Prescribed Opioid Use in Patients with HIV Tied to Elevated Pneumonia Risk

A new study led by Yale School of Medicine investigators has found that individuals with HIV who take prescription opioids for pain have an increased risk for developing community-acquired pneumonia.

Recent research has found that use of widely prescribed opioid analgesics such as codeine, morphine, and fentanyl can reduce natural killer cell activity, causing immunosuppressive effects and increasing the risk of serious infections. Individuals with HIV have used opioids to help manage chronic pain associated with the infection, but the new study published in the journal JAMA Internal Medicine investigated the association between use of prescribed opioids and community-acquired pneumonia requiring hospitalization among patients living with and without HIV.

For the investigation, the research team conducted a nested case-control study using data collected from January 1, 2000, through December 31, 2012, in the Veterans Aging Cohort Study, a prospective study of individuals with HIV who received care at a Veterans Health Administration (VA) medical center in the United States and used an uninfected group for comparison. Data from 25,392 participants were collected in the final analytic sample, including 14,906 people living with HIV and 10,486 uninfected patients, 98.9% of whom were male with a mean age of 55 years. There were 4246 cases of community-acquired pneumonia requiring hospitalization and 21,146 controls without community-acquired pneumonia.

The investigators found that current use of medium or high doses of opioids was associated with the greatest risk of community-acquired pneumonia compared with no current or past use of prescribed opioids in patients with and without HIV. Among patients prescribed opioids, the study found that pneumonia risk also increased in patients with known immunosuppressive properties. In stratified analyses, the risk of pneumonia was consistently greater among people living with HIV with current prescribed opioid use, especially immunosuppressive opioids.

The study is the first to compare the association of prescribed opioids with community-acquired pneumonia risk among those with and without HIV infection, and suggests that HIV infection may make patients more susceptible to the effects of prescribed opioids, including at lower doses. In an interview with Contagion®, study co-author Jennifer Edelman, MD, assistant professor of medicine at Yale School of Medicine, explained that further research is needed to understand whether the risk of pneumonia associated with prescribed opioid use can be reduced through use of lower dose and non-immunosuppressive opioids, along with other pain management strategies.

“Pain is complicated and often multifactorial in origin and the best treatment depends on the underlying cause,” Dr. Edelman said. “However, simple things like movement—such as exercise and physical therapy—can be very helpful for decreasing pain while improving overall health and even immune response. If medications are needed, [it is] best to use topical medications and/or non-opioid medications when possible. In addition, it is important to address factors that contribute to pain and may complicate its management, including substance use, malnutrition, and mental illness.”

The study also highlights the importance of receiving pneumococcal and influenza vaccinations for patients taking immunosuppressive opioids, particularly those with HIV. “We found that after accounting for other factors, receipt of these vaccines was highly protective against pneumonia requiring hospitalization among patients with and without HIV,” Dr. Edelman concluded.