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. Author manuscript; available in PMC: 2024 Apr 1.
Published in final edited form as: AIDS Care. 2022 Jun 2;35(4):614–623. doi: 10.1080/09540121.2022.2076801

Chronic pain and substance use disorders among older sexual minority men living with HIV: Implications for HIV disease management across the HIV care continuum

S Wade Taylor a,b, Samantha M McKetchnie b,c, Abigail W Batchelder b,c,d, Amy Justice e, Steven A Safren b,c,f, Conall O’Cleirigh b,c,d
PMCID: PMC9715850  NIHMSID: NIHMS1833165  PMID: 35653300

Abstract

HIV continues to be a critical health issue for sexual minority men (SMM) in the USA. Chronic pain is common in individuals with HIV, including older SMM, and is associated with substance use behaviors. This cross-sectional study sought to address a gap in the literature by characterizing interrelationships among chronic pain, substance use disorders (SUDs), medication adherence, and engagement in HIV care among older (≥50) SMM living with HIV and chronic pain (N = 63). The unadjusted relationship between an opioid use disorder and pain indicated that participants with an opioid use disorder reported higher pain ratings than those without. Presence of alcohol use disorder was significantly associated with missed HIV-care appointments due to chronic pain or substance use, showing that individuals with an alcohol use disorder reported more missed appointments in the past year. Higher pain was significantly associated with the same missed appointments variable, such that those reporting higher pain ratings also reported more missed appointments in the past year. These findings provide preliminary evidence of the interrelationships among chronic pain, SUDs, and engagement in HIV care among older SMM living with HIV and suggest that pain management in this population might support fuller engagement in HIV care.

Keywords: Chronic pain, SMM, MSM, HIV, older adults, substance use

Introduction

Nearly half of all people living with HIV in the United States (US) are aged 50 or older (CDC, 2018). This group, which includes sexual minority men (SMM) who account for 66–69% of new HIV diagnoses, has the potential to live as long as their peers without HIV (; CDC, 2020a; CDC, 2020b; Jang et al., 2011). However, they are equally prone to developing chronic health conditions that affect quality of life (Balderson et al., 2013). Chronic pain, defined as daily persistent or recurrent pain lasting longer than 3 months, is one of these conditions (Cervia et al., 2010; Krashin et al., 2012; Merlin et al., 2013). It can include pain unrelated to HIV (such as back pain or cancer-related pain), pain related directly to HIV (such as HIV neuropathy) and pain secondary to HIV treatment (such as ART-related neuropathy) (Marcus et al., 2000). Pain among PLWH has been undertreated (Breitbart et al., 1996; Breitbart et al., 1998; Bruce et al., 2017), increases during later stages of illness (Krashin et al., 2012), is associated with poorer quality of life (Namisango et al., 2012; UNAIDS, 2002), likely affects patients’ adherence to HIV medications (Broekmans et al., 2009), and is associated with increased mortality risk (Torrance et al., 2010). In addition, interpretation of patient-reported pain among patients living with HIV may be complicated by cooccurring conditions including anxiety and substance use disorders (Jacobson & O’Cleirigh, 2019).

Among the general population, it is well established that chronic pain is associated with increase substance use and substance use disorders (SUDs) (Witkiewitz & Vowles, 2018; Martel et al., 2017; Zale et al., 2015; Morasco et al., 2011). These relationships also exist among PLWH (Bruce et al., 2017; Merlin et al., 2019; Pence et al., 2006; Merlin et al., 2012b). In fact, PLWH with chronic pain were more likely to report comorbid drug abuse than participants without pain, use alcohol and illicit substances in addition to prescribed medications (e.g., Opioid analgesics) to address their chronic pain (Merlin et al., 2012a). Data from a 2016 meta-analysis noted that, despite high rates of chronic pain among PLWH, there were few clinical trials exploring pharmacological or non-pharmacological interventions (Merlin et al., 2016). Furthermore, initial research highlights several potential benefits of the use of long-term opioid therapy to treat chronic pain in PLWH, including reduced risk of virologic failure and more effective management of pain (Merlin et al., 2019). These findings indicate the need for further exploration of the relationships between chronic pain, HIV, and opioid use.

