Katie Eder

Noting successful HIV/AIDS prevention efforts rely on early diagnosis, an analysis published in the March 2014 issue of 

 estimates that improved access to health insurance through the Affordable Care Act (ACA) will increase the number of patients getting tested for HIV by nearly 500,000 over a 5-year period, though that impact would be amplified if all US states opted to expand Medicaid coverage.

As part of an issue-wide series concerning the effects of the ACA’s implementation on HIV/AIDS patients, a team of researchers from the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California modeled the impact of health insurance expansion on testing, diagnoses, and HIV-unaware status between 2013 and 2017.

For their study, the investigators used 2 scenarios to offer upper and lower estimates of the ACA’s impact. The first anticipated only the 18 states and the District of Columbia that had committed to expanding Medicaid as of July 2013 actually did so, while the second assumed all 50 states and the District of Columbia participated in Medicaid expansion.

For both scenarios, the researchers used a macrosimulation model — which relied on data from reputable public- and private-sector sources, including the US Centers for Disease Control and Prevention (CDC) &mdash; to estimate the ACA’s impact on “the number of newly insured people who gained coverage as a result of the ACA; the number of the newly insured who were tested for HIV and who would not have been tested without coverage; and the number of the newly tested who were newly diagnosed as HIV-positive, and thus were newly aware of their HIV status.”

At the conclusion of their study, the authors predicted the ACA will “substantially increase the number of people being tested for HIV, with an additional 603,024 people being tested if all states expand Medicaid, (or) an additional 466,153 people if only the 18 committed states and the District of Columbia expand Medicaid,” which they noted is a 30% difference in impact. Although the study period was extended through 2017, the researchers’ model showed almost all of the increase in HIV testing will occur before 2016.

In terms of the effect of those presumed increases in testing, the authors found 2,598 additional new HIV diagnoses will be made by 2017 in the 18-state Medicaid expansion scenario, or 3,300 in the all-state scenario. In addition, HIV unawareness will be reduced by 22% between 2013 and 2017 among those unknowingly living with HIV/AIDS who become newly insured through the ACA.

“Making HIV-positive people aware of their status is at the forefront of HIV prevention. Yet, there are millions of people living with HIV/AIDS in the United States who are unaware of their HIV status,” the authors wrote. “A multi-prong approach is needed, (and) our analysis indicates that increasing health insurance might be an important part of such an approach.”

Since the ACA’s affect on HIV testing and diagnoses would be 30% greater if all states expanded eligibility for Medicaid coverage, the researchers advised that “policymakers should consider such epidemiological benefits when analyzing insurance expansion policies.”

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Noting successful HIV/AIDS prevention efforts rely on early diagnosis, an analysis estimates that improved access to health insurance through the Affordable Care Act will increase the number of patients getting tested for HIV by nearly 500,000 over a 5-year period, though that impact would be amplified if all US states opted to expand Medicaid coverage. 

How Obamacare Will Affect HIV/AIDS Prevention

Despite rampant opioid misuse, abuse, and diversion self-reported by chronic pain patients in a study presented at the American Pain Society 33rd Annual Scientific Meeting, held April 30, 2014, to May 3, 2014, in Tampa, FL, primary care providers tended to downgrade the patients’ risk for engaging in those drug-related aberrant behaviors, indicating a gap between physicians’ objective risk assessment for opioid abuse and the actual extent of the problem.

Using data from the ACCESS and ConVERT studies conducted in chronic pain patients receiving Avinza (extended-release morphine sulfate) or Embeda (extended-release morphine sulfate/naltrexone hydrochloride), respectively, Beatrice Setnik, PhD; and Carl L. Roland, PharmD, MS; and Glenn C. Pixton, MS, of Pfizer, Inc., alongside Kenneth W. Sommerville, MD, of the Duke University Medical Center in Durham, NC, “compare(d) investigator assessment of patient risk for behaviors related to prescription opioid misuse, abuse, and diversion with patient self-reports with patient self-reports of these activities and with the objective urine drug testing.”

Although both of the studies utilized patient medical history, urine drug test results, and physician ratings of the patients’ risk levels for aberrant behaviors related to opioids, each implemented different risk assessment questionnaires.

