The results show that the majority of patients with opioid use disorder developed this disorder following the presence of chronic pain. A plausible explanation for some of these cases, although not directly demonstrated by the data collected, is iatrogenic causation via use of opioid medication prescriptions for pain. As hypothesized, this group, as well as the OUD First group and Same Time group, had greater rates of co-occurring psychiatric and medical conditions compared to the No Pain group. Patients with mental health and multiple pain problems often present with more physical and psychological distress, resulting in greater frequency of opioid prescribing in primary care practices . Some unexpected, though not totally surprising, differences emerged between the OUD First and Pain First groups. The OUD First group generally had higher rates of other substance use disorders, commensurate with rates in the No Pain group. This was not unanticipated, as both groups were early-identified addiction patients and may have more genetic and environmental predisposition to developing substance use disorders than did the Pain First Group. The Pain First group had generally higher rates of co-occurring medical problems than did the OUD First group. Part of the explanation for this phenomenon may be related to the age of the Pain First group; that group was older and thus more prone to medical illness. It may also be possible that the Pain First group had a longer duration of pain, which contributed to declining health status. Several limitations should be considered when interpreting the results of this study. This was a study using medical record data. As in any research that uses data from medical records, variation in physician documentation and health insurance requirements may introduce bias in the data that are captured. The clinical data were initially recorded for clinical reasons and not specifically for research purposes, so the accuracy of the data may be less than that collected for research purposes. Further, as in other records-based research,vertical horticulture we do not have the information about patient diagnoses outside the system in our study and therefore are unable to ascertain the new OUD diagnosis except that it’s the first OUD diagnosis in the healthcare system under study.

Participants were predominantly white patients living in the Los Angeles area of the United States, potentially limiting generalizability to patients in other regions. Our findings are dependent on the extent, accuracy, and validity of the data available in the EHR dataset. For example, because OUD diagnosis information was obtained from the EHR, we were not able to distinguish if prescription or nonprescription opioids were used or the route of administration. Both mislabeling of people who do not actually have OUD and under-recognition of true OUD diagnoses could affect the true prevalence of OUD in the sample. Since addiction can be under-recognized in the EHR, it is possible that a subset of patients may not have been identified as having an OUD; thus, there may be some patients in the Pain First group that may actually belong in the OUD First group. Despite these limitations, the study revealed some important findings. As would be expected, the majority of patients in this general healthcare or medical setting were white and with private insurance or the resources to pay for their healthcare, as opposed to being black or members of Hispanic ethnic minorities, and without health insurance, who are more often treated in the public treatment system in Los Angeles. Nevertheless, comorbidities are common among patients in both settings. Somewhat surprising is that the rates of co-occurring chronic pain conditions and mental disorders appear even higher than most rates reported in the literature in connection with OUD, often heroin use disorder, treated in public settings. However, medical conditions among OUD patients treated in publicly funded programs are mostly based on self-report, whereas the present study allowed the delineation of the specific rates of several major co-morbid physical health and other disease diagnoses among OUD patients in a general medical setting. This study demonstrated that regardless of demographic differences, OUD is similarly associated with high morbidity among patients in the private sector as in the public sector, which put them at high risk for mortality. The Pain First group demonstrated the highest rates of physical and mental health problems.

As discussed earlier, opioid prescriptions for pain in some of these individuals could have increased the risk for OUD and related problems. On the other hand, because screening for drug use is not mandated in primary care and some other medical settings, OUD may not be recognized and treated until very late in the addiction course, exacerbating the negative consequences of the disorder. Regardless of the potential causes, expanding training for medical professionals to improve screening, early intervention, support, and monitoring could prevent some of the excess morbidity associated with OUD. Furthermore, implementation of recent CDC guidelines addressing opioid prescribing for chronic non-cancer pain may provide additional risk mitigation in patients with chronic pain prior to their development of OUD . Comorbid OUD and chronic pain complicates treatment decision-making, predicts poor outcomes, and increases healthcare costs . Similarly, studies of healthcare claims data reveal that the most challenging and costliest OUD patients had high rates of preexisting and concurrent medical comorbidities and mental health disorders . The present study reveals the type and extent of comorbidities among OUD patients, results that support improving clinical practice by addressing the complex treatment needs in this population. Finally, studies utilizing the EHR data of patient populations with substance use disorders are important in identifying the scope of the problem and the extent of medical, mental health, and substance use comorbidities that necessitate better models of assessment and coordinated care plans.The human immunodeficiency virus epidemic is shifting away from people who inject drugs , as most new cases of HIV in the U.S. are attributed to unsafe sexual practices. In 2014, sexual contact comprised 94% of new HIV infections in the U.S. . Among PWID, sexual risk behaviors are independently associated with HIV transmission, and may be a larger factor in HIV transmission than injection behavior . Sexual risk behaviors that lead to the transmission of HIV and substance use are intertwined behaviors.

