Denial of prescription pain medication among people who use drugs in Vancouver, Canada.

BACKGROUND: People who use drugs experience pain at two to three times the rate of the general population and yet continue to face substantial barriers to accessing appropriate and adequate treatment for pain. In light of the overdose crisis and revised opioid prescribing guidelines, we sought to identify factors associated with being denied pain medication and longitudinally investigate denial rates among people who use drugs. METHODS: We used multivariable generalized estimating equations analyses to investigate factors associated with being denied pain medication among people who use drugs reporting pain in three prospective cohort studies in Vancouver, Canada. Analyses were restricted to study periods in which participants requested a prescription for pain from a healthcare provider. Descriptive statistics detail denial rates and actions taken by participants after being denied. RESULTS: Among 1168 participants who requested a prescription for pain between December 2012 and March 2020, the median age was 47 years and 63.0% were male. Among 4,179 six-month observation periods, 907 (21.7%) included a report of being denied requested pain medication. In multivariable analyses, age was negatively associated with prescription denial (adjusted odds ratio [AOR] = 0.98, 95% confidence interval [CI]:0.97-0.99), while self-managing pain (AOR = 2.48, 95%CI:2.04-3.00), experiencing a non-fatal overdose (AOR = 1.51, 95%CI:1.22-1.88), engagement in opioid agonist therapy (AOR = 1.32, 95%CI:1.09-1.61), and daily use of heroin or other unregulated opioids (AOR = 1.32, 95%CI:1.05-1.66) were positively associated with being denied. Common actions taken (n = 895) after denial were accessing the unregulated drug supply (53.5%), doing nothing (30.6%), and going to a different doctor/emergency room (6.1%). The period following the introduction of new prescribing guidelines was not associated with a change in denial rates. CONCLUSIONS: A substantial proportion of people who use drugs continue to be denied prescriptions for pain, with such denial associated with important substance use-related harms, including non-fatal overdose. Guidelines specific to the pharmaceutical management of pain among people who use drugs are needed.

The effect of depressive symptoms on pain in a substance-using population with persistent pain: a cross-sectional cohort study.

BACKGROUND: In light of the ongoing opioid overdose crisis, there is an urgent need for research on the impacts of mental health among people presenting with concurrent pain and substance use. This study examined the effect of depressive symptoms on pain severity and functional interference among people who use drugs (PWUD) during a community-wide overdose crisis. METHODS: From December 1st 2016 to December 31st 2018, 288 participants in two cohort studies of PWUD in Vancouver, Canada completed interviewer-administered questionnaires that included the Brief Pain Inventory and PROMIS Emotional Distress-Depression instruments. Generalized linear regression modelling (GLM) was used to examine the cross-sectional effect of depressive symptoms and other confounding factors on pain severity and interference. RESULTS: Moderate to severe depressive symptoms were significantly associated with greater pain-related functional interference (adjusted ß = 1.24, 95% confidence interval [CI] = 0.33-2.15), but not significantly associated with greater average pain severity (adjusted ß = 0.22, 95% CI = - 0.3 - 0.82), when controlling for confounding variables. Reported daily heroin use (adjusted ß = 1.26, 95% CI = 0.47-2.05) and non-fatal overdose (adjusted ß = 1.02, 95% CI = 0.08-1.96) were also significantly associated with greater pain-related functional interference. CONCLUSIONS: In a substance-using population, greater pain-related functional interference was positively associated with depressive symptoms as well as overdose and daily heroin use. These findings emphasize the need to address the functional impact of pain, mental health comorbidity, and high-risk substance use that may contribute to overdose and other harms.

Pain and Barriers to Accessing Health Services Among People Who Use Drugs.