For instance, the investigators in the ACCESS study utilized several tools to determine their patients’ risk for opioid misuse and abuse, including “treatment agreement, card for obtaining/tracking prescriptions, (the) Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R), (and) pill count,” whereas those participating in the ConVERT study completed the Investigator Risk Assessment Questionnaire (IRAQ) at the first visit in order to evaluate the perceived risk of opioid misuse, abuse, and diversion in a given patient and document the sources used to make the risk assessment, the poster authors observed.

On the self-assessment side, patients in the ACCESS study also completed the 24-item SOAPP-R, while those in the ConVERT study filled out the 17-item Current Opioid Misuse Measure (COMM) and the Self-Reported Misuse, Abuse, and Diversion (SR-MAD) questionnaire.

According to Setnik and her co-authors, the investigators in the ACCESS study designated 46.9% of the patients as low risk for aberrant behaviors, 51.8% as moderate, and a mere 1.3% as high risk. Similarly, in the ConVERT study, the investigators labeled the vast majority of the patients as low risk for abuse (89.3%), misuse (84.2%), and diversion (94.3%) — assessments they based “mostly on medical history (84.9%), patient interview (81.7%), and history of treating/knowing the patient (67.8%) … (while) only 21.5% of investigators used questionnaires to assess risk.” Less than 2% of patients were considered high risk for each of those behaviors by the investigators in the ConVERT study.

Yet, 24.8% of the patients who completed the SOAPP-R indicated high risk of opioid abuse, misuse, and diversion; 40.6% of COMM responders were categorized as engaging in the drug-related aberrant behaviors; and an astounding 60% of those who filled out the SR-MAD questionnaire admitted using more opioids than prescribed (Figure 1).

In response to those findings, the poster authors suggested that “physicians may require additional education and/or training on the appropriate interpretation and identification of signals resulting from risk assessment tools.”

However, Roland pointed out during the poster presentation that “the way this was set up was under a certificate of confidentially, so the patients were told their physicians would not see the results.” Thus, he said “it would be difficult for physicians to implement these methods in clinical settings.”

Despite rampant opioid misuse, abuse, and diversion self-reported by chronic pain patients in a study presented at the American Pain Society 33rd Annual Scientific Meeting, primary care providers tended to downgrade the patients' risk for engaging in those drug-related aberrant behaviors, indicating a gap between physicians' objective risk assessment for opioid abuse and the actual extent of the problem.

Physicians Often Underestimate the Risk of Opioid Abuse, Misuse, and Diversion in Chronic Pain Patients

Among adult patients with multiple sclerosis (MS), pain severity can impact performance on cognitive tests, suggesting that pain independently contributes to impaired brain function in MS.

For their pilot study presented at the American Pain Society 33rd Annual Scientific Meeting, held April 30, 2014, to May 3, 2014, in Tampa, FL, Anna L. Kratz, PhD, of the Center for Outcomes Development & Application in the Department of Physical Medicine and Rehabilitation at the University of Michigan, and Tiffany J. Braley, MD, MS, of Multiple Sclerosis and Sleep Disorders Centers in the Department of Neurology at the University of Michigan, examined the correlation between pain intensity and cognitive test scores in 40 adult patients diagnosed with MS and explored the underlying mechanisms among those elements, such as sleep duration.

While previous studies have linked pain severity to cognitive functioning in the general population and determined that cognitive dysfunction is more common in those with chronic pain, the authors said “little has been done to explore symptoms that may exacerbate cognitive dysfunction in MS, including pain,” despite the fact that approximately two-thirds of MS patients have a chronic pain condition, 25% of whom experience severe chronic pain.

Within the current research sample, 26 patients had relapsing-remitting MS, 9 had secondary-progressive MS, and 5 had primary-progressive MS. Subjects were excluded from the study if they demonstrated “severe cognitive impairment, severe depression, visual and/or hearing impairments, lack of independent mobility, use of medical treatment for obstructive sleep apnea (OSA), and drug and/or alcohol dependence,” Kratz and Braley said.

