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Center for Care Delivery and Outcomes Research

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Chronic Pain And Opioid Harms Reduction

Goal: Reduce opioid-related harms and improve health and functional outcomes for Veterans with chronic pain. 

Background: Veterans are disproportionately affected by chronic pain, which is prevalent among 20-30% of U.S. adults, resulting annually in $560-$635 billion in health care costs and lost productivity. Opioid prescribing for chronic pain increased dramatically from the 1990s to the early 2010s, despite a lack of evidence supporting it. This expansion of opioid therapy failed to improve the population burden of pain, but generated an epidemic of prescription opioid-related deaths, addiction, and other serious harms. As opioid management has strained health system resources, effective non-pharmacologic interventions for chronic pain have too often been overlooked and pervasive disparities in chronic pain management processes and outcomes have persisted.

Chronic Pain and Opioid Harms Reduction investigators have made foundational contributions to defining the challenges in this area and to informing current high-priority efforts to address opioid harms and improve pain outcomes. Examples include research documenting racial differences in chronic pain treatment, which was recognized as a Science Advance in Pain Research award by the Interagency Pain Research Coordinating Committee, and development and validation of the PEG 3-item pain scale, which was distributed in the 2016 Turn the TideRx pocket guide by the Office of the Surgeon General to over 2.3 million physicians and other health professionals. 

Expertise in Pain and Opioid Harms Reduction: CCDOR’s Pain and Opioid Harms Reduction research group includes 5 core investigators who have played key roles in advancing research and policy in collaboration with a national network of pain and opioid researchers within and outside of VA. Between FY 2015-2017, they led 8 federally-funded grants and 1 systematic review aimed at improving management of pain and reducing harms from opioids. They simultaneously authored 70 peer-reviewed publications and contributed to key national initiatives, including the Centers for Disease Control and Prevention (CDC) opioid prescribing guidelines and the Department of Health and Human Services’ National Pain Strategy. Impacts in the areas of research, policy and practice underscore CCDOR Pain and Opioid Harms Reduction investigators’ roles as leaders in this area. These include participating in a U.S. House of Representatives Committee on Veterans Affairs roundtable on the opioid crisis, developing a quality improvement toolkit for opioid agonist treatment programs for national dissemination, and co-chairing the VA HSR&D State of the Art (SOTA) conference on non-pharmacologic approaches for chronic pain management. This SOTA was instrumental in informing VHA policies on integrative health and a $81 million NIH-DoD-VA Pain Management Collaboratory initiative. 

 Highlights: 

  • Dr. Krebs recently received a $10 million award from the Patient Centered Outcomes Research Institute (PCORI) to conduct a large pragmatic randomized trial at 9 VA facilities comparing 2 care management models (telecare collaborative management; integrated pain team management) for improving pain management and reducing opioid use in VA patients on high-dose long-term opioid therapy for chronic pain. This study will also evaluate buprenorphine rotation as an approach to opioid dose reduction in long-term high-dose opioid therapy, using a model developed by collaborators at the West Haven VA. Dr. Hagedorn is leading the process evaluation of this study, which will inform intervention adaptations and implementation strategies.
  • Dr. Krebs is also studying patient-reported functional and quality of life outcomes of opioid prescribing changes in a large prospective cohort of VA primary care patients receiving long-term opioid therapy. Study findings will identify successful approaches and target gaps in VHA efforts to achieve patient-centered pain management and opioid safety goals.
  • Benzodiazepines are commonly prescribed for patients with chronic pain and often co-prescribed along with opioids, substantially increasing the risk of opioid-related death. Dr. Hagedorn is collaborating with Dr. Keith Humphrey at the Palo Alto VA (in partnership with the OMHSP and the Academic Detailing program) on a proposal to decrease benzodiazepine prescribing using patient and provider targeted implementation strategies.
  • In the next 5 years, Dr. Burgess will conduct a series of studies examining interventions for chronic pain aimed at empowering patients with pain self-manage techniques.
  • Dr. Burgess is studying a proactive outreach model to increase physical activity and improve pain-related outcomes among Veterans with chronic musculoskeletal pain.
  • Dr. Burgess was also recently awarded a 6-year study to test 2 approaches for delivering mindfulness-based interventions for chronic pain as part of the NIH-DoD-VA Pain Management Collaboratory.
  • Over the next 5 years, the Pain and Opioid Harms Reduction research group will expand its portfolio to include evidence-based interventions to treat problems co-occurring with chronic pain. For example, Dr. Koffel will conduct research to identify strategies to improve patient engagement in and reach of Cognitive Behavioral Therapy for Insomnia (CBT-I) to patients with chronic pain. This work will result in adaptations to CBT-I for chronic pain patients and implementation strategies to promote referral for this effective but underused intervention.
  • Dr. Hagedorn is conducting a study designed to increase implementation of evidence-based pharmacologic treatments for opioid use disorder in VHA facilities that fall in the lowest quartile on the OMHSP’s Psychotropic Drug Safety Initiative’s metric for monitoring uptake. The project employs intensive external facilitation, an evidence-based implementation strategy that identifies local barriers and develops individualized implementation action plans while enhancing knowledge of and use of nationally available resources.
  • Dr. Hagedorn is also collaborating with Dr. Bart at Hennepin County Medical Center in Minneapolis on a National Institute on Drug Abuse (NIDA) Clinical Trials Network proposal testing the effectiveness of initiating buprenorphine treatment for opioid use disorder during hospitalization compared to providing a referral to substance use disorder treatment (current standard of care) on initiation of and retention in substance use disorder treatment.