The US opioid crisis has reached older people with HIV

People with HIV aged 65 and older were more likely to be prescribed opioids and be diagnosed with opioid use disorder than HIV-negative older adults in the US, according to data presented by Dr Stephanie Shiau to the Conference on Retroviruses and Opportunistic Infections (CROI 2024) in Denver recently.

Background

Approximately 2.5 million adults in the US had opioid use disorder in 2021, with only 22% receiving medications, such as methadone, to treat it. Between 1999 and 2021, there have been an estimated 645,000 deaths from opioid overdose in the US, including from both prescription and illicit opioids, such as heroin and fentanyl. Tighter restrictions on opioid prescribing in recent years have often resulted in people with opioid use disorder who had previously been prescribed opioids seeking out illicit opioids.

In the US, the percentage of adults aged 65 and older with HIV has continued to grow since 2000, reaching nearly 15% of all people living with HIV in 2021. Problematic use of opioids by older adults is associated with adverse effects including sedation, cognitive impairment, falls, fractures and constipation.

The study

Medicare is a federal health insurance programme for people aged 65 and older in the US. Researchers used Medicare claims data from a sample of 20% of fee-for-service beneficiaries from 2008 to 2019. A total of 124,488 beneficiaries with HIV were matched to 373,464 people without HIV. They were matched in terms of factors such as age, sex, race/ethnicity, and state of residence.

Most of the sample were male (68% in 2008; 74% in 2019), with an even split between White and Black people in 2008 (41% each) but with more White people in 2019 (49%). The largest age group represented for all years was aged between 65 to 69, around 47 to 48% of the total sample for the duration of the study period.

Researchers were interested in seeing if people in the sample had been prescribed at least one opioid medication and diagnosed with opioid use disorder. Additionally, they wanted to see if there were any prescriptions that would meet a number of ‘high-risk’ criteria.

Opioid differences based on HIV status

Despite decreases in opioid prescribing over time, a higher percentage of people with HIV received at least one opioid prescription between 2008 to 2019 – from a high of 43% in 2010 to a low of 32% in 2019. In comparison, prescribing to HIV-negative people ranged from a high of 36% in 2010 to a low of 25% in 2019. Over the study period, people with HIV were 1.3 to 1.4 times more likely to receive an opioid prescription than HIV-negative people.

Similarly, people with HIV were significantly more likely to be diagnosed with opioid use disorder – between 2% to 5% during the study period compared to 0.6% to 2% in HIV-negative people.

The same was true when the researchers looked at the ‘high-risk’ prescription criteria. People with HIV were significantly more likely to:

• Receive two or more overlapping opioid prescriptions for more than a week (Odds Ratios for the study period: 1.4 to 1.7)
• Meet or exceed 90mg of total morphine milligram equivalents (MME, a measure of opioid dose strength) (OR: 1.5 to 1.7)
• Meet or exceed 90 consecutive days of prescription opioid coverage (OR: 1.5 to 1.7)
• Use medication such as methadone or buprenorphine that is usually prescribed for opioid use disorder (OR: 2.7 to 7.5)
• Be hospitalised or visit an emergency room because of opioids (OR: 2.5 to 3.6).

Conclusion

While this study did not include data on how many people were diagnosed with chronic pain or pain disorders, it nonetheless sheds light on a consistent and concerning phenomenon.

“Medicare beneficiaries with HIV have higher odds of receiving opioid prescriptions, being diagnosed with opioid use disorder, and receiving ‘high-risk’ opioid prescriptions compared to HIV-negative beneficiaries,” Shiau concluded. “These trends were consistent across all years of data. Our findings may help guide opioid use management among this vulnerable population.”