the exam room and down the hall because I refused to renew his prescription that had been given by an outside provider. We deal with this. So now that we've gone through the negative aspects of treating patients, let's turn to the positives. How do you screen for opioid use disorder among your patients, and what can the folks in practice do to see if they have a patient with this disorder?
Eaton: I am very spoiled in that our clinic has standardized screening tools. There are a lot of screening tools available that clinics can use at intake or triage. You can have your nurse do them. Some of them are two questions — if patients have used any nonmedical, nonprescribed substances and the frequency of use of these substances. Some of these short screening tools can then be a launching board for you as the clinician. If the patient answers yes, you know you're going to need to ask more questions. At our clinic, we use something called the ASSIST (Alcohol, Smoking, and Substance Involvement Screening Test). There is a NIDA (National Institute on Drug Abuse) Quick Screen, and there is a RODS (Rapid Opioid Dependence Screen). There are multiple validated scores that have been used and validated in patients with HIV that are really good at screening initially. But no, they're not a screening tool. They're not a diagnostic tool. You do then need to sit down with the patient and ask them these questions. My general approach to my patients when they're new to my opioid clinic is starting way back in adolescence.
Saag: You've already alluded to this, but it seems to me there's two basic types of presentations that we encounter. The first group of patients, which we've already talked about, are those who have chronic pain. You mentioned doing an assessment for what the pain is like and what has been done for the pain in the past. Then you alluded to substitution therapy with some of the opioid agonists. The second group of patients are those who have been on opioids for a long time and you're trying to get them off. Let's start with the first situation. Somebody comes in, they've had chronic pain, and they want something to treat it. What are the ways you might approach using the current opioid agonists you mentioned — buprenorphine or methadone — in that setting?
Eaton: In general, when patients come to me, they have identified that they have chronic pain, and a lot of them are uncomfortable with the amount or the frequency of the opioids they're taking. They're tired of taking pills multiple times a day. They're tired of being treated differently by doctors and health systems as "drug seeking." A lot of them want to convert to a more convenient once-daily dosing. Now, it's important to know that methadone really is still restricted to methadone clinics. I am not a methadone prescriber. I don't work in a methadone clinic. But it is a good option for some people. Some of my older patients have been stable on methadone for years. There are drug-drug interactions. There is a risk of overdose, so this is something to monitor in those patients. Also, drug-drug interactions are more relevant for antiretroviral therapy. What's different about buprenorphine is that it is a medication that anyone with a DEA (US Drug Enforcement Administration) license can prescribe in the outpatient setting for patients with opioid use disorder. This is new, effective December 2022. You may have seen that the X-waiver was dropped — the X-waiver being additional training and certification required for any primary care provider or any prescriber who is prescribing buprenorphine to treat opioid use disorder.
Saag: You can use this often as a way of treating people with opioid use disorder. You can also use it to treat chronic pain, just in general. You might have somebody who has chronic pain who is not on opioids. In the past, you would have prescribed an opioid, but you can use buprenorphine in that setting. Describe how you would use it for de novo chronic pain management.
Eaton: As I mentioned earlier, buprenorphine is a partial opioid agonist. What's good about this is that it does not have the acute euphoria associated with some of the full agonists. It is long acting and it can be prescribed once daily. For patients who are on high doses of oral opioids — that's the most common example — we have a protocol where they come into clinic, and we counsel them about this option. If they're interested, they have to come off of their oral opioid agonists — for example, oxycodone. We have a protocol that is termed inducing patients on buprenorphine. It's something that can be done at home. Patients commonly prefer to start this induction at home. They start a smaller dose of 4-8 mg of buprenorphine. Over the period of several hours, they'll increase the dose. Most people are going to need 16 mg total during the first day, and then they adjust up to potentially 24 mg a day over the next day. Again, there are tools I'm happy to share with you that walk through how to induce patients on buprenorphine. But what patients like is that they can do this within the comfort of their own home. There are over-the-counter medications we can prescribe for them if they have some symptoms of mild withdrawal. For anxiety, you can prescribe some Atarax [hydroxyzine] or clonidine if they're feeling irritable. To be honest, most of my patients have not needed anything to treat the discomfort of withdrawal symptoms as long as I counsel them so they're prepared and know what they're likely to experience. It is not something they want to do while they're at work or when they are required to be highly productive or effective in any role. They're going to need some time to transition from that oral opioid regimen they were on to the buprenorphine, which is sublingual. I should say that the most common formulation of buprenorphine is sublingual under the tongue. We do have to counsel them about how it's absorbed through the oral mucosa. There are some long-acting injectables and other opportunities for buprenorphine that have other methods of delivery, but the most common one now is either a tablet or film under the tongue.
