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Original Investigation
January 7, 2019

Association of Prescribed Opioids With Increased Risk of Community-Acquired Pneumonia Among Patients With and Without HIV

Author Affiliations
  • 1Department of Medicine, Yale School of Medicine, New Haven, Connecticut
  • 2Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
  • 3Veterans Affairs Connecticut Healthcare System, West Haven
  • 4Department of Medicine, University of Washington, Seattle
  • 5HIV/AIDS Program, National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland
  • 6DC Veterans Affairs Medical Center, Washington, DC
  • 7Department of Medicine, George Washington University, Washington, DC
  • 8Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah
  • 9Department of Medicine, University of Utah, Salt Lake City
  • 10Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
  • 11Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
  • 12Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
  • 13Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
JAMA Intern Med. Published online January 7, 2019. doi:10.1001/jamainternmed.2018.6101
Key Points

Question  What is the association between prescribed opioids and community-acquired pneumonia requiring hospitalization among patients living with and without HIV?

Findings  In this nested case-control study of 4246 cases and 21 146 controls (25 392 participants), prescribed opioids were independently associated with community-acquired pneumonia in patients living with and without HIV. In addition, the risk for community-acquired pneumonia increased with higher opioid doses and opioids with known immunosuppressive properties.

Meaning  These findings suggest that prescribed opioids independently contribute to community-acquired pneumonia risk among patients living with and without HIV; efforts to minimize prescribed opioid use, as well as to minimize use of higher doses and immunosuppressive opioids, may help mitigate this risk.

Abstract

Importance  Some opioids are known immunosuppressants; however, the association of prescribed opioids with clinically relevant immune-related outcomes is understudied, especially among people living with HIV.

Objective  To assess the association of prescribed opioids with community-acquired pneumonia (CAP) by opioid properties and HIV status.

Design, Setting, and Participants  This nested case-control study used data from patients in the Veterans Aging Cohort Study (VACS) from January 1, 2000, through December 31, 2012. Participants in VACS included patients living with and without HIV who received care in Veterans Health Administration (VA) medical centers across the United States. Patients with CAP requiring hospitalization (n = 4246) were matched 1:5 with control individuals without CAP (n = 21 146) by age, sex, race/ethnicity, length of observation, and HIV status. Data were analyzed from March 15, 2017, through August 8, 2018.

Exposures  Prescribed opioid exposure during the 12 months before the index date was characterized by a composite variable based on timing (none, past, or current); low (<20 mg), medium (20-50 mg), or high (>50 mg) median morphine equivalent daily dose; and opioid immunosuppressive properties (yes vs unknown or no).

Main Outcome and Measure  CAP requiring hospitalization based on VA and Centers for Medicare & Medicaid data.

Results  Among the 25 392 VACS participants (98.9% male; mean [SD] age, 55 [10] years), current medium doses of opioids with unknown or no immunosuppressive properties (adjusted odds ratio [AOR], 1.35; 95% CI, 1.13-1.62) and immunosuppressive properties (AOR, 2.07; 95% CI, 1.50-2.86) and current high doses of opioids with unknown or no immunosuppressive properties (AOR, 2.07; 95% CI, 1.50-2.86) and immunosuppressive properties (AOR, 3.18; 95% CI, 2.44-4.14) were associated with the greatest CAP risk compared with no prescribed opioids or any past prescribed opioid with no immunosuppressive (AOR, 1.24; 95% CI, 1.09-1.40) and immunosuppressive properties (AOR, 1.42; 95% CI, 1.21-1.67), especially with current receipt of immunosuppressive opioids. In stratified analyses, CAP risk was consistently greater among people living with HIV with current prescribed opioids, especially when prescribed immunosuppressive opioids (eg, AORs for current immunosuppressive opioids with medium dose, 1.76 [95% CI, 1.20-2.57] vs 2.33 [95% CI, 1.60-3.40]).

Conclusions and Relevance  Prescribed opioids, especially higher-dose and immunosuppressive opioids, are associated with increased CAP risk among persons with and without HIV.

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