title: When human immunodeficiency virus (HIV) treatment goals conflict with guideline-based opioid prescribing: A qualitative study of HIV treatment providers.
abstract: BACKGROUND
  Human immunodeficiency virus (HIV)-infected patients have a high prevalence of chronic pain and opioid use, making HIV care a critical setting for improving the safety of opioid prescribing. Little is known about HIV treatment providers' perspectives about opioid prescribing to patients with chronic pain.
  
  
  METHODS
  The authors administered a questionnaire and conducted semistructured telephone interviews with 18 HIV treatment providers (infectious disease specialists, general internists, family medicine physicians, nurse practitioners, and physician assistants) in Bronx, NY. Open-ended interview questions focused on providers' experiences, beliefs, and attitudes about opioid prescribing and about the use of guideline-based opioid prescribing practices (conservative prescribing, and monitoring for and responding to misuse). Transcripts were thematically analyzed using a modified grounded theory approach.
  
  
  RESULTS
  Eighteen HIV treatment providers included 13 physicians, four nurse practitioners, and one physician assistant. They were 62% female, 56% white, and practiced as HIV treatment providers for a mean of 14.6 years. Most reported always or almost always using opioid treatment agreements (56%) and urine drug testing (61%) with their patients on long-term opioid therapy. HIV treatment providers tended to view opioid prescribing for chronic pain within the "HIV paradigm," a set of priorities and principles defined by three key themes: (1) primacy of HIV goals, (2) familiarity with substance use, and (3) the clinician as ally. The HIV paradigm sometimes supported, and sometimes conflicted with, guideline-based opioid prescribing practices. For HIV treatment providers, perceived alignment with the HIV paradigm determined whether and how guideline-based opioid prescribing practices were adopted. For example, the primacy of HIV goals superseded conservative opioid prescribing when providers prescribed opioids with the goal of retaining patients in HIV care.
  
  
  CONCLUSIONS
  These findings highlight unique factors in HIV care that influence adoption of guideline-based opioid prescribing practices. These factors should be considered in future research and initiatives to address opioid prescribing in HIV care.
authors: a Albert Einstein College of Medicine and Montefiore Medical Center , Bronx, New York , USA.
authors: Joanna L
authors: JL
authors: Starrels
authors: b Center for Alcohol Studies , Rutgers University , New York , New York , USA.
authors: Deena
authors: D
authors: Peyser
authors: a Albert Einstein College of Medicine and Montefiore Medical Center , Bronx, New York , USA.
authors: Lorlette
authors: L
authors: Haughton
authors: a Albert Einstein College of Medicine and Montefiore Medical Center , Bronx, New York , USA.
authors: Aaron
authors: A
authors: Fox
authors: c School of Medicine, University of Alabama at Birmingham , Birmingham , Alabama , USA.
authors: Jessica S
authors: JS
authors: Merlin
authors: a Albert Einstein College of Medicine and Montefiore Medical Center , Bronx, New York , USA.
authors: Julia H
authors: JH
authors: Arnsten
authors: a Albert Einstein College of Medicine and Montefiore Medical Center , Bronx, New York , USA.
authors: Chinazo O
authors: CO
authors: Cunningham
mesh_terms: D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000627:therapeutic use; D059350:Chronic Pain / Q000188:drug therapy; D005260:Female; D019983:Guideline Adherence; D015658:HIV Infections / Q000188:drug therapy*; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel / Q000523:psychology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D036301:Qualitative Research
chemical_list: D000701:Analgesics, Opioid
keywords: Chronic pain; HIV; opioid analgesics