Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2022 Jun 22.
Published in final edited form as: Drug Alcohol Depend. 2021 Mar 18;222:108662. doi: 10.1016/j.drugalcdep.2021.108662

Race and Satisfaction with Pain Management among Patients with HIV Receiving Long-Term Opioid Therapy

Anisha P Ganguly 1, Marlene C Lira 2, Sara Lodi 3, Leah S Forman 4, Jonathan A Colasanti 5,6, Emily C Williams 7,8, Jane M Liebschutz 9, Carlos del Rio 5,6, Jeffrey H Samet 2,10,11, Judith I Tsui 12
PMCID: PMC9215531  NIHMSID: NIHMS1811885  PMID: 33775447

Abstract

Introduction:

Management of chronic pain is an essential aspect of HIV primary care. Previous literature in the general population has elucidated racial disparities in the evaluation and treatment of pain. This study examined racial/ethnic differences in patient satisfaction and barriers to pain management among a cohort of PWH receiving LTOT.

Materials and Methods:

Patient-reported survey and EMR data were compared between non-white (n=135; 81.3%) and white (n=31; 18.7%) patients in a cohort of 166 PWH receiving LTOT in two clinics in Atlanta and Boston. Quantile and linear regression were used to evaluate the association between race and pain management outcomes: 1) satisfaction with pain management (0–10) and −2) patient-related barriers to pain management, including patient perceptions of pain medications, fatalism, and communication about pain. Models were adjusted for sex, age, clinical site, and baseline general health.

Results:

Non-white participants were noted to receive chronic opioids for a shorter mean duration of time than white participants (6.0 versus 11.0 years, p<0.001) and lower mean morphine equivalent daily dose (MEDD) than white participants (28.1 versus 66.9 mg, p<0.001). In adjusted analyses, there was no significant difference in satisfaction with pain management among non-white and white participants (p=0.101). There was no significant difference in barriers to pain management in unadjusted (p=0.335) nor adjusted models (p=0.397).

Conclusion:

While non-white PWH were noted to have received lower doses of chronic opioids and for shorter duration than white PWH, satisfaction with pain management was similar. Patient-related barriers to pain management were similar among non-white and white PWH.

Keywords: racial disparities, HIV, chronic opioids, satisfaction with pain management

1. Introduction

As HIV has evolved into a chronic disease with complex comorbidities, chronic pain management among people with HIV (PWH) has become a necessary component of HIV primary care (Jiao et al., 2016; Miaskowski et al., 2011). PWH represent a patient population with complex medical needs and social determinants of health that may shape chronic pain and attitudes towards the management of pain (Merlin et al., 2014; Uebelacker et al., 2015). While PWH commonly experience chronic pain similar to the general population such as chronic lower back pain and osteoarthritis (Perry et al., 2013), PWH are also at risk for specific HIV-associated pain syndromes, such as HIV peripheral neuropathy and osteonecrosis (Borges et al., 2017; Kaku and Simpson, 2014). Previous research by Merlin and colleagues has delineated a biopsychosocial framework for chronic pain in HIV emphasizing how unique biological factors, co-morbid psychiatric illness, substance use disorder, and environmental stressors shape the experience of chronic pain among PWH (Merlin et al., 2014).

In the United States, non-white people are disproportionately represented among PWH, with African-Americans comprising 45% of PWH, compared to 13% of the general population (CDC, 2020a, 2020b; Song et al., 2017; U.S. Census Bureau, 2019). Disparities in access and utilization of pre-exposure prophylaxis (PrEP) among certain demographics has driven racial disparities in HIV incidence (Goldstein et al., 2018; Marcus et al., 2016). In addition to disparities in epidemiology, racial disparities in clinical outcomes such as viral suppression, medication adherence, and HIV-associated mortality have been previously characterized (Castel et al., 2016; Lemly et al., 2009; Rubin et al., 2010). Within the domain of HIV primary care, non-white PWH have been shown to be less likely to achieve guideline-appropriate control of co-morbid hypertension, diabetes, and hyperlipidemia (Richardson et al., 2016). Given the layers of disparities that exist at the level of HIV prevention, HIV treatment, and HIV primary care, racial disparities likely occur in the management of chronic pain among PWH. Systemic racism and implicit bias may present additional challenges for non-white PWH engaging in chronic pain management.

Prior studies in the general population have demonstrated that racial disparities exist in how pain is assessed and treated, with non-white patients often reporting higher pain burden and untreated pain in a variety of clinical settings (Anderson et al., 2009; Green et al., 2003). Previous research in the outpatient setting analyzing data from the National Ambulatory Medical Care Survey demonstrated racial disparities among black and Hispanic patients in receipt of opioids for back pain and abdominal pain (Ly, 2019). Furthermore, research in the primary care setting on chronic non-cancer pain has shown that racial disparities in pain management have a significant impact on quality of life (Ezenwa and Fleming, 2012).