BACKGROUND: The opioid overdose crisis underscores the need for health services among people who use drugs (PWUD) with concurrent pain. AIMS: Investigating the effect of pain on barriers to accessing health services among PWUD. DESIGN: Prospective cohort study. SETTINGS: A setting of universal access to no-cost medical care in Vancouver, Canada from June 2014 to May 2016. PARTICIPANTS/SUBJECTS: PWUD who completed at least one study interview. METHODS: Data derived from interviewer-administered questionnaires were used for multivariable generalized linear mixed-effects multiple regression (GLMM) analyses. RESULTS: Among 1,348 PWUD, 469 (34.8%) reported barriers to accessing health services at least once during the study period. The median average pain severity was 3 (IQR: 0-6) out of 10. A dose-response relationship was observed between greater pain and increased odds of reporting barriers to accessing health services (adjusted odds ratio [AOR]: 1.59, 95% confidence interval [CI]: 1.15-2.21, p = .005 for mild versus no pain; AOR: 1.76, 95% CI: 1.30-2.37, p < .001 for moderate versus no pain; AOR: 2.55, 95% CI: 1.92-3.37, p < .001 for severe versus no pain). Common barriers included poor treatment by health professionals, socio-structural barriers such as transportation or mobility, and long wait lists or wait times. CONCLUSIONS: Pain may be a significant risk factor associated with increased barriers to accessing health services among PWUD. Attention to pain management may improve access to health services, and reducing barriers to health services may conversely improve pain management and its related risks and harms.

The Impact of Childhood Emotional Abuse on Pain Interference Among People with Chronic Pain who Inject Drugs in Vancouver, Canada.

OBJECTIVE: High levels of chronic pain interference with daily activities are known to negatively impact quality of life. Although mental health conditions have been associated with pain interference and child abuse, research has been mixed regarding it acting as a mediator, with even less known among people who inject drugs. Therefore, we sought to explore childhood emotional abuse and pain interference among this population. METHODS: Data were derived from two prospective cohort studies of community-recruited people who inject drugs in Vancouver, Canada, between June 2014 and November 2016. We employed multivariable generalized estimating equations to examine the relationship between childhood emotional abuse and pain interference in the past six months. We also conducted a mediation analysis to examine whether mental health disorder diagnoses mediated this association. RESULTS: Among 822 eligible participants, 341 (41.5%) reported childhood emotional abuse. In a multivariable analysis, experiencing childhood emotional abuse remained independently associated with pain interference (adjusted odds ratio = 1.33, 95% confidence interval [CI] = 1.05-1.70) after adjusting for a range of confounders. Results from the mediation analysis yielded a statistically significant positive average causal mediation effect (ß = 0.01, 95% CI = 0.001-0.02). Approximately 12% of the effect was due to mediation. CONCLUSIONS: Our results demonstrate among people who inject drugs with chronic pain, those who experienced childhood emotional abuse were more likely to report pain interference, which was partially mediated by mental health disorder diagnosis history. These findings highlight the importance of incorporating screening and appropriate treatment for mental illness into chronic pain treatment.

Pain as a risk factor for substance use: a qualitative study of people who use drugs in British Columbia, Canada.

BACKGROUND: People who use drugs have a significantly higher prevalence of chronic non-cancer pain compared to the general population, yet little is known about how various policy, economic, physical, and social environments may serve as risk or protective factors in the context of concurrent pain and substance use. Therefore, this study sought to explore perspectives, risks, and harms associated with pain among people who use drugs. METHODS: Thirteen focus group interviews were held across British Columbia, Canada, from July to September 2015. In total, 83 people who had lived experience with substance use participated in the study. Using an interpretive description approach, themes were conceptualized according to the Rhodes' Risk Environment and patient-centered care frameworks. RESULTS: Participants described how their experiences with inadequately managed pain in various policy, economic, physical, and social environments reinforced marginalization, such as restrictive policies, economic vulnerability, lack of access to socio-physical support systems, stigma from health professionals, and denial of pain medication leading to risky self-medication. Principles of patient-centered care were often not upheld, from a lack of recognition of patients as experts in understanding their unique pain needs and experiences, to an absence of shared power and decision-making, which often resulted in distrust of the patient-provider relationship. CONCLUSIONS: Various risk environments and non-patient-centered interactions may contribute to an array of health and social harms in the context of inadequately managed pain among people who use drugs.

Risky and rushed public crack cocaine smoking: the potential for supervised inhalation facilities.