During the study’s baseline visit, the investigators calculated the patients’ PROMIS Pain Intensity and Expanded Disability Status Scale (EDSS) scores and then showed them how to use a wrist-worn accelerometer, which continuously collected data on objective sleep parameters by recording ambient light and physical movements. In order to assess the association between pain and cognitive performance with and without sleep duration as a factor, the authors conducted the Controlled Oral Word Association Test (COWAT), Judgment of Line Orientation (JLO) test, and the Symbol Digit Modalities Test (SDMT) on the patients.

When they left out sleep duration in their analysis, Kratz and Braley found “pain intensity was independently associated with poorer performance on tests of verbal fluency (COWAT), visuospatial judgment (JLO), attention, working memory, and psychomotor speed (SDMT) above and beyond the effects of age and MS-related disability.” In fact, pain severity explained 8-10% of the variance in performance across those cognitive tests.

Even after they included sleep duration, the researchers said “the associated between pain and cognitive functioning was maintained for … poorer visuospatial judgment (JLO) and verbal fluency (COWAT).” In this set of regression models, pain intensity similarly accounted for 5-10% of the deviation in cognitive test performance.

Based on their findings, Kratz and Braley speculated that “pain contributes to cognitive dysfunction in MS beyond the effects of neuronal damage, cumulative neurological disability, or actigraphy-based sleep measures.” Additionally, the investigators said further research on the mechanisms underlying this association “could lead to novel advances in the management of cognitive dysfunction in MS through pain-based interventions.”

Pain Intensity Contributes to Cognitive Dysfunction in Multiple Sclerosis

In a research poster presented at the American Pain Society 33rd Annual Scientific Meeting, held April 30, 2014, to May 3, 2014, in Tampa, FL, medical and nursing schools that reported extensively incorporating the topic of pain care into prelicensure curricula did not offer more robust pain management education programs than those indicating minimal or moderate pain course integration.

Within their “Pain Education at US Medical and Nursing Schools” study, Jennifer Mongoven, MPH; Heather M. Young, PhD, RN, FAAN; Ian Koebner, MSc, MAOM, LAc; and Scott M. Fishman, MD, of the Department of Anesthesiology and Pain Medicine and the Betty Irene Moore School of Nursing at the University of California, Davis, pointed out that most healthcare professional education programs in the US have not emphasized pain management in their curricula, despite the fact that approximately 100 million Americans suffer from chronic pain.

To gain insight on the current state of pain education in the United States, the research team distributed a Web-based survey to 64 medical and nursing schools selected from 

’s 2011 Best Graduate Schools rankings. Of those top-ranked institutions, 13 medical schools and 18 nursing schools responded to the survey.

In the survey, responders were asked to rate how well their prelicensure programs incorporate pain into curricula on a 1-10 scale, with a score of 1 meaning pain is not covered at all and a score of 10 meaning pain management is covered extensively. Although the mean score across all 31 schools was 6.33, the researchers classified the individual programs into 3 categories based on the extent to which they reported integrating pain education: minimal, moderate, and extensive.

Among the 4 medical schools and 9 nursing schools that indicated extensive pain integration, “3 offered stand-alone courses in pain and reported an average of 4.5 other courses that incorporated the topic of pain,” the poster authors wrote. However, among the 7 medical schools and 10 nursing schools that specified only moderate pain incorporation, “4 reported stand-alone courses and averaged 5.3 additional courses;” therefore, “schools reporting extensive integration of pain did not appear to suggest a more robust pain management program than those reporting lower ratings,” they noted.

While some medical and nursing schools reported including pain management topics in a variety of mandatory and optional courses focused on pharmacotherapy, obstetrics, surgery, and palliative care, several others indicated limiting pain education to basic science courses. Still, the medical schools utilized clerkships as a mechanism for teaching pain care.

Taken altogether, the preliminary study findings “indicate pain is inconsistently incorporated into curricula for both nursing and medicine prelicensure programs (and) suggest a conflict may exist between the perceived and actual incorporation of pain management within curricula,” Mongoven, Young, Koebner, and Fishman concluded. Even so, they acknowledged, “more research is needed on how schools can easily assess and map the level of which the topic of pain management is incorporated into curricula.”

Medical and nursing schools that reported extensively incorporating the topic of pain care into prelicensure curricula do not offer more robust pain management education programs than those indicating minimal or moderate pain course integration.