Racial/ethnic differences among PWH with chronic pain have been relatively unexplored to date but may have important implications for the delivery of equitable care for PWH. The objective of this study was to assess differences in patient satisfaction with pain management and barriers to pain management by race among a cohort of PWH receiving long-term opioid therapy (LTOT). Given prior research demonstrating inequities in pain burden and treatment among non-white patients, we hypothesized that non-white PWH would report lower satisfaction with chronic pain management and increased barriers to pain management.

2. Materials and Methods

Patient Cohort and Data Source

We conducted a cross-sectional analysis of baseline survey and electronic medical record (EMR) data from a cohort of PWH receiving LTOT that was included as part of a pragmatic clinical trial of an intervention targeted to providers to improve opioid prescribing in two HIV clinics in Atlanta and Boston (NCT02564341), details of which have previously been published (Lira et al., 2019; Samet et al., 2020). Recruitment for the cohort took place from July 2015 to December 2016. Inclusion criteria for the cohort participants included (1) ≥18 years of age, (2) diagnosis of HIV infection, (3) receipt of ≥3 opioid prescriptions ≥21 days apart within a 6 month period in the prior year, and (4) attendance at least 1 visit to the study clinical sites within the prior 18 months. Exclusion criteria included (1) provision of contact information of two individuals to assist with follow-up during the study, (2) possession of a telephone, and (3) English proficiency. Participation in the cohort study was open to all patients on LTOT, not just those whose providers were enrolled in the parallel clinical trial.

Study Design and Measures

The exposure for this study was self-reported race, defined as non-white, comprised of those who identified as African American (73%) and other race (9%, includes those reporting more than one race) vs. white. Descriptive statistics were used to compare demographic data, HIV outcomes, behavioral risk factors, diagnosis of opioid use disorder, patient-reported duration of chronic pain, duration of LTOT, reported pain severity as measured by the Brief Pain Inventory (Tan et al., 2004), and morphine equivalent daily dose (MEDD) across race groups. The primary outcome was patient satisfaction with pain management (0, “not at all satisfied” to 10, “extremely satisfied”), comprised of an average of four questions evaluating patient satisfaction with the clinic, medications, physician interaction, and nursing interaction, all as related to pain management. The secondary outcome was patient-related barriers towards pain management, as quantified using a modified version of the Barriers Questionnaire (BQ-II), a standardized tool used to assess beliefs towards chronic pain (Gunnarsdottir et al., 2002; Kwon et al., 2013). The BQ-II is a 27-item questionnaire encompassing four domains of patient-related barriers to pain management, including perceptions of physiologic effects of pain medications, fatalism towards pain management, communication about pain, and perceived harm of pain management. Composite scores were calculated by taking the average of included BQ-II questions ranging from 0 to 5, with higher scores representing increased barriers towards management of chronic pain (Gunnarsdottir et al., 2002).

Analytic Methods

Quantile regression was used to evaluate the association between race and patient satisfaction due to right-skewed distribution of patient-reported satisfaction. Because satisfaction scores were generally high, we examined differences in the 25th percentile for this outcome, as this was where we hypothesized differences in satisfaction would occur. Linear regression was used to evaluate the relationship between race and barriers towards pain management. All models were adjusted a priori for age, sex, clinical site, and baseline general health as determined by the Veterans RAND 12-item health survey (Le et al., 2006). Additional exploratory analyses adjusted for duration of chronic pain and for pain severity. Analyses were conducted using SAS 9.4. Institutional Review Boards of Boston University, Emory University, and the Grady Research Oversight Committee approved this study.

3. Results

The study population included 166 PWH, 135 (81.3%) non-white and 31 (18.7%) white (Table 1). There were no significant differences between non-white and white participants in sex, age, clinical site, or baseline general health. Non-white participants were more likely to self-identify as heterosexual than white participants. White participants were more likely to be MSM and report injection drug use as risk factors for HIV infection than non-white participants. White participants had been diagnosed with HIV for longer than non-white participants, 21.4 compared to 17.3 years (p=0.014). There were no significant differences in HIV viral suppression or CD4 count between non-white and white participants. While white participants had a higher rate of lifetime use of illicit opioids and injection drug use, there was no significant difference in diagnosis of opioid use disorder during the past year. White participants reported longer duration of chronic pain, 13.9 years, compared to 7.3 years among non-white participants. Non-white participants had been taking chronic opioids for a mean duration of 6.0 years, compared to 11.0 years among white participants (p<0.001). Non-white participants were prescribed a mean MEDD of 28.1 mg, compared to 66.9 mg for white participants (p<0.001).