BACKGROUND: Despite the multitude of public health and community harms associated with crack cocaine use, little is known about factors associated with smoking crack in public and related risks such as rushed public crack smoking. METHODS: Data were derived from two prospective cohort studies of people who use illicit drugs in Vancouver, Canada between 2010 and 2014. Multivariable generalized estimating equations were used to identify the prevalence and correlates of public crack smoking and rushed public crack smoking. RESULTS: In total, 1085 participants who had smoked crack in the prior six months were eligible for the analysis, of which 379 (34.9 %) reported always or usually smoking crack in public in the previous six months at some point during the study period. Factors positively and independently associated with public crack smoking included public injection drug use (adjusted odds ratio [AOR]: 5.42, 95 % confidence interval [CI]: 3.76-7.82), homelessness (AOR: 3.48, 95 % CI: 2.77-4.36), at least daily crack use (AOR: 2.69, 95 % CI: 2.19-3.31), crack pipe sharing (AOR: 1.98, 95 % CI: 1.60-2.46), drug dealing (AOR: 1.59, 95 % CI: 1.30-1.94), recent incarceration (AOR: 1.47, 95 % CI: 1.09-1.98), noticing police presence when buying or using drugs (AOR: 1.30, 95 % CI: 1.06-1.60), and younger age (AOR: 1.03, 95 % CI: 1.01-1.04). Rushed public crack smoking, which was reported by 216 (28.8 %) of 751 participants who had smoked crack in public at least once during the study period, was positively and independently associated with homelessness (AOR: 2.61, 95 % CI: 1.96-3.49), at least daily crack use (AOR: 1.48, 95 % CI: 1.11-1.98), crack pipe sharing (AOR: 1.44, 95 % CI: 1.10-1.89), drug dealing (AOR: 1.39, 95 % CI: 1.04-1.86), and younger age (AOR: 1.02, 95 % CI: 1.01-1.04). CONCLUSIONS: A high prevalence of public crack smoking and rushed public crack smoking was observed in this setting. These findings point to the need for implementing and evaluating evidence-based public health interventions, such as supervised inhalation facilities, to reduce the risks and harms associated with smoking crack in public.

High prevalence of syringe lending among HIV-positive people who inject drugs in Bangkok, Thailand.

BACKGROUND: Syringe sharing continues to be a major driver of the HIV pandemic. In light of efforts to enhance access to sterile syringes and promote secondary prevention among HIV-positive individuals, we sought to identify the prevalence and correlates of used syringe lending among self-reported HIV-positive people who inject drugs (PWID) in Bangkok, Thailand. FINDINGS: We used bivariable statistics to examine factors associated with self-reported syringe lending among self-reported HIV-positive PWID participating in the Mitsampan Community Research Project, a serial cross-sectional study of PWID in Bangkok, between June 2009 and October 2011. In total, 127 individuals were eligible for this analysis, including 25 (19.7%) women. Twenty-one (16.5%) participants reported syringe lending in the prior 6 months. Factors significantly associated with syringe lending included daily methamphetamine injection (odds ratio (OR) = 10.2, 95% CI, 2.1-53.6), daily midazolam injection (OR = 3.1, 95% CI, 1.1-8.7), use of drugs in combination (OR = 4.5, 95% CI, 1.0-41.6), injecting with others on a frequent basis (OR = 4.25, 95% CI, 1.3-18.3), and not receiving antiretroviral therapy (OR = 2.9, 95% CI, 1.1-7.9). CONCLUSIONS: A high prevalence of syringe lending was observed among self-reported HIV-positive PWID in Bangkok, which was associated with high intensity drug use, polysubstance use, and frequently injecting with others. It is particularly concerning that individuals who lent syringes were more likely to be untreated for HIV disease given the known benefits of antiretroviral provision on the prevention of HIV transmission. These findings underscore the need to expand access to sterile syringes and HIV treatment among HIV-positive PWID in Thailand.

Estimating the prevalence and correlates of pain among people living with HIV who use unregulated drugs in a Canadian setting.