Prior research suggests that substance use and SUDs in older adults living with HIV do not decline with age (Justice & Braithwaite, 2012; Millar et al., 2017; Rabkin et al., 2004), with some indication that substance use might increase in older adults (Skalski et al., 2013; Wu & Blazer, 2013). Ompad et al. (2014) reported that approximately 48% of older SMM living with HIV used an illicit drug in the past 30 days. This substance use among older PLWH occurs in the complex context of co-occurring health conditions, which may include ongoing substance use (including tobacco and alcohol), polypharmacy and medication adherence, geriatric issues, and psychosocial influences (Deren et al., 2019). For alcohol use, Kuerbis et al. (2019) found that among older adults living with HIV, heavy drinking predicted daily worse pain and vice versa. Furthermore, polysubstance use (e.g., Alcohol and marijuana, alcohol and crack/cocaine) among older adults living with HIV has the potential to affect engagement in HIV-care and ART medication adherence (Batchelder et al., 2020; Dale et al., 2016; Parson et al., 2014).

Among PLWH, consistent engagement in care and adherence to ART are necessary for optimal disease management; missed HIV-clinic visits may even increase all-cause mortality (Mugavero et al., 2014). Importantly, the intersection of pain, mood, and substance abuse can result in suboptimal retention in HIV primary care (Merlin et al., 2012). For example, untreated pain and SUD symptoms may lower the likelihood of achieving optimal HIV medication adherence (Surratt et al., 2015), while problematic substance use may affect ART adherence, lead to viral load rebound or sustained non-suppression, create disparities along the HIV care continuum and result in poorer HIV treatment outcomes (Meyer et al., 2013). This situation is complicated further by the fact that mood and substance use disorders are under-diagnosed and under-treated in HIV primary care settings (O’Cleirigh et al., 2015). Also, there is preliminary evidence that detectable viral loads might be associated with increased pain sensitivity (Goodin et al., 2017). However, in the context of chronic pain among older SMM living with HIV, the impact of SUDs on engagement in HIV care and medication adherence remains largely unexplored in the published literature.

Taken together, we know that older PLWH have a large clinical pain burden and that there has been little research into effective treatment options. Further, in an effort to treat their own pain, individuals may turn to the misuse of prescription medications or use of illicit substances, and that the impact of this substance use on engagement in HIV care and HIV disease outcomes is not well understood. To fill these gaps in the extant literature, this study was designed to characterize a sample of older SMM living with HIV with respect to chronic pain, substance and alcohol use disorders, and engagement in care (delineated by missed appointments/medication adherence). We hypothesize that substance use disorders and higher levels of reported chronic pain are associated with poorer engagement in HIV care and less optimal medication adherence.

Materials and methods

Setting and procedures

This was a cross-sectional study to characterize how substance use disorders affect engagement in HIV care and medication adherence among older SMM living with HIV who report chronic pain. For this study, SMM were defined as cis-gender men who have sex with men. Study activities took place at The Fenway Institute, the research division of Fenway Health, Boston, MA. All participants underwent phone screening to determine eligibility. Potentially eligible participants completed the informed consent procedure and signed a medical records release form for the study team to obtain data on viral load, CD4 count, and prescribed ART and pain medications. Study procedures were approved by the Fenway Health Institutional Review Board. Participants completed self-report questionnaires and participated in a clinician administered diagnostic interview. Participants were paid $50 and were provided with a targeted referral as needed (e.g., Substance use treatment, pain clinics, social workers).

Participants

Participants were recruited from a convenience sample at Fenway Health and more broadly from the community via venue outreach (bars, clubs, cruising areas), word of mouth and advertising (print, clinic flyers and electronic media), and from older LGBT community organizations and caregiving services in the Boston area. Participants were eligible for the study if they were: (1) a man who has sex with men; (2) ≥ 50 years old; (3) living with HIV; (4) reporting chronic pain for ≥ 3 months; and (5) using illicit substances and/or abusing pain prescription medications in the past 6 months.

Measures

Sociodemographic characteristics

Participants self-reported age, sexual orientation (gay/homosexual, bisexual, other/not sure), race (Black/African American, White, other), ethnicity (Hispanic/ Latino, Not Hispanic/Latino), annual income, and education level.

Clinical characteristics

Participants self-reported years since HIV diagnosis, HIV viral load and CD4 counts (verified via medical record). Participants’ viral loads were extracted from medical records, and then dichotomized by detectability or undetectability (≤40 copies/ml) (CDC, 2018).

Resource utilization questionnaire

Via clinician-administered questionnaire, the study team collected extensive resource utilization data regarding participants’ inpatient, outpatient, emergency department and mental health visits. Included in this assessment was the number of HIV appointments missed in the past year due to chronic pain or substance use.