Table 1:

Demographics and Baseline Characteristics of Non-white and White PWH

Characteristic Overall

(n=166)		 Non-white

(n=135)		 White

(n=31)		 P-value
Male 108 (65.1%) 86 (63.7%) 22 (71.0%) 0.123
Hispanic 15 (9.0%) 14 (10.4%) 1 (3.2%) 0.437
Study Site
 Boston 54 (32.5%) 40 (29.6%) 14 (45.2%) 0.096
 Atlanta 112 (67.5%) 95 (70.4%) 17 (54.8%)
Baseline General Health Score from Veterans RAND 12 Item Health Survey (VR-12), Mean (St Dev) 35.1 (10.6) 35.3 (10.7) 34.2 (10.4) 0.589
Current smoker 91 (54.8%) 71 (52.6%) 20 (64.5%) 0.229
Sexual Orientation
 Straight/Heterosexual 112 (67.5%) 97 (71.9%) 15 (48.4%) 0.003
 Gay/Lesbian/Queer/Homosexual 38 (22.9%) 23 (17.0%) 15 (48.4%)
 Bisexual 15 (9.0%) 14 (10.4%) 1 (3.2%)
 Other 1 (0.6%) 1 (0.7%) 0 (0.0%)
HIV Transmission Route
 MSM/IV Drug Use 9 (5.4%) 4 (3.0%) 5 (16.1%) 0.005
 MSM only 42 (25.3%) 32 (23.7%) 10 (32.3%)
 IV Drug Use 20 (12.0%) 14 (10.4%) 6 (19.4%)
 Blood Products 13 (7.8%) 11 (8.1%) 2 (6.5%)
 Presumed heterosexual only 82 (49.4%) 74 (54.8%) 8 (25.8%)
Years Since HIV Diagnosis, Mean Years (St Dev) 18.1 (8.4) 17.3 (8.8) 21.4 (5.4) 0.014
HIV Viral Suppression
 HIV Viral Load <200 copies/ml 147 (89.1%) 118 (88.1%) 29 (93.5%) 0.53
 HIV Viral Load >200 copies/ml 18 (10.9%) 16 (11.9%) 2 (6.5%)
CD4 Count, Median (IQR) 449 (308–695) 446 (303–667) 478 (350–810) 0.61
Current Diagnosis of Opioid Use Disorder 32 (19.4%) 26 (19.4%) 6 (19.4%) 0.99
Lifetime Use of Illicit Opioids 43 (25.9%) 29 (21.5%) 14 (45.2%) 0.007
Lifetime Injection Drug Use 39 (25.3%) 25 (19.8%) 14 (50.0%) <0.001
Reported Duration of Pain, Mean Years (St Dev) 8.5 (8.2) 7.3 (7.2) 13.9 (10.1) <0.001
Duration of Prescription Opioid Use, Mean Years (St Dev) 7.0 (7.0) 6.0 (6.6) 11.0 (7.3) <0.001
Pain Severity Subscale from Brief Pain Inventory, Mean (St Dev) 6.3 (2.2) 6.5 (2.1) 5.4 (2.2) 0.006
Mean Morphine Equivalent Daily Dose (mg) Mean (St Dev) 35.3 (53.6) 28.1 (42.1) 66.9 (81.2) <0.001
Patient Satisfaction with Pain Management * 8.4 (2.0) 8.5 (1.8) 7.7 (2.4) 0.022
Patient Barriers to Pain Management Score ** 2.6 (1.1) 2.7 (1.2) 2.4 (1.0) 0.340
Open in a new tab
*

0=not at all satisfied, 10=extremely satisfied

**

0=pain beliefs presenting no barrier to pain management, 5=pain beliefs presenting strong barrier to pain management

In unadjusted analyses, non-white race was associated with higher satisfaction with pain management (difference in 25th percentiles 1.17, CI 0.04–2.30, p=0.043) but not in barriers to pain management (difference in means 0.21, CI −0.22–0.65, p=0.335) (Table 2). After adjusting for sex, age, clinical site, and baseline general health, there was no significant difference between white and non-white groups for satisfaction with pain management (adjusted difference in 25th percentiles 1.02, CI −0.20–2.24, p=0.101) or barriers to pain management (adjusted difference in means 0.19, CI −0.25–0.63, p=0.397). Results did not materially change in additional models adjusting for duration of chronic pain when the outcome was satisfaction with pain management (adjusted difference in 25th percentiles 0.98, CI −0.20–2.15, p=0.103) nor when the outcome was barriers to pain management (adjusted difference in means 0.26, CI −0.20–0.72, p=0.269). After adjustment for pain severity, non-white race was associated with higher satisfaction with pain management (difference in 25th percentiles 1.47, CI 0.12–2.82, p=0.033) but not in barriers to pain management (difference in means 0.16, CI −0.29–0.61, p=0.495).