Although prevalent among people living with human immunodeficiency virus (HIV) (PLWH) and people who use unregulated drugs (PWUD), pain and its possible links to substance use patterns and engagement in HIV treatment remains poorly characterized. We sought to evaluate the prevalence and correlates of pain among a cohort of PLWH who use un-regulated drugs. Between December 2011 and November 2018, 709 participants were recruited, and data were analyzed using generalized linear mixed-effects (GLMM). At baseline, 374 (53 percent) individuals reported moderate-to-extreme pain in the previous 6 months. In a multivariable model, pain was significantly associated with nonmedical prescrip-tion-opioid use (adjusted odds ratio (AOR) = 1.63, 95 percent confidence interval (CI): 1.30-2.05), nonfatal overdose (AOR = 1.46, 95 percent CI: 1.11-1.93), self-managing pain (AOR = 2.25, 95 percent CI: 1.94-2.61), requesting pain medication in the previous 6 months (AOR = 2.01, 95 percent CI: 1.69-2.38), and ever being diagnosed with a mental illness (AOR = 1.47, 95 percent CI: 1.11-1.94). Establishing accessible pain management interventions that address the complex intersection of pain, drug use, and HIV-infection has potential to improve quality of life outcomes among this population.

Methadone maintenance therapy service components linked to improvements in HIV care cascade outcomes: A systematic review of trials and observational studies.

BACKGROUND: The beneficial links between engagement in methadone maintenance therapy (MMT) and HIV treatment outcomes have been extensively described. Nevertheless, people who use drugs (PWUD) continue to experience suboptimal HIV treatment outcomes. In this systematic review, we sought to identify components of MMT service provision that are associated with improvements in HIV care outcomes across the HIV care cascade. METHODS: We searched for peer-reviewed studies in online databases. To be eligible for inclusion in this review, studies must have involved a population or sub-population of PWUD engaged in MMT; report improved uptake of HIV testing, exposure to ART, or HIV-1 RNA plasma viral load suppression; provide details on MMT services; and be published in English between 1 January 2006 until 31 December 2018. RESULTS: Out of the 5594 identified records, 22 studies were eligible for this systematic review. Components of MMT services associated with HIV care cascade outcomes described in the studies were classified in three categories of care models: 1) standard MMT care with adequate doses, 2) standard MMT care and alongside additional medical component(s), and 3) standard MMT care, additional medical component(s) as well as informational or instrumental social support. CONCLUSION: The few studies identified reflect a scarcity of evidence on the role of social support to increase the benefits of MMT for PWUD who are living with HIV. Further research is needed to assess the role of medical and social service components in MMT care delivery in advancing PWUD along the HIV care cascade.

Greater Pain Severity is Associated with Inability to Access Addiction Treatment Among a Cohort of People Who Use Drugs.

AIM: Given that co-occurring pain is prevalent among people who use drugs (PWUD), we sought to explore the effect of pain severity on accessing addiction treatment. METHODS: Data were derived from two prospective cohort studies of PWUD in Vancouver, Canada from June 2014 to May 2016. Multivariable generalized linear mixed-effects multiple regression (GLMM) analyses were used to investigate the association between average pain severity and self-reported inability to access addiction treatment. RESULTS: Among 1348 PWUD, 136 (10.1%) reported being unable to access addiction treatment at least once over the study period. Individuals who reported being unable to access addiction treatment had a significantly higher median average pain severity score (median=5, IQR=0-7) compared to individuals reporting no inability to access addiction treatment (median=3, IQR=0-6, p=0.038). Greater pain severity was independently associated with higher odds of reporting inability to access addiction treatment (AOR: 1.75, 95%CI: 1.08-2.82 for mild-moderate vs no pain; AOR: 1.98, 95%CI: 1.27-3.09 for moderate-severe vs no pain). CONCLUSION: PWUD with greater pain severity may be at higher risk of being unable to access addiction treatment, or vice versa. While further research is needed to confirm causal associations, these data suggest that there may be underlying pathways or mechanisms through which pain may be associated with access to addiction treatment for PWUD.

Characterising the association between positive hepatitis C virus antibody and pain among people who inject drugs.