HIV medication adherence

Participants self-reported adherence to HIV medication during the past two weeks using a tool from the AIDS Clinical Trial Group (ACTG), which asked participants to rate their ability to take their medications as prescribed and the estimated percentage of HIV medications taken as prescribed (Lu et al., 2008).

Pain measures

Pain was measured using the Pain, Enjoyment, General Activity (PEG) (Krebs et al., 2009), a 3-item self-report scale that assesses pain intensity, enjoyment in life, and interference with general activity (average pain in the past week – 0–5 scale) and the Brief Pain Inventory (BPI) Short Form (10-items) that identifies pain duration and its functional interference (average pain in the past 30 days – 0–10 scale).

Alcohol and illicit substance use disorders

To assess substance use disorders, the study team used the Mini-International Neuropsychiatric Interview (M.I.N.I.), English Version 7.0.0 for the Diagnostic Statistical Manual-V. The MINI is a structured clinician-administered diagnostic interview that has good reliability and validity, comparable to the Structured Clinical Interview for DSM-IV (SCID-IV) (Sheehan et al., 1998). A variable for each substance use disorder was created, with results dichotomized by the presence or absence of a diagnosis Table 1.

Table 1.

Descriptive characteristics of older HIV-infected SMM who report chronic pain.

N=63
Age (years), mean (SD) 57.19 (5.616)
Sexual orientation, n (%)
Gay/homosexual 46 (73.0%)
Bisexual 12 (19.0%)
Other/Not Sure 3 (4.8%)
Missing 2 (3.2%)
Race, n (%)
Black/African American 25 (39.7%)
White 32 (50.8%)
Other 4 (6.3%)
Multiracial 2 (3.2%)
Ethnicity, n (%)
Hispanic/Latino 4 (6.4%)
Not Hispanic/Latino 57 (90.4%)
Missing 2 (3.2%)
Income (personal), n (%)
$10,000 or less 15 (23.8%)
$10,001 to $20,000 30 (47.6%)
$20,001 to $40,000 13 (20.6%)
Over $40,000 3 (4.8%)
Missing 2 (3.2%)
Education level, n (%)
No formal education/some HS 0 (0%)
HS diploma or GED 16 (25.4%)
Some college/AA/technical school 15 (23.8%)
BS/BA/Some grad school/MA/PhD/JD 27 (42.9%)
Missing 5 (7.9%)
Years since HIV diagnosis, mean (SD) 21.59 (8.50)
Substance/Alcohol Use Disorders
Opioid Use Disorder, n (%) 12 (19%)
Cannabis Use Disorder, n (%) 18 (28.6%)
Stimulant Use Disorder, n (%) 27 (42.9%)
Alcohol Use Disorder, n (%) 17 (27%)
HIV Disease, Care, and Treatment
Self-report medication adherence ≤80%, n (%) 11 (17.5%)
Detectable viral load (≥40 copies/ml), n (%) 7 (11.1%)
Number of self-reported missed HIV appointments due to chronic pain or substance use, mean (SD) 0.60 (1.13)
Percentage of HIV medication doses missed in the past 2 weeks mean (SD) 9.81 (13.59)
Pain
Average self-reported pain in the past week (range = 0–10), mean (SD) 5.41 (2.27)
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Statistical methods

All data analyses were completed using Statistics SPSS (Version 22). For dichotomous variables, such as opioid use disorder, we used logistic regression to examine relationships with viral load detectability. We used linear regression to examine relationships between substance use disorder, average pain in the past week, number of missed HIV appointments due to chronic pain or substance use, and percentage of missed HIV medication doses in the past 2 weeks. For both logistic and linear regressions, we used age, years since HIV diagnosis, race, ethnicity, and education as covariates. In Tables 2 and 3 we reported both unadjusted and adjusted relationships with diagnosis and education level as covariates. Age was not included as a covariate because it was highly correlated (r = 0.77) with years since HIV diagnosis.

Table 2.

Unadjusted relationships between SUDs, reported chronic pain and engagement in care.