Table 2:

Relationships between Race and Patient Satisfaction with Pain Management and Barriers to Pain Management among 166 PWH

Patient Satisfaction towards Pain Management (25th Percentile Regression) Patient Barriers to Pain Management (Linear Regression)
Unadjusted Difference in 25th Percentile (CI) Adjusted Difference in 25th Percentile (CI) Unadjusted Difference in Means (95% CI) Adjusted Difference in Means (95% CI)
Race 1.17 (0.04, 2.30)* 1.02 (−0.20, 2.24) 0.21 (−0.22, 0.65) 0.19 (−0.25, 0.63)
Sex 0.41 (−0.66, 1.48) 0.33 (−0.04, 0.69)
Age −0.14 (−0.72, 0.45) −0.01 (−0.23, 0.22)
Site −0.68 (−1.7, 0.34) 0.02 (−0.35, 0.39)
Baseline General Health 0.07 (0.02, 0.11)** −0.01 (−0.02, 0.01)
Open in a new tab
*

p<0.05

**

p<0.01

4. Discussion

In this analysis, we describe differences in patient satisfaction with pain management for non-white relative to white individuals within a population of PWH on LTOT. Overall, patient satisfaction with chronic pain management was high across both groups, with an average score of 8.37 out of 10. While non-white participants were noted to have reported higher pain severity and to have received lower doses of opioids and for shorter duration, we did not observe lower satisfaction in their pain management, nor did we observe any differences reflecting increased barriers to pain management.

Previous literature in non-HIV populations has shown that non-white patients are more likely to report under-treatment of pain. Among PWH, non-white patients have been found to underreport HIV-related symptom burden, including pain (Lee et al., 2009; Schnall et al., 2018). Given that non-white PWH have been shown to have suboptimal management of co-morbid chronic conditions like diabetes and hypertension (Richardson et al., 2016), we hypothesized that similar disparities would manifest in the management of chronic pain.

Consistent with prior studies in the general population, we found differences in receipt of opioid therapy among non-white compared to white patients. To our knowledge, these findings represent the first assessment of racial/ethnic differences in pain management among PWH receiving LTOT. However, unlike previous literature in non-HIV populations, our study demonstrates that satisfaction with chronic pain management was not worse among non-white compared to white PWH receiving LTOT, despite higher reported pain severity and differences in the quantity and duration of receipt of opioids. These findings were contrary to what was hypothesized.

Although somewhat surprising, results may be viewed as consistent with our current understanding of the limitations of opioids for chronic pain. Research in the general population has clearly shown that chronic opioid therapy is not associated with less pain, and carries substantial risks, over time, compared to non-opioid strategies (Krebs et al., 2018). Individuals receiving higher doses of LTOT may report lower satisfaction with pain management due to perceived inefficacy of LTOT and thus requesting higher doses or due to complications from LTOT like opioid-induced hyperalgesia (Lee et al., 2011). Furthermore, HIV pain syndromes are often treated more effectively with non-opioid treatment modalities, and increased doses or duration of LTOT results do not necessarily yield increased satisfaction with chronic pain management among PWH (Krashin et al., 2012).

Within the population of PWH, chronic pain has been known to intersect with psychosocial factors, including substance use (Merlin et al., 2014). Among our study population, there was no difference in current diagnosis of opioid use disorder among non-white and white PWH, though white participants reported increased lifetime use of illicit opioids and injection drug use. This could indicate that white patients may have had higher thresholds for opioid response due to prior opioid use. Additionally, white PWH were more likely to be MSM and report injection drug use as risk factors for HIV transmission than non-white PWH. These differences in behavioral risk factors may signal differing prior experience with pain management. Behavioral risk factors like prior substance use may have contributed to the increased dosage and longer duration of LTOT observed among white PWH compared to non-white PWH. Additionally, white PWH had been diagnosed with HIV for longer than non-white PWH, which could similarly connote experience in the healthcare system and in advocating for health needs, including for chronic pain.

These results may also indicate that many other factors influence patients’ satisfaction with pain management rather than opioid therapy alone. Possible factors may include strong patient-provider relationships and high levels of patient engagement, both of which are associated with increased patient satisfaction among PWH (Flickinger et al., 2013; Mûnene and Ekman, 2015; Sullivan et al., 2000). These factors may be particularly significant for non-white PWH overcoming systemic barriers in order to engage in long-term pain management (Mitchell et al., 2017). Additionally, provider-level factors could have bridged the gap between pain severity and satisfaction with pain management observed among non-white PWH. Given that the study sites were at two academic medical centers that have historically emphasized care of the underserved, provider bias that often impedes chronic pain management for non-white PWH may have been mitigated. The study population consisted of majority non-white patients, which could suggest that these clinical sites and therefore their healthcare providers may have had more experience in delivering equitable care for a diverse patient population.

