Nicotinic partial agonists show no effect on opioid use in HIV-positive smokers

INTRODUCTION: Cigarette and opioid use are two leading causes of preventable death and disability in the United States and are often comorbid. Nicotinic partial agonists, such as varenicline and cytisine, are considered highly effective for Nicotine Use Disorder in the general population. However, their efficacy and safety in smokers who use opioids remain unclear, with concerns about reduced efficacy or increased opioid use. We evaluated the impact of nicotinic agonists compared to nicotine replacement therapy (NRT) on opioid and cigarette use. METHODS: We conducted a secondary analysis of the St PETER HIV study, a randomized, double-blinded, placebo-controlled trial of 400 HIV-positive individuals recruited from July 2017 to December 2020 at HIV care sites in St. Petersburg, Russia. Participants (daily smokers with risky alcohol use) were randomized to varenicline, cytisine, or NRT. Our analysis focused on the 97 participants who reported opioid use at baseline. Logistic regression assessed the relationship between treatment arms and our primary outcome of self-reported opioid use. Hochberg-adjusted p-values accounted for multiple comparisons. RESULTS: The 97 St. PETER HIV participants with baseline opioid use exhibited significant differences from non-opioid users: higher rates of HCV infection; lower CD4 counts; and higher alcohol consumption and smoking rate. Among this opioid use subgroup, there was no significant difference in self-reported opioid use between participants randomized to nicotinic partial agonists and those randomized to NRT at 1, 3, 6 or 12 months. CONCLUSIONS: Nicotinic partial agonists do not significantly impact opioid use outcomes compared to NRT in persons who use opioids. Clinicians should consider these options as part of a treatment approach to address nicotine use in this population.