Saag: It would be a little bit different for someone who's not been on opioids. You would just use the lower dose and not have the aggressive ramp-up of dosing, I'm sure. Let's talk about the use of Narcan, also known as naloxone. You want to prescribe Narcan every time you give somebody this drug, right?
Eaton: Absolutely. Narcan reverses opioid overdose. It is most commonly a nasal spray. It is very safe. It is not harmful if you give it to someone who's not overdosing. It is no big deal. But we do give it to everyone who comes to our clinic whether they walk away with the buprenorphine prescription or not. Currently, more of my patients are using Narcan for friends, neighbors, nieces, and loved ones than themselves because most of my patients are on buprenorphine. They're taking it. They are highly unlikely to overdose even if they inadvertently come in contact with fentanyl. What I'm hearing from my patients is that everybody in my apartment knows I always have Narcan, and someone's knocking on my door at 8 am or 10 pm because someone is having an opioid overdose or they suspect an opioid overdose.
Saag: My sense is that in the last year or two that Narcan has been responsible for saving more lives than anything else. That's a critical thing for all of us to do. I understand that they're actually talking about making it accessible over the counter. It isn't there yet. But maybe that's not a bad idea. But let's transition to the hospital. For a lot of people who, as you mentioned earlier, had chronic pain or were on chronic opioids, doctors started cutting back and the medical society started intervening, saying they can't do that anymore. Patients turn to the street, in essence, to get street drugs. A lot of times it's heroin. They're injecting heroin and then they get infectious complications. They do not just get abscesses in their arms or other places, but they actually get endocarditis. When someone gets admitted with opioid use disorder or endocarditis, what can you do in the hospital to get them on the path toward safer use of opioids?
Eaton: This is a really important touchpoint, especially here in a state where a lot of our patients don't have access to community-based addiction care. They're showing up either after an overdose because they want help or they're showing up with a complication like endocarditis. I think the easiest and most optimal place to start treatment with buprenorphine is in the ER. The reason I say this is because patients are often in withdrawal when they come in. However, over the course of 24-48 hours, they may be getting abscesses lanced. They need to get an echocardiogram and uncomfortable procedures, and they're likely going to get put on IV opioids. It's really hard at that point to turn that ship around and replace those full agonists with something like buprenorphine. Buprenorphine is safe even when someone is going to require surgery and needs some additional PRN pain medications. You can start them on buprenorphine in the ER and then if they go to surgery, have a discussion with addiction medicine and anesthesia clinicians. They know how to add additional opioids on top of that, perioperatively. It's really hard when you're 7 days into an admission, the patient has had painful procedures, and they're on high doses of opioids. It's really hard to get them to come off of those. Withdrawal, even mild to moderate withdrawal, which we recommend before starting buprenorphine, is really hard. I will say that one thing that has become increasingly popular that we're hearing more literature on and that I use in my clinic is this concept called microdosing. Microdosing is where you don't require the patient to come off of their other opioids. You slowly up titrate the buprenorphine, starting with 0.25-mg every couple of hours. You're slowly replacing opioid on the opioid receptors with the buprenorphine. You're slowly replacing the heroin on their opioid receptors if they're out in the community or replacing other opioids if they're in the hospital. You don't precipitate withdrawal, which is the risk if you dramatically shift from one to the other, but you're slowly replacing it. There are protocols for microdosing in the literature. I'm using microdosing in my clinic for patients who have really refractory opioid use disorder. They can't come off fentanyl. They're too uncomfortable. They're not ready to go to inpatient rehab. They want help. I will write out this pretty intensive protocol increasing the buprenorphine by 0.2 unit fractions of a tablet. The same thing is being done in the hospital setting for patients who are on high doses of pain medications to slowly transition to that long-acting partial agonist.
Saag: If we focus on the inpatient setting, you mentioned the emergency department. It's kind of hard these days to make anything happen there because they are so overwhelmed with patients in many of the hospitals. But let's say we have somebody who's in the hospital. They're getting IV therapy for endocarditis. They have an opioid use disorder. You've been very successful in helping set up an addiction therapy consult service. Can you briefly describe what that is? Then, importantly, what happens when that person comes home? How do you continue that?