These findings may also suggest that non-white PWH do not report lower satisfaction despite lower levels of pain treatment because of lower expectations for pain management as a result of longstanding structural racism in how pain is managed across medical settings. The differences in receipt of treatment noted in these study findings may reflect differences in upstream social determinants of health which are often associated with race (LaVeist, 2005). Per the theory of fundamental causes, differences in socioeconomic status contribute to health disparities through the ability to engage with the healthcare system, access to resources and social capital to advocate for health (Phelan and Link, 2013). As demonstrated by previous research demonstrating that non-white PWH underreport symptom burden (Schnall et al., 2018), non-white PWH may not feel empowered or be equipped to advocate for pain management as strongly as white PWH. In our study population, non-white PWH did report higher pain severity but demonstrated similar satisfaction with pain management, despite receipt of lower doses of LTOT and for shorter duration. These ostensibly contradictory findings could be explained by lowered expectations for pain management among non-white PWH navigating a healthcare system that has been historically less receptive their pain needs (Akinlade, 2020; Ghoshal et al., 2020). White PWH in this study may have received higher doses of LTOT and for longer duration because of increased efficiency in interacting with a healthcare system more explicitly designed for them compared to non-white participants. Conversely, non-white PWH seeking management for chronic pain may encounter a healthcare system more primed to underestimate their reported pain or to label their pain concerns as drug-seeking (Burgess et al., 2008).

It is heartening that this study found satisfaction in pain management was overall high among non-white and white patients alike, as management of chronic pain among PWH is important not only for patient satisfaction with care, but also for clinical outcomes. Suboptimal management of chronic pain has been associated with lower adherence to antiretroviral (ARV) medications (Surratt et al., 2015), and LTOT specifically has been associated with lower rates of virologic failure (Merlin et al., 2018). Management of chronic pain among PWH also impacts patient retention and healthcare utilization (Jiao et al., 2016; Merlin et al., 2012).

These study findings should be considered in the context of its limitations. Overall, patient satisfaction was high among this population of PWH receiving LTOT over the course of multiple years. Individuals with lower satisfaction who may have left to seek care elsewhere earlier in the course of treatment may not be represented in these findings. African American and Hispanic/Latinx participants were grouped together as “non-white” due to small sample size. However, a corresponding strength of this study is the larger percentage of non-white participants (81.3%), which provides greater insight into the experience of chronic pain among non-white PWH, a population of individuals often underrepresented in pain research. Nonetheless, the greater percentage of non-white participants in this study reflects the demographics of the clinical sites, one of which serves a primarily non-white, African-American patient population, which may not be generalizable to all settings. The study population represented two clinical sites, Boston and Atlanta, which differed in racial distribution between their clinic patient populations. Additionally, the study participants received care in academic institutions in large urban areas, which may not be reflective of other settings delivering HIV care. The study was cross-sectional at one time point and does not capture patient satisfaction or attitudes over time. We did not directly assess patient perceptions of racism or bias with regards to LTOT in this study, and interpretations should be considered hypothesis-generating.

5. Conclusions

In summary, we observed that among PWH receiving LTOT, satisfaction with pain management was not lower among non-white participants compared to white participants, and patient-related barriers to pain management were similar among both groups. These findings add to the body of literature on pain disparities by assessing for differences in pain management among the unique population of PWH. This study may provide insights for providers caring for PWH with chronic pain and support the delivery of guideline-concordant, culturally competent care.

Highlights.

  • Non-white PWH received lower doses and shorter courses of opioids than white PWH.

  • Pain satisfaction was not significantly different among non-white and white PWH.

  • Barriers to pain management were similar among non-white and white PWH.

Acknowledgements

The authors thank Ellie Pickering for her contribution to literature review for this study.

Role of Funding Source

The original trial from which the data in this project was derived was supported by the National Institute on Drug Abuse under grant R01DA037768; the Center for AIDS Research at Emory University under Grant P30AI050409; and the Providence/Boston Center for AIDS Research under grant P30AI042853. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug Abuse or the National Institutes of Health.

Appendix 1:

Chronic Pain Conditions across Non-White and White PWH

Pain Condition Non-White White
Abdominal Pain 3 (2.2%) 1 (3.2%)
Arthritis 8 (6.0%) 1 (3.2%)
Avascular Necrosis 9 (6.7%) 0 (0%)
Back Pain 28 (20.9%) 6 (19.4%)
Cancer 4 (3.0%) 0 (0%)
Cervical Pain 2 (1.5%) 1 (3.2%)
Chest Pain 3 (2.2%) 0 (0%)
Dermatological Problem 2 (1.5%) 0 (0%)
Fibromyalgia 2 (1.5%) 1 (3.2%)
Genital/Rectal Pain 2 (1.5%) 0 (0%)
Headaches/Migraines 3 (2.2%) 2 (6.5%)
HIV Pain 0 (0%) 1 (3.2%)
Joint Pain 25 (18.7%) 3 (9.7%)
Multiple Pains 17 (12.7%) 7 (22.6%)
Peripheral Neuropathy 16 (11.9%) 7 (22.6%)
Post-Surgical Pain 3 (2.2%) 0 (0%)
Postherpetic Neuralgia 2 (1.5%) 0 (0%)
Sciatica 2 (1.5%) 0 (0%)
Unspecified Chronic Pain 3 (2.2%) 1 (3.2%)
Open in a new tab

Footnotes

Declaration of Competing Interest

No conflicts declared.