Number of missed HIV-care appointments in the past year due to chronic pain or substance usea Viral load, dichotomized by detectable vs undetectable b Percentage of HIV medication doses missed in the past 2 weeksa Average self-reported pain in the past weeka
Opioid Use Disorder b = .35; t(61) = 2.94, p = .01 χ2 = .16; p = .69; OR = 1.44; 95% CI [.24,8.57] b = −.05; t(57) = −.37, p = .71 b = .31; t(61) = 2.51, p = .02
Stimulant Use Disorder b = .02; t(61) = .16, p = .87 χ2 = .70; p = .40; OR = .38; 95% CI [.04,3.47] b = .39; t(57) = 3.16, p = .003 b = −.12; t(61) = −.912, p = .37
Cannabis Use Disorder b = −.06; t(61) = −.46, p = .65 χ2 = .73; p = .39; OR = .60; 95% CI [.06,6.45] b = −.01; t(57) = −.11, p = .92 b = .12; t(61) = 1.31, p = .20
Alcohol Use Disorder b = .34 t(61) = 2.85, p = .01 χ2 = .90; p = .34; OR = .34; 95% CI [.04,3.12] b = .35; t(57) = 2.83, p = .01 b = .206; t(61) = 1.65, p = .11
Average pain in the past week b = .27; t(61) = 2.16, p = .04 χ2 = .19; p = .67; OR = 1.08; 95% CI [.76,1.53] b = .08; t(57) = .63, p = .53 -
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a

Linear regression.

b

Logistic regression.

Table 3.

Adjusted relationships between SUDs, reported chronic pain and engagement in care.

Number of missed HIV-care appointments in the past year due to chronic pain or substance usea Viral load, dichotomized by detectable vs undetectable b Percentage of HIV medication doses missed in the past 2 weeksa Average pain in the past weeka
Opioid Use Disorder b = .30; t(54) = 2.20, p = .03 χ2 = .14; p = .70; OR = .60; 95% CI [.04,8.56] b = −.06; t(50) = −.42, p = .68 b = .25; t(54) = 1.84, p = .07
Stimulant Use Disorder b = .14; t(54) = 1.02, p = .31 χ2 = .54; p = .46; OR = .47; 95% CI [.06,3.59] b = .47; t(50) = 3.68, p = .001 b = −.13; t(54) = −.96, p = .34
Cannabis Use Disorder b = .03; t(54) = .20, p = .85 χ2 = .00; p = .95; OR = .91; 95% CI [.04,19.32] b = .05; t(50) = .31, p = .76 b = −.06; t(54) = −.42, p = .68
Alcohol Use Disorder b = .28; t(54) = 2.17, p = .04 χ2 = .00; p = 1.00; OR = .00; 95% CI [.00] b = .40; t(50) 3.00, p = .004 b = .16; t(54) = 1.13, p = .26
Average pain in the past week b = .29; t(54) = 2.20, p = .03 χ2 = .43; p = .51; OR = .87; 95% CI [.58,1.32] b = .02; t(50) = .14, p = .89 -
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a

Linear regression.

b

Logistic regression.

Results

Demographics

Detailed participant characteristics are reported in Table 1. Mean age for participants was 57.19 (SD = 5.62). Among the sample (N = 63), 74.2% identified as gay/ homosexual, 19.4% as bisexual, and 6.4% were unsure of their sexual orientation. Over half of the sample identified as White (54.8%), while approximately 43% identified as Black/African American and 7% as Hispanic/ Latino. Less than 1/3 of participants reported earning more than $20,000 per year, with approximately half of the sample endorsing yearly income between $10,000 and $20,000. Generally, participants had been living with HIV for many years, with the mean number of years since HIV diagnosis being 21.6 (SD = 8.50).

Nineteen percent of the sample met diagnostic criteria for an opioid use disorder, 28.6% met for cannabis use disorder, 42.9% met for a stimulant use disorder, and 27% met for alcohol use disorder. Regarding engagement in HIV-related medical care, 31.7% endorsed having missed at least one (1) HIV-care appointment due to chronic pain or substance use in the past year, with a mean of 0.6 missed appointments per year (SD = 1.13). In our sample, 17.5% self-reported HIV medication adherence at or below 80%. Eleven percent of our sample had a detectable viral load. Participants in the sample had missed an average of 9.8% of their HIV medication doses in the past 2 weeks (SD = 13.59). When asked about average pain level, participants reported a mean level of 5.41 out of 10 (SD = 2.27).

Substance use and chronic pain

In the unadjusted relationships, the presence of an opioid use disorder was significantly associated with average pain in the past week (b = .31, p = .02), indicating that individuals who had an opioid use disorder reported pain ratings .31 points higher (on a 0–10 scale) than the remainder of the sample. This level of significance was lost once covariates were introduced, but the relationship was still trending (b = .25, p = .07). Relationships between average pain in the past week and other substance use disorders (stimulants, cannabis, and alcohol) did not reach statistical significance with or without covariates.

