Are we missing opioid-related deaths among people with HIV?

Ascertainment of unnatural and overdose death may be unreliable among individuals with life-limiting conditions such as HIV infection. We sought to determine whether the relationship between opioid use and unnatural death differs among decedents with HIV (DWH) and those without.

Decedents in the Veterans Aging Cohort Study (VACS) from 2002 to 14 were linked to the National Death Index cause of death file. Deaths were classified as unnatural, overdose (a subset of unnatural), or other. We defined opioid use as self-reported illicit use or receipt of prescribed opioids. Treating unnatural and overdose deaths as outcomes, we calculated odds ratios for opioid exposure by HIV status, with and without adjustment for disease severity using VACS Index.

Among 561 decedents without HIV (DWOH) and 884 DWH, 11 % and 8 % respectively were classified as unnatural deaths and 4 % and 2 % were classified as overdose deaths. Among DWOH, opioid use was associated with 2-fold greater odds of unnatural (OR 2.3; 95 % CI 1.3-4.0) and 4-fold greater odds of overdose death (OR 4.5; 95 % CI 1.5-13.7); in adjusted analyses, opioid use was associated with unnatural death (OR 2.6; 95 % CI 1.3-4.9) and with overdose (OR 4.2; 95 % CI 1.4-12.7). Opioid use was not associated with unnatural or overdose death among DWH.

Opioid use was strongly associated with unnatural and overdose death among DWOH but not among DWH suggesting potential differential misclassification. Caution should be used in interpreting prevalence, incidence and risk factors for unnatural and overdose cause of death among patients with life-limiting conditions such as HIV.