INTRODUCTION AND AIMS: People who inject drugs (PWID) are a key group within the hepatitis C virus (HCV) pandemic. Chronic pain is a common condition among PWID as these individuals are often exposed to soft tissue infections due to injections and violence. This study aims to characterise the relationship between HCV exposure and pain among PWID. DESIGN AND METHODS: Data were derived from three prospective cohorts of PWID in Vancouver, Canada, between December 2011 and November 2016. The primary outcome was pain severity, which was defined based on the Euroqol EQ-5D-3L pain subscale. A bivariable and multivariable ordinal generalised estimating equations model was used to quantify the association between HCV exposure and pain among participants. RESULTS: One thousand and twelve of 2038 participants (50%) reported moderate/extreme pain at baseline. In total, 1473 (72%) participants were HCV-antibody positive. In unadjusted analyses, HCV exposure was positively associated with increased pain [odds ratio (OR) = 1.47; 95% confidence interval (CI): 1.20-1.81]. However, once adjusted for known confounders in multivariable analyses, HCV exposure did not remain significantly associated with increased pain (adjusted OR = 1.00; 95%CI: 0.78-1.28). DISCUSSION AND CONCLUSIONS: In this sample of PWID, HCV exposure was not significantly associated with pain once other factors were considered. These various factors may explain the elevated risk of pain among PWID and should be addressed in future initiatives when managing pain among PWID with HCV exposure. Future studies should also examine whether pain changes with changes in HCV status (i.e. active vs. cleared infection).

The relationship between childhood emotional abuse and chronic pain among people who inject drugs in Vancouver, Canada.

BACKGROUND: People who inject drugs (PWID) often contend with chronic pain as a result of illness and trauma, and such pain is known to have significant impacts on mental health, quality of life, and substance use behaviours. Although PWID are also known to have high rates of childhood trauma, little is known about how childhood emotional abuse may be associated with chronic pain in this population. OBJECTIVE: We undertook this study to explore emotional abuse and chronic pain among PWID. PARTICIPANTS AND SETTING: This study comprised a total of 1459 participants in Vancouver, Canada between June 2014 and November 2016. METHODS: We employed multivariable generalized estimating equations with data derived from two prospective cohort studies of community-recruited PWID to examine the relationship between childhood emotional abuse and chronic pain in the past six months. RESULTS: Among eligible participants, 591 (40.5%) reported childhood emotional abuse, and 760 (52.1%) reported chronic pain in the previous six months. In a multivariable analysis, experiencing childhood emotional abuse remained independently associated with chronic pain (adjusted odds ratio: 1.25; 95% confidence interval: 1.01-1.53) after adjustment for a range of socio-demographic and drug use confounders. CONCLUSIONS: Our findings suggest that childhood emotional abuse may have lasting relationships with chronic pain among PWID, potentially through established physiological and psychological mechanisms. Current chronic pain treatment may benefit from the evaluation of life course vulnerabilities that may be amenable to earlier interventions. Further, increased availability of effective trauma-informed chronic pain treatment is needed among this vulnerable population.

Dose-response relationship between functional pain interference and nonmedical analgesic use: Findings from a nationally representative Canadian survey.

BACKGROUND: Despite the epidemic of nonmedical analgesic use (NMAU) in North America, there is a scarcity of research quantifying the effect of pain on NMAU. AIMS: This study sought to investigate the relationship between NMAU and functional pain interference, defined as the perceived level of interference in performing activities of daily living due to pain, in a population-based sample of the general Canadian population. METHODS: Data from the 2012 Canadian Community Health Survey (CCHS)-Mental Health, a nationally representative cross-sectional survey, were used to conduct bivariable and multivariable logistic regression analyses. RESULTS: The weighted prevalences of pain and NMAU were 20.6% and 6.6%, respectively. After adjusting for age, sex, education, culture/race, and chronic mental health diagnosis, a dose-response relationship was observed between higher functional pain interference and increased odds of NMAU, ranging from 1.61 (95% confidence interval [CI], 1.22-2.12) to 2.98 (95% CI, 2.21-4.01) from the lowest to the highest levels of functional pain interference. Elevated odds of NMAU were also observed among younger respondents aged 20-29 years and 15-19 years, respondents with a chronic mental illness diagnosis, and males. Secondary analyses revealed that the dose-response relationship between greater function pain interference and increased odds of NMAU persisted within subgroups with and without mental illness, as well as within subgroups aged 40 to 69. CONCLUSIONS: These findings highlight the potential role of pain on increasing NMAU and the need for targeted strategies to reduce harms of NMAU among high-risk subgroups such as young adults.