Substance use and engagement in HIV care

The number of self-reported missed HIV-care appointments due to chronic pain or substance use was significantly associated with diagnosis of an opioid use disorder (unadjusted: b = .35, p = .01; adjusted: b = .30, p = .03) and alcohol use disorder (unadjusted: b = .34, p = .01; adjusted: b = .28, p = .04), as well as average pain in the past week (unadjusted: b = .27, p = .04; adjusted: b = .29, p = .03). Relationships with stimulant use disorder and cannabis use disorder were not statistically significant.

Although the relationships between opioid and cannabis use and the percentage of missed HIV medication doses in the past 2 weeks were not statistically significant, there were strong associations with stimulant use (unadjusted: b = .39, p = .003; adjusted: b = .47, p = .001) and alcohol use (unadjusted: b = .35, p = .01; adjusted: b = .40, p = .004). However, viral load detectability was not significantly associated with SUD or chronic pain.

Discussion

Our study team examined the relationships between chronic pain and substance use disorders (SUDs) and their association with engagement in HIV-care among older sexual minority men (SMM) living with HIV. In our sample, we found that higher pain scores were significantly associated with missed HIV-care appointments due to chronic pain and substance use. Although participants in our sample were generally well linked to HIV-care and largely adherent to their treatment, some participants reported missed clinical appointments due to chronic pain and substance use. Our results are consistent with some emerging research that chronic pain affects retention in HIV primary care (Merlin et al., 2012). In addition, some of our sample reported suboptimal HIV medication adherence and detectable viral loads. It is well known that continuity in HIV health care across the continuum is essential to maximize positive health outcomes (CDC, 2014; Eaton, Saag, & Mugavero, 2014; Gardner et al., 2011). Therefore, it is important to understand better the complexity and intersection of HIV, chronic pain, and SUDs among older PLHV as related to HIV health. The 2017 HIVMA of IDSA Clinical Practice Guideline for the Management of Chronic Pain in Patients Living with HIV, endorsed by the Infectious Diseases Society of America, provides recommendations to assist clinicians to address these complex medical issues and promote medical and psychosocial well-being (Bruce et al., 2017).

Our results also indicate the presence of an alcohol SUD was significantly associated with missed HIV-care appointments due to chronic pain or substance use. Unhealthy alcohol use is prevalent among people living with HIV and is associated with negative HIV treatment outcomes over time (Amin & Douaihy, 2018; Edelman et al., 2018; Nicholas et al., 2014), with heavy drinking being associated with worse retention in HIV care (Monroe et al., 2016). Some evidence suggests alcohol use is associated with adverse health outcomes among older people living with HIV (Ge et al., 2018). As well, alcohol use disorder that intersects with cognitive dysfunction might lead to condomless anal sex (CAS) among older PLWH (Kupprat et al., 2017). If these patients are not consistently engaged in care or have unsuppressed HIV viral loads, then they are more likely to sexually transmit HIV. However, based on our literature search, our research appears to be the only empirical study that addresses alcohol use disorder among older MSM living with HIV who report chronic pain.

We also found that chronic pain was trending toward a significant association with opioid use disorder. These results are consistent with some existing literature that demonstrates a relationship between opioid use among patients with chronic pain (Kaye et al., 2017) and an association between chronic pain and opioid use among PLWH (Krashin et al., 2012). Prescription opioid use is common among PLWH (Canan et al., 2018; Edelman et al., 2013; Silverberg et al., 2012), with emerging evidence that repeated opioid use might amplify chronic pain states (Liu et al., 2016). However, Voon et al. (Voon et al., 2017) noted a lack of high-quality primary evidence and research that address the opioid epidemic in relation to chronic pain and substance misuse. Longitudinal trends among PLWH indicate that chronic use of opioids is associated with older age; however, opioid prescriptions decreased substantially among people who were engaged in long-term HIV-care (Brunet et al., 2017), suggesting that retention in care might play a role in decreasing opioid use.

We found no significant associations between higher levels of chronic pain and cannabis use disorder, stimulant use disorder, or alcohol use disorder, despite notable rates of substance use disorders within the sample (28% for cannabis use disorder, 43% for stimulant use disorder, and 27% of participants for alcohol use disorder). There is some evidence that cannabis use might be well tolerated and effective to relieve chronic pain (Abrams et al., 2007); some of our participants might use cannabis for this reason. Cannabis is also associated with lower likelihood of prescribed opioid use, perhaps suggesting cannabis could reduce the need for opioid analgesics (Whiting et al., 2015). However, the efficacy of marijuana for treatment of pain remains uncertain (Sohler et al., 2018), and more research is needed in the era of medical and legalized recreational marijuana use.