Author Disclosures

All authors report no potential conflicts of interest.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

References

  1. Akinlade O, 2020. Taking Black Pain Seriously [WWW Document]. N. Engl. J. Med URL 10.1056/NEJMpv2024759 (accessed 12.24.20). [DOI] [PubMed]
  2. Anderson KO, Green CR, Payne R, 2009. Racial and Ethnic Disparities in Pain: Causes and Consequences of Unequal Care. J. Pain 10, 1187–1204. 10.1016/j.jpain.2009.10.002 [DOI] [PubMed] [Google Scholar]
  3. Borges ÁH, Hoy J, Florence E, Sedlacek D, Stellbrink H-J, Uzdaviniene V, Tomazic J, Gargalianos-Kakolyris P, Schmid P, Orkin C, Pedersen C, Leen C, Pradier C, Mulcahy F, Ridolfo AL, Staub T, Maltez F, Weber R, Flamholc L, Kyselyova G, Lundgren JD, Mocroft A, EuroSIDA F, 2017. Antiretrovirals, Fractures, and Osteonecrosis in a Large International HIV Cohort. Clin. Infect. Dis 64, 1413–1421. 10.1093/cid/cix167 [DOI] [PubMed] [Google Scholar]
  4. Burgess DJ, Crowley-Matoka M, Phelan S, Dovidio JF, Kerns R, Roth C, Saha S, van Ryn M, 2008. Patient race and physicians’ decisions to prescribe opioids for chronic low back pain. Soc. Sci. Med 1982 67, 1852–1860. 10.1016/j.socscimed.2008.09.009 [DOI] [PubMed] [Google Scholar]
  5. Castel AD, Kalmin MM, Hart RLD, Young HA, Hays H, Benator D, Kumar P, Elion R, Parenti D, Ruiz ME, Wood A, D’Angelo L, Rakhmanina N, Rana S, Bryant M, Hebou A, Fernández R, Abbott S, Peterson J, Wood K, Subramanian T, Binkley J, Happ LP, Kharfen M, Masur H, Greenberg AE, 2016. Disparities in achieving and sustaining viral suppression among a large cohort of HIV-infected persons in care – Washington, DC. AIDS Care 28, 1355–1364. 10.1080/09540121.2016.1189496 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. CDC, 2020a. HIV and African Americans [WWW Document]. URL https://www-cdc-gov.offcampus.lib.washington.edu/hiv/group/racialethnic/africanamericans/index.html (accessed 10.4.20).
  7. CDC, 2020b. HIV and Hispanics/Latinos [WWW Document]. URL https://www.cdc.gov/hiv/group/racialethnic/hispaniclatinos/index.html (accessed 10.4.20).
  8. Ezenwa MO, Fleming MF, 2012. Racial Disparities in Pain Management in Primary Care. J. Health Disparities Res. Pract 5, 12–26. [PMC free article] [PubMed] [Google Scholar]
  9. Flickinger TE, Saha S, Moore RD, Beach MC, 2013. Higher Quality Communication and Relationships are Associated with Improved Patient Engagement in HIV Care. J. Acquir. Immune Defic. Syndr 1999 63, 362–366. 10.1097/QAI.0b013e318295b86a [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Ghoshal M, Shapiro H, Todd K, Schatman ME, 2020. Chronic Noncancer Pain Management and Systemic Racism: Time to Move Toward Equal Care Standards. J. Pain Res 13, 2825–2836. 10.2147/JPR.S287314 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Goldstein RH, Streed CG, Cahill SR, 2018. Being PrEPared — Preexposure Prophylaxis and HIV Disparities. N. Engl. J. Med 379, 1293–1295. 10.1056/NEJMp1804306 [DOI] [PubMed] [Google Scholar]
  12. Green CR, Anderson KO, Baker TA, Campbell LC, Decker S, Fillingim RB, Kaloukalani DA, Lasch KE, Myers C, Tait RC, Todd KH, Vallerand AH, 2003. The Unequal Burden of Pain: Confronting Racial and Ethnic Disparities in Pain. Pain Med 4, 277–294. 10.1046/j.1526-4637.2003.03034.x [DOI] [PubMed] [Google Scholar]
  13. Gunnarsdottir S, Donovan HS, Serlin RC, Voge C, Ward S, 2002. Patient-related barriers to pain management: the barriers questionnaire II (BQ-II). PAIN 99, 385–396. 10.1016/S0304-3959(02)00243-9 [DOI] [PubMed] [Google Scholar]
  14. Jiao JM, So E, Jebakumar J, George MC, Simpson DM, Robinson-Papp J, 2016. Chronic pain disorders in HIV primary care: clinical characteristics and association with healthcare utilization. PAIN 157, 931–937. 10.1097/j.pain.0000000000000462 [DOI] [PubMed] [Google Scholar]
  15. Kaku M, Simpson DM, 2014. HIV neuropathy. Curr. Opin. HIV AIDS 9, 521–526. 10.1097/COH.0000000000000103 [DOI] [PubMed] [Google Scholar]
  16. Krashin D, Merrill J, Trescot A, 2012. Opioids in the management of HIV-related pain. Pain Physician 15, ES157–68. [PubMed] [Google Scholar]