Eaton: It is really important to incorporate a team-based approach like with so many of our services we offer in the hospital. Having a team-based approach includes having communication between infectious diseases and addiction medicine doctors or having a nurse who can follow up with the patient when the doctors are busy. The nurse may follow up with, "Hey, you know, Mr Smith, we saw you this morning, and we offered you buprenorphine. You weren't ready. I want to check in with you." The team-based approach can reinforce that counseling. Often, having a pharmacist involved can be key. It is having that discussion between the addiction doctors and the infectious diseases doctors and thinking about what a patient needs for their endocarditis but also how it will look when they go home to their rural community in Alabama and anticipating that. What are the resources there? It's essential to have a team. A lot of these admissions end with a premature discharge, which is a term we talk about a lot in the literature. We know that 20%-30% of these patients will leave prematurely, often because of stigmatizing language or an uncomfortable environment for someone who uses substances. The patient will leave and you haven't had time to write their vancomycin orders or transition them to buprenorphine. A lot of the research is how to anticipate those premature discharges and set the patient up for success. Maybe you give them oral Bactrim [trimethoprim/sulfamethoxazole]. We have literature to show that even for endocarditis it is better than nothing. Clinicians can go ahead and put in buprenorphine orders and have that naloxone waiting for them. Maybe they can already have a referral into their local health department or their local low-barrier FQHC (Federally Qualified Health Center) where they offer buprenorphine. Those types of things are critical because we can do a lot in the hospital, but we don't have control over how long that admission will be. Once patients leave our hospital in rural and poor communities, they get no care. We see this because they cycle in and out of our ERs for their primary care. Anticipating needs is key — knowing where they're going and what the social support looks like or what the medical support looks like, and really teeing up a plan in the event that they leave before you see them again.
Saag: And they should leave with Narcan.
Eaton: Yes. They should leave with Narcan.
Saag: Narcan is maybe more important than the Bactrim. Our time is running by quickly. You have done a fantastic job of ensuring that at least a percentage of our patients are not lost to follow-up when they get discharged but rather follow up in your clinic so you can keep them engaged in care. Not only does that help with our patients' opioid use disorder, but it keeps them in care for their HIV management. That's the ideal. Clinicians can continue that and help patients through the experience of seeking street drugs that carries with it enormous risk — not just from the infections, but the drugs can get laced with fentanyl and there are unintentional drug overdoses that happen all the time. What do you think the future's going to be in the next 3-5 years in terms of the opioid use crisis that we have in the United States in general?
Eaton: What we learned from the pandemic was that the future needs to include lots of accessible, low-barrier options, and this includes a combination of scheduled brick-and-mortar appointments, walk-in capacity, and telehealth options, and also care teams that include people like a peer recovery support person. There's a peer on my team in my clinic who has lived experience with opioid use, and half of the time, my patients don't need to see a medical provider. They need to see someone with her background — a social worker, case manager, or even a nurse for counseling support and a motivational interview. A really comprehensive approach, a very interdisciplinary team, and the ability to see patients frequently, take walk-ins, and reach them virtually through a telephone or smartphone for frequent assessments is where we need to be. That's what we did at 1917 Clinic during the pandemic. We kept people engaged. We kept their viral load suppressed. The future needs to include more HIV clinics that treat opioid use disorder on-site. You know this. We had patients return to 1917 Clinic who had been out of care simply because they heard they could get buprenorphine there. We all need to aspire to that.
Saag: Today, we've been talking to Dr Ellen Eaton about opioid use disorder. We've reviewed how this happened in terms of a legacy from chronic pain treatment with chronic opioid use. A lot of our patients with HIV have chronic pain, and we learned about focusing on the nature of the pain, some other nonopioid approaches we can use to manage the pain, and finding the source of the pain and getting that taken care of. But when opioids are indicated, we should use opioid agonists such as buprenorphine as a pain management approach. We should make sure every person who has opioid use disorder has Narcan, has access to it, and takes it home with them, and we should make sure we keep up with this. If they've used Narcan, we should give them another nasal spray they can have available that will reduce mortality from opioid use disorders in general in the population. We also discussed management in the outpatient setting that can be linked to inpatient admissions, where we not only continue care for the opioid use disorder but also make sure patients remain engaged in care for HIV as well. It is an emerging area. It's something we all need to focus on, and this is a launchpad for a lot of us to think carefully about how we manage this in our practices. Ellen, thank you for joining us today. It's been wonderful.
Eaton: Thanks for having me.
Saag: Thanks to everybody in the audience for tuning in. If you haven't done so already, take a moment to download the Medscape app to listen and subscribe to this podcast series on HIV and other opportunities for continuing education. This is Dr Michael Saag for InDiscussion.
Listen to additional seasons of this podcast.
Resources
Opioid Continuum of Care for Persons Living With HIV: The First 8 Months
Medications to Treat Opioid Use Disorder Research Report: Overview
The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)
Rapid Opioid Dependence Screen (RODS)
Removal of Data Waiver (X-Waiver) Requirement
Buprenorphine Initiation Strategies for Opioid Use Disorder and Pain Management: A Systematic Review
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Cite this: HIV and Opioid Use Disorder: Screening Tools, Chronic Pain Management, and Access to Care in the Outpatient Setting - Medscape - May 10, 2023.
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