Contexte: Malgré l'épidémie d'usage non médical d'analgésiques en Amérique du Nord, les études quantifiant l'effet de la douleur sur l'usage non médical d'analgésiques sont peu nombreuses.But: Cette étude visait à étudier le lien entre l'usage non médical d'analgésiques et l'interférence de la douleur sur le plan fonctionnel, définie comme le niveau d'interférence perçu dans la réalisation des activités quotidiennes attribuable à la douleur, au sein d'un échantillon populationnel issu de la population canadienne en général.Méthodes: Des données tirées de l'Enquête sur la santé dans les collectivités canadiennes­ Santé mentale 2012, une enquête transversale représentative au niveau national, ont été utilisées pour mener des analyses de régression logistique bivariée et multivariée.Résultats: La prévalence pondérée de la douleur et de l'usage non médical d'analgésiques était de 20,6 % et de 6,6 % respectivement. Après les ajustements liés à l'âge, au sexe, à l'éducation, à la culture ou à la race, ainsi qu'à un diagnostic de maladie mentale chronique, une relation dose - réponse a été observée entre un niveau plus élevé d'interférence de la douleur sur le plan du fonctionnement et l'augmentation des rapports de cotes de l'usage non médical d'analgésiques, qui allaientt de 1,61 (95 % IC: 1,22 ­ 2,12) à 2,98 (95 % IC : 2,21 ­ 4,01), du niveau le plus faible d'interférence de la douleur sur le plan du fonctionnementau au niveau le plus élevé. Des rapports de cote de l'usage non médical d'analgésiques élevés ont aussi été observés chez les plus jeunes répondants âgés de 20 à 29 ans et de 15 à 19 ans, ainsi que chez les répondants ayant reçu un diagnostic de maladie mentale chronique et chez les hommes. Des analyses secondaires ont révélé que la relation dose ­ réponse entre une plus grande interférence de la douleur sur le plan du fonctionnement et des rapports de cotes de l'usage non médical d'analgésiques plus élevés persistait au sein de sous-groupes atteints et non atteints de maladie mentale, ainsi qu'au sein de sous-groupes de participants âgés de 40 à 69 ans.Conclusions: Ces résultats mettent en lumière le rôle potentiel de la douleur dans l'augmerntation de l'usage non médical d'analgésiques et la nécessité d'avoir recours à des stratégies ciblées pour réduire les effets néfastes causés par l'usage non médical d'analgésiques chez des sous-groupes à haut risque tel que les jeunes adultes.

Chronic pain and opioid misuse: a review of reviews.

OBJECTIVE: The crisis of prescription opioid (PO) related harms has focused attention toward identifying and treating high-risk populations. This review aims to synthesize systematic reviews on the epidemiology and clinical management of comorbid chronic pain and PO or other substance misuse. METHODS: A systematic database search was conducted to identify systematic reviews published between 2000 and 2016. Eligible studies were systematic reviews related to chronic non-cancer pain and PO or other substance misuse. Evidence from the included reviews was synthesized according to epidemiology and clinical management themes. RESULTS: Of 1908 identified articles, 18 systematic reviews were eligible for final inclusion. Two meta-analyses estimated the prevalence of chronic non-cancer pain in individuals using POs non-medically to be approximately 48% to 60%, which is substantially higher than the prevalence of chronic non-cancer pain in general population samples (11% to 19%). Five systematic reviews estimated the rates of PO or other opioid use in chronic pain populations with substantial variation in results (0.05% to 81%), likely due to widely varying definitions of dependence, substance use disorder, misuse, addiction, and abuse. Several clinical assessment and treatment approaches were identified, including: standardized assessment instruments; urine drug testing; medication counts; prescription drug monitoring programs; blood level monitoring; treatment agreements; opioid selection; dosing and dispensing strategies; and opioid agonist treatment. However, the reviews commonly noted serious limitations, inconsistencies, and imprecision of studies, and a lack of evidence on effectiveness or clinical utility for the majority of these strategies. CONCLUSION: Overall, current systematic reviews have found a lack of high-quality evidence or consistent findings on the prevalence, risk factors, and optimal clinical assessment and treatment approaches related to concurrent chronic pain and substance misuse. Given the role of systematic reviews in guiding evidence-based medicine and health policy, there is an urgent need for high-quality primary research to guide future systematic reviews to address the escalating epidemic of harms related to chronic pain and substance misuse.