Stimulant use, in particular, is associated with greater sex risk behaviors , including having unprotected sex . Prescription medications, including sedatives and painkillers, are also associated with sexual risk behaviors . Moreover, moderate drinking and having an alcohol dependence diagnosis have been associated with an increased likelihood of having multiple sex partners. Having sex under the influence of drugs and/or alcohol enhances sexual risk behaviors and is more strongly associated with new infections of HIV than is unprotected receptive anal intercourse with a partner of unknown HIV status . Substance use can negatively impact judgment and decision making, leading to sexual risk behaviors , such as trading sex for drugs or money , unprotected sexual intercourse , and unprotected sex with multiple partners . Alcohol users are likely to seek the immediate rewards without considering the long-term consequences while under the influence . It is important to consider the trajectories of substance use and sexual risk behaviors concurrently in order to decrease the transmission of HIV. Substance use disorder treatment, including methadone maintenance programs and outpatient drug free settings, may be an important venue for prevention of sexual transmission. While enrollment in drug treatment reduces drug-related HIV risk behaviors, such as injection drug use ,hydroponic rack system many substance users in treatment continue to engage in sex risk behaviors . As substance use is linked to sexual risk behaviors that can transmit HIV, it is possible that decreases in substance use may coincide with decreases in risk behaviors. Little is known about the temporal relationship between drug and alcohol use severity and high risk sexual behaviors among individuals in substance use treatment . The current study extends past research by examining whether reductions in alcohol and drug use severity predicted reductions in sexual risk behaviors among men in SUD treatment who were followed for a six month period. We hypothesized that decreases in drug and alcohol use at follow-up would coincide with decreases in sex risk behaviors. Participants were enrolled in a multi-site clinical trial of the National Institute on Drug Abuse Clinical Trials Network designed to test an experimental risk-reduction intervention, Real Men Are Safe , a five-session intervention that included motivation enhancement exercises and skills training, against a standard one-session HIV education intervention that taught HIV prevention skills. The intervention was delivered by counselors in SUD treatment programs, and approved by the local Institutional Review Boards. Details about this study have been published in greater detail elsewhere . In the parent study, participation was restricted to men in SUD treatment, who were at least 18 years of age, reported engaging in unprotected vaginal or anal intercourse during the prior six months, were willing to be randomly assigned to one of two interventions and complete study assessments, and were able to speak and understand English. HIV status was not assessed as part of this study. Exclusion criteria included gross mental status impairment, which was defined as severe distractibility, incoherence or retardation as measured by the Mini Mental Status Exam or clinician assessment, or having a primary sexual partner who was intending to become pregnant over the course of the trial.

All participants enrolled from methadone maintenance needed to be stabilized in treatment for at least 30 days to ensure the greatest likelihood that they had achieved a stable dose of methadone before starting the intervention groups. Participants were examined prior to receiving the clinical intervention and six months following the intervention. All participants provided informed consent prior to participating.Participants were recruited from seven methadone maintenance and seven outpatient drug free treatment programs in the U.S. that are affiliated with the CTN to participate in a research study on HIV risk reduction interventions. These modalities were chosen as the program’s counselors were trained to deliver the intervention. The treatment programs represented different geographic regions, population density, and HIV prevalence rates. Programs were located in U.S. states that included California, Connecticut, Kentucky, New Mexico, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Washington, and West Virginia; they treated patients in urban , suburban , and rural areas . Recruitment was accomplished through posters and fliers posted in clinic waiting rooms, announcements about the study to clinic patients at group therapy meetings, directly through a participant’s individual counselor, and at clinic “open houses” designed to introduce the study to clinic patients. Most participants from the drug-free outpatient clinics were recruited close to treatment entry, to reduce the possibility of early dropout. Assessments were conducted at baseline, prior to randomization, and six months after. Alcohol and drug use severity were assessed with the Addiction Severity Index-Lite , a standardized clinical interview that provides problem severity profiles in seven domains of functioning by providing an overview of problems related to substance use, in addition to days of use . This instrument has been used in many studies of drug and alcohol abusing populations and its reliability and validity are well-established . Composite scores for each problem domain are derived ranging from zero to one, with higher scores representing greater need for treatment. For the purposes of this study, only the composite scores for the alcohol and drug domains were analyzed. These composite scores are calculated based on the number of days of recent drug and alcohol use , problems arising from this use, and the desire for seeking treatment. We also provided days of recent use of alcohol to intoxication, cannabis, heroin, cocaine, sedatives/hypnotics/tranquilizers, and other opiates.In bivariate analysis, we compared sex risk behaviors, recent substance use, and ASI drug and alcohol composite scores at baseline and follow-up to monitor changes over time. As the ASI drug and alcohol composite scores did not meet the conditions of normality, we used Mann-Whitney U tests and Spearman correlations. Next, we compared sex risk behaviors and ASI composite scores at baseline and at six month-follow-up. Wilcoxon signed-rank tests were used for continuous data and categorical variables with more than two levels and McNemar’s tests were used for dichotomous categorical data . Multinomial multi-variable logistic regression analysis was used to test the hypothesis that reductions in ASI alcohol and drug use severity composite scores would predict reductions in sexual risk behaviors.