  17. Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, Kroenke K, Bair MJ, Noorbaloochi S, 2018. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA 319, 872–882. 10.1001/jama.2018.0899 [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Kwon JH, Hui D, Chisholm G, Hong WT, Nguyen L, Bruera E, 2013. Experience of Barriers to Pain Management in Patients Receiving Outpatient Palliative Care. J. Palliat. Med 16, 908–914. 10.1089/jpm.2012.0610 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. LaVeist TA, 2005. Disentangling race and socioeconomic status: A key to understanding health inequalities. J. Urban Health 82, iii26–iii34. 10.1093/jurban/jti061 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Le K, A, S., W, R., Xs R, A L, Dr M, 2006. Dissemination of Methods and Results From the Veterans Health Study: Final Comments and Implications for Future Monitoring Strategies Within and Outside the Veterans Healthcare System [WWW Document]. J. Ambulatory Care Manage 10.1097/00004479-200610000-00007 [DOI] [PubMed] [Google Scholar]
  21. Lee KA, Gay C, Portillo CJ, Coggins T, Davis H, Pullinger CR, Aouizerat BE, 2009. Symptom Experience in HIV-Infected Adults: A Function of Demographic and Clinical Characteristics. J. Pain Symptom Manage 38, 882–893. 10.1016/j.jpainsymman.2009.05.013 [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Lee M, Silverman S, Hansen H, Patel V, Manchikanti L, 2011. A comprehensive review of opioid-induced hyperalgesia. Pain Physician 14, 145–161. [PubMed] [Google Scholar]
  23. Lemly DC, Shepherd BE, Hulgan T, Rebeiro P, Stinnette S, Blackwell RB, Bebawy S, Kheshti A, Sterling TR, Raffanti SP, 2009. Race and Sex Differences in Antiretroviral Therapy Use and Mortality among HIV-Infected Persons in Care. J. Infect. Dis 199, 991–998. 10.1086/597124 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Lira MC, Tsui JI, Liebschutz JM, Colasanti J, Root C, Cheng DM, Walley AY, Sullivan M, Shanahan C, O’Connor K, Abrams C, Forman LS, Chaisson C, Bridden C, Podolsky MC, Outlaw K, Harris CE, Armstrong WS, del Rio C, Samet JH, 2019. Study Protocol for the Targeting Effective Analgesia in Clinics for HIV (TEACH) Study – A Cluster Randomized Controlled Trial and Parallel Cohort to Increase Guideline Concordant Care for Long-term Opioid Therapy among People Living with HIV. HIV Res. Clin. Pract 20, 48–63. 10.1080/15284336.2019.1627509 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Ly DP, 2019. Racial and Ethnic Disparities in the Evaluation and Management of Pain in the Outpatient Setting, 2006–2015. Pain Med. Malden Mass 20, 223–232. 10.1093/pm/pny074 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Marcus JL, Hurley LB, Hare CB, Silverberg MJ, Volk JE, 2016. Disparities in uptake of HIV preexposure prophylaxis in a large integrated healthcare system. Am. J. Public Health 106, e2. 10.2105/AJPH.2016.303339 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Merlin JS, Long D, Becker WC, Cachay ER, Christopoulos KA, Claborn K, Crane HM, Edelman EJ, Harding R, Kertesz SG, Liebschutz JM, Mathews WC, Mugavero MJ, Napravnik S, O’Cleirigh C, C., Saag MS, Starrels JL, Gross R, 2018. Brief Report: The Association of Chronic Pain and Long-Term Opioid Therapy With HIV Treatment Outcomes. JAIDS J. Acquir. Immune Defic. Syndr 79, 77–82. 10.1097/QAI.0000000000001741 [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Merlin JS, Westfall AO, Raper JL, Zinski A, Norton WE, Willig JH, Gross R, Ritchie CS, Saag MS, Mugavero MJ, 2012. Pain, Mood, and Substance Abuse in HIV: Implications for Clinic Visit Utilization, ART Adherence, and Virologic Failure. J. Acquir. Immune Defic. Syndr 1999 61, 164–170. 10.1097/QAI.0b013e3182662215 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Merlin JS, Zinski A, Norton WE, Ritchie CS, Saag MS, Mugavero MJ, Treisman G, Hooten WM, 2014. A Conceptual Framework for Understanding Chronic Pain in Patients with HIV. Pain Pract 14, 207–216. 10.1111/papr.12052 [DOI] [PubMed] [Google Scholar]