Treatment of opioid use disorder in an innovative community-based setting after multiple treatment attempts in a woman with untreated HIV.

Opioid use disorder is associated with significant health and social harms. Various evidence-based interventions have proven successful in mitigating these harms, including harm reduction strategies and pharmacological treatment such as methadone. We present a case of a 35-year-old HIV-positive woman who was off antiretroviral therapy due to untreated opioid use disorder, and had a history of frequently self-discharging from hospital against medical advice. During the most recent hospital admission, the patient was transferred to an innovative community-based clinical support residence that supported harm reduction. Initially, she received methadone to only manage the withdrawal symptoms rather than for long-term maintenance therapy. However, with gradual dose increases to treat cravings and withdrawal, she ultimately discontinued all drug use and reinitiated antiretroviral therapy. This case highlights that patients whose goal is not abstinence can be successfully treated for acute medical illnesses and comorbid substance use disorders using harm reduction approaches, including appropriate dosing of pharmacotherapy.

Denial of prescription analgesia among people who inject drugs in a Canadian setting.

INTRODUCTION AND AIMS: Despite the high prevalence of pain among people who inject drugs (PWIDs), clinicians may be reluctant to prescribe opioid-based analgesia to those with a history of drug use or addiction. We sought to examine the prevalence and correlates of PWIDs reporting being denied of prescription analgesia (PA). We also explored reported reasons for and actions taken after being denied PA. DESIGN AND METHODS: Using data from two prospective cohort studies of PWIDs, multivariate logistic regression was used to identify the prevalence and correlates of reporting being denied PA. Descriptive statistics were used to characterise reasons for denials and subsequent actions. RESULTS: Approximately two-thirds (66.5%) of our sample of 462 active PWIDs reported having ever been denied PA. We found that reporting being denied PA was significantly and positively associated with having ever been enrolled in methadone maintenance treatment (adjusted odds ratio 1.76, 95% confidence interval 1.11-2.80) and daily cocaine injection (adjusted odds ratio 2.38, 95% confidence interval 1.00-5.66). The most commonly reported reason for being denied PA was being accused of drug seeking (44.0%). Commonly reported actions taken after being denied PA included buying the requested medication off the street (40.1%) or obtaining heroin to treat pain (32.9%). DISCUSSION AND CONCLUSIONS: These findings highlight the challenges of addressing perceived pain and the need for strategies to prevent high-risk methods of self-managing pain, such as obtaining diverted medications or illicit substances for pain. Such strategies may include integrated pain management guidelines within methadone maintenance treatment and other substance use treatment programs.

Pain Among High-Risk Patients on Methadone Maintenance Treatment.

The complexity of treating concurrent pain and opioid dependence among many methadone-maintained individuals presents a major challenge in many clinical settings. Furthermore, recent expert guidelines have called for increased research on the safety of methadone in the context of chronic pain. This study explores the prevalence and correlates of pain among a prospective cohort of people who use illicit drugs in Vancouver, British Columbia, Canada, who reported enrollment in methadone maintenance treatment (MMT) between 2011 and 2014. Among the 823 participants eligible for this analysis, 338 (40.9%) reported moderate pain and 91 (11.1%) reported extreme pain at the first study visit. In multivariable, generalized, linear mixed model analyses, higher pain severity was positively and independently associated with self-managing pain (adjusted odds ratio [AOR] 2.15, 95% confidence interval [CI] 1.77-2.60), patient perception of methadone dose being too low (AOR 1.82, 95% CI 1.41-2.34), older age (AOR 1.31, 95% CI 1.13-1.51), having a physical disability (AOR 4.59, 95% CI 3.73-5.64), having ever been diagnosed with a mental illness (AOR 1.44, 95% CI 1.13-1.84), white ethnicity (AOR 1.42, 95% CI 1.10-1.83), and marijuana use (AOR 1.25, 95% CI 1.02-1.52). These findings suggest several areas for clinical intervention, particularly related to patient education and alternative analgesic approaches for MMT patients experiencing pain. Perspective: To better understand the complexity of concurrent pain and opioid dependency among individuals on methadone maintenance treatment, this article describes the prevalence and correlates of higher pain severity among methadone-maintained people who use illicit drugs. Patients on methadone with comorbid pain may benefit from education and alternative analgesic approaches.