We are not aware of literature that identifies an association between chronic pain and stimulant use disorder. However, it is well known that stimulant use disorder decreases patients’ ability to be adherent to ART and achieve undetectable viral loads (Jin et al., 2018; Rajasingham et al., 2012) and increases mortality risk among PLWH (Adams et al., 2018). Therefore, more work is needed to assess the interaction of stimulant use disorder, chronic pain and HIV engagement in care should be investigated among older people living with HIV.

This study has several limitations that need to be considered when generalizing these results. First, the sample for this study was modest (n = 63) and not representative of the demographics of the larger health center; trends in the analysis could change with additional power. Second, we gathered self-reported data on chronic pain, substance use, and engagement in HIV-care by asking participants to recall experiences of past week, two weeks, month, etc. While the use of self-reported participant recall is convenient and may be appropriate for small cross-sectional data collection, real-time, clinician-administered assessments could increase the accuracy of responses. For engagement in HIV care, specifically ART adherence, self-report estimates have been shown to be overestimated. Use of dried blood spot analysis in a cross-sectional study would provide biological verification of medication taking habits (Alcaide et al., 2017). In addition, the question that assess for HIV medical appointment attendance asks that participants report the number of HIV appointments missed due to “chronic pain and substance use.” Although substance use is closely linked to experiences of chronic pain for many of our participants, others could have missed appointments due to chronic pain or substance use, but not both. It would be helpful to implement a standard measurement for engagement in HIV care. Finally, we were not able to obtain medical records for the entire sample (results were not returned for 10 out of 63 participants), as a few participants declined to sign the medical record release and some record requests were not fulfilled by medical facilities, limiting the viral load data.

This study sought to address a gap in the published epidemiological literature by characterizing the interrelationships among chronic pain, SUDs, and medication adherence and engagement in HIV care in older SMM living with HIV. Our findings indicate older SMM living with HIV may experience barriers to optimal engagement in HIV-care, including chronic pain and substance use. The presence of these barriers indicates a need for substance use treatment and pain management interventions that are tailored to this population and the unique challenges they face. Our data underscore the need for targeted evidence-based behavioral treatment for these patients to improve ART adherence and retention in HIV-care across the HIV care continuum (Kay et al., 2016; O’Cleirigh & Safren, 2007). The psychosocial and medical needs of PLWH who are prescribed opioids to manage pain are complex, and chronic opioid treatment is problematic (Krashin et al., 2012). Furthermore, Martel et al. (Martel et al., 2017) identified high comorbidity rates between chronic pain and SUDs and confirmed that several biological and psychological factors are linked to SUDs in patients with chronic pain. The results of the current study provide more evidence to investigate potential biopsychosocial and comorbid conditions associated with chronic pain and opioid SUD among older SMM living with HIV. Clinicians could consider the benefits and risks of pharmacological and non-pharmacologic treatments for chronic pain among PLWH (Merlin et al., 2016). The 2017 HIVMA of IDSA Clinical Practice Guideline for the Management of Chronic Pain in Patients Living with HIV provides guidance and empirical evidence for researchers and clinicians who work with these patients (Bruce et al., 2017).

While multi-pronged, wrap around care services have been shown to be effective and managing the complex health needs of PLWH (Bernard et al., 2016), it is important to acknowledge that many community-based HIV care clinics lack the resources to support such comprehensive services. Additionally, there are limits to the amount of time providers can spend counseling patients on issues related to chronic pain and substance during busy HIV care appointments (Genberg et al., 2019; Thompson, 2011). In resource- or time- limited settings, a strong network of referrals to local pain and substance use management clinics may provide patients with the scaffolding they need to address key factors that are impacting their ability to fully engage in HIV care. Future research could further explore the pathways among problematic substance use (most notably, alcohol and opioids), chronic pain, and engagement in HIV-care, and the ways in which providers can best leverage biobehavioral interventions to support their patients’ health outcomes.

Acknowledgements

Funding for this project is from R21DA038197. Some of the additional author time was from supported by K23DA043418 (Batchelder) and 9K24DA040489 (Safren). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Receives royalties from Oxford University Press, Guilford Publications, and Springer/Humana Press for books related to cognitive behavioral therapy.

Funding

This work was supported by Integrated Behavioral Treatment for Chronic Pain/Drug Use in Older MSM with HIV: [Grant Number R21DA038197].

Footnotes

Disclosure statement

No potential conflict of interest was reported by the author(s).

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