  30. Miaskowski C, Penko JM, Guzman D, Mattson JE, Bangsberg DR, Kushel MB, 2011. Occurrence and Characteristics of Chronic Pain in a Community-Based Cohort of Indigent Adults Living With HIV Infection. J. Pain 12, 1004–1016. 10.1016/j.jpain.2011.04.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Mitchell MM, Nguyen TQ, Maragh-Bass AC, Isenberg SR, Beach MC, Knowlton AR, 2017. Patient-Provider Engagement and Chronic Pain in Drug-Using, Primarily African American Persons Living with HIV/AIDS. AIDS Behav. 21, 1768–1774. 10.1007/s10461-016-1592-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Mûnene E, Ekman B, 2015. Association between patient engagement in HIV care and antiretroviral therapy medication adherence: cross-sectional evidence from a regional HIV care center in Kenya. AIDS Care 27, 378–386. 10.1080/09540121.2014.963020 [DOI] [PubMed] [Google Scholar]
  33. Perry BA, Westfall AO, Molony E, Tucker R, Ritchie C, Saag MS, Mugavero MJ, Merlin JS, 2013. Characteristics of an Ambulatory Palliative Care Clinic for HIV-Infected Patients. J. Palliat. Med 16, 934–937. 10.1089/jpm.2012.0451 [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Phelan JC, Link BG, 2013. Fundamental Cause Theory, in: Cockerham WC (Ed.), Medical Sociology on the Move: New Directions in Theory. Springer; Netherlands, Dordrecht, pp. 105–125. 10.1007/978-94-007-6193-3_6 [DOI] [Google Scholar]
  35. Richardson KK, Bokhour B, McInnes DK, Yakovchenko V, Okwara L, Midboe AM, Skolnik A, Vaughan-Sarrazin M, Asch SM, Gifford AL, Ohl ME, 2016. Racial Disparities in HIV Care Extend to Common Comorbidities: Implications for Implementation of Interventions to Reduce Disparities in HIV Care. J. Natl. Med. Assoc 108, 201–210.e3. 10.1016/j.jnma.2016.08.001 [DOI] [PubMed] [Google Scholar]
  36. Rubin MS, Colen CG, Link BG, 2010. Examination of Inequalities in HIV/AIDS Mortality in the United States From a Fundamental Cause Perspective. Am. J. Public Health 100, 1053–1059. 10.2105/AJPH.2009.170241 [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Samet JH, Tsui JI, Cheng DM, Liebschutz JM, Lira MC, Walley AY, Colasanti JA, Forman LS, Root C, Shanahan CW, Sullivan MM, Bridden CL, Abrams C, Harris C, Outlaw K, Armstrong WS, del Rio C, 2020. Improving the Delivery of Chronic Opioid Therapy Among People Living With Human Immunodeficiency Virus: A Cluster Randomized Clinical Trial. Clin. Infect. Dis 10.1093/cid/ciaa1025 [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Schnall R, Siegel K, Jia H, Olender S, Hirshfield S, 2018. Racial and Socioeconomic Disparities in the Symptom Profile of Persons Living with HIV. AIDS Care 30, 774–783. 10.1080/09540121.2017.1417532 [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Song R, Hall HI, Green TA, Szwarcwald CL, Pantazis N, 2017. Using CD4 Data to Estimate HIV Incidence, Prevalence, and Percent of Undiagnosed Infections in the United States. JAIDS J. Acquir. Immune Defic. Syndr 74, 3–9. 10.1097/QAI.0000000000001151 [DOI] [PubMed] [Google Scholar]
  40. Sullivan LM, Stein MD, Savetsky JB, Samet JH, 2000. The Doctor–Patient Relationship and HIV-infected Patients’ Satisfaction with Primary Care Physicians. J. Gen. Intern. Med 15, 462–469. 10.1046/j.1525-1497.2000.03359.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Surratt HL, Kurtz SP, Levi-Minzi MA, Cicero TJ, Tsuyuki K, O’Grady CL, 2015. Pain Treatment and Antiretroviral Medication Adherence Among Vulnerable HIV-Positive Patients. AIDS Patient Care STDs 29, 186–192. 10.1089/apc.2014.0104 [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Tan G, Jensen MP, Thornby JI, Shanti BF, 2004. Validation of the brief pain inventory for chronic nonmalignant pain. J. Pain 5, 133–137. 10.1016/j.jpain.2003.12.005 [DOI] [PubMed] [Google Scholar]
  43. Uebelacker LA, Weisberg RB, Herman DS, Bailey GL, Pinkston-Camp MM, Stein MD, 2015. Chronic Pain in HIV-Infected Patients: Relationship to Depression, Substance Use, and Mental Health and Pain Treatment. Pain Med. 16, 1870–1881. 10.1111/pme.12799 [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. U.S. Census Bureau, 2019. U.S. Census Bureau QuickFacts: United States [WWW Document]. URL https://www.census.gov/quickfacts/fact/table/US/RHI225219 (accessed 10.4.20).

RESOURCES