Depression and sexual risk behaviours among people who inject drugs: a gender-based analysis.

UNLABELLED: Background Although many people who inject drugs (PID) contend with comorbidities, including high rates of mental illness, limited attention has been given to the differences in comorbidities among men and women or the potential links between psychiatric disorders and HIV risk behaviours. We sought to longitudinally examine associations between depression and HIV-related sexual risk behaviours among PID, stratified by gender. METHODS: Data were derived from a prospective cohort of PID in Vancouver, Canada between December 2005 and November 2009. Using generalised estimating equations, we examined the relationship between depressive symptoms and two types of sexual HIV risk behaviours: engaging in unprotected sex; and having multiple sexual partners. All analyses were stratified by self-reported gender. RESULTS: Overall, 1017 PID participated in this study, including 331 (32.5%) women. At baseline, women reported significantly higher depressive symptoms than men (P<0.001). In multivariate generalised estimating equations analyses, after adjustment for potential social, demographic and behavioural confounders, more severe depressive symptomology remained independently associated with engaging in unprotected sex [adjusted odds ratio (AOR)=1.62, 95% confidence interval (CI): 1.18-2.23] and having multiple sexual partners (AOR=1.54, 95% CI: 1.09-2.19) among women, but was only marginally associated with having multiple sexual partners among men (AOR=1.18, 95% CI: 0.98-1.41). CONCLUSIONS: These findings call for improved integration of psychiatric screening and treatment services within existing public health initiatives designed for PID, particularly for women. Efforts are also needed to address sexual risk-taking among female PID contending with clinically significant depression.

Denial of pain medication by health care providers predicts in-hospital illicit drug use among individuals who use illicit drugs.

BACKGROUND: Undertreated pain is common among people who use illicit drugs (PWUD), and can often reflect the reluctance of health care providers to provide pain medication to individuals with substance use disorders. OBJECTIVE: To investigate the relationship between having ever been denied pain medication by a health care provider and having ever reported using illicit drugs in hospital. METHODS: Data were derived from participants enrolled in two Canadian prospective cohort studies between December 2012 and May 2013. Using bivariable and multivariable logistic regression analyses, the relationship between having ever been denied pain medication by a health care provider and having ever reported using illicit drugs in hospital was examined. RESULTS: Among 1053 PWUD who had experienced ≥ 1 hospitalization, 452 (44%) reported having ever used illicit drugs while in hospital and 491(48%) reported having ever been denied pain medication. In a multivariable model adjusted for confounders, having been denied pain medication was positively associated with having used illicit drugs in hospital (adjusted OR 1.46 [95% CI 1.14 to 1.88]). CONCLUSIONS: The results of the present study suggest that the denial of pain medication is associated with the use of illicit drugs while hospitalized. These findings raise questions about how to appropriately manage addiction and pain among PWUD and indicate the potential role that harm reduction programs may play in hospital settings.

Self-management of pain among people who inject drugs in Vancouver.

AIMS: To evaluate factors and methods associated with self-management of pain among people who inject drugs (IDUs) in Vancouver (Canada). PATIENTS & METHODS: This cross-sectional study used bivariate statistics and multivariate logistic regression to analyze self-reported responses among 483 IDUs reporting moderate-to-extreme pain in two prospective cohort studies from 1 December 2012 to 31 May 2013. RESULTS: Median age was 49.6 years (interquartile range: 43.9-54.6 years), 33.1% of IDUs were female and 97.5% reported self-management of pain. Variables independently and positively associated with self-managed pain included having been refused a prescription for pain medication (adjusted odds ratio: 7.83; 95% CI: 1.64-37.3) and having ever been homeless (adjusted odds ratio: 3.70; 95% CI: 1.00-13.7). Common methods of self-management of pain included injecting heroin (52.7%) and obtaining diverted prescription pain medication from the street (65.0%). CONCLUSION: Self-management of pain was common among IDUs who reported moderate-to-extreme pain in this setting, particularly among those who had been refused a prescription for pain medication and those who had ever been homeless. These data highlight the challenges of adequate pain management among IDUs.