BACKGROUND/RATIONALE:
The use of long-term opioid therapy (LTOT) has increased dramatically in recent decades. More than 500,000 Veterans are treated with opioid pain medications in spite of inadequate evidence of long-term benefit and growing evidence of harm. Overdose deaths due to opioid medications are now the leading cause of adult injury death in the United States, surpassing motor vehicle accidents. The risk of overdose increases in a dose-dependent manner. It is therefore possible that opioid dose reduction, or opioid tapering, may prevent opioid-related adverse events without negatively impact pain or quality of life. To this end, the Opioid Safety Initiative promotes opioid dose reduction, or opioid tapering, in several high-risk scenarios and instructs VHA networks to establish "safe and effective tapering programs". However, several important evidence gaps must first be addressed. First, evidence-based, effective protocols to guide tapering are lacking, especially in primary care settings where the majority of chronic pain is managed. Second, patient outcomes in opioid tapering are not well characterized. Opioid tapering may reduce risk and improve quality of life. Alternatively, opioid tapering may adversely impact pain, function and substance use. This proposal addresses these research gaps by adapting a collaborative care intervention to provide Veteran-centered, Veteran-driven opioid tapering support in VA primary care.

OBJECTIVE(S):
Aim 1: Describe the prevalence and correlates of Veterans' desire to taper long-term opioid therapy.

Aim 2: Adapt a collaborative care intervention to support opioid tapering in VA primary care.

Aim 3: Conduct a single arm pilot feasibility study to support opioid tapering in a VA primary care setting.

METHODS:
In Aim 1, we will conduct a structured phone interview among 300 Veterans to measure patient-reported desire to taper LTOT and examine its association with patient engagement and other patient and medication characteristics.

In Aim 2, we will adapt existing intervention components (medication management, patient education, collaborative care, longitudinal support) by incorporating tapering-specific elements (Motivational Interviewing, goal setting, multidisciplinary care, peer support). We will use the Nominal Group Technique to achieve Veteran and provider consensus.

In Aim 3, we will conduct a single arm pilot feasibility study to support opioid tapering in a VA primary care setting. We will recruit 40 Veterans on LTOT. We will measure the intervention's feasibility and acceptability and collect pilot data on patient-reported outcomes.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
This work is critically important to Veterans and VA healthcare systems nationally. It is well-aligned with the VA's National Pain Management Strategy with its emphasis on primary care-based programs to promote Veteran-centered pain care. Career development activities will build the applicant's expertise in 1) patient-reported outcome measurement; 2) behavior change intervention development; 3) pragmatic clinical trial design. This will be facilitated by mentorship, coursework, and seminars to leverage resources within the Denver-Seattle COIN, the University of Colorado and the VA's national pain research community. The mentorship, training, and protected time afforded by this award will ensure the applicant's development as an independent investigator and leader in the development and implementation of Veteran-centered, Veteran-driven, effective pain care.

PUBLICATIONS:

Journal Articles

1. Gordon AJ, Kenny M, Dungan M, Gustavson AM, Kelley AT, Jones AL, Hawkins E, Frank JW, Danner A, Liberto J, Hagedorn H. Are x-waiver trainings enough? Facilitators and barriers to buprenorphine prescribing after x-waiver trainings. The American journal on addictions. 2022 Mar 1; 31(2):152-158.
2. Quinlan TAG, Roberts AW, Frank JW, Whittington MD. Health costs of women with chronic overlapping pain conditions by opioid and complementary and integrative health use. Health services research. 2021 Dec 1; 56(6):1233-1244.
3. Bastian LA, Cohen SP, Katsovich L, Becker WC, Brummett BR, Burgess DJ, Crunkhorn AE, Denneson LM, Frank JW, Goertz C, Ilfeld B, Kanzler KE, Krishnaswamy A, LaChappelle K, Martino S, Mattocks K, McGeary CA, Reznik TE, Rhon DI, Salsbury SA, Seal KH, Semiatin AM, Shin MH, Simon CB, Teyhen DS, Zamora K, Kerns RD, NIH-DOD-VA Pain Management Collaboratory. Stakeholder Engagement in Pragmatic Clinical Trials: Emphasizing Relationships to Improve Pain Management Delivery and Outcomes. Pain medicine (Malden, Mass.). 2020 Dec 12; 21(Suppl 2):S13-S20.
4. Seal KH, Becker WC, Murphy JL, Purcell N, Denneson LM, Morasco BJ, Martin AM, Reddy K, Iseghem TV, Krebs EE, Painter JM, Hagedorn H, Pyne JM, Hixon J, Maguen S, Neylan TC, Borsari B, DeRonne B, Gibson C, Matthias MS, Frank JW, Krishnaswamy A, Li Y, Bertenthal D, Chan A, Nunez A, McCamish N. Whole Health Options and Pain Education (wHOPE): A Pragmatic Trial Comparing Whole Health Team vs Primary Care Group Education to Promote Nonpharmacological Strategies to Improve Pain, Functioning, and Quality of Life in Veterans-Rationale, Methods, and Implementation. Pain medicine (Malden, Mass.). 2020 Dec 12; 21(Suppl 2):S91-S99.
5. Frank JW, Bohnert ASB, Sandbrink F, McGuire M, Drexler K. Implementation and Policy Recommendations from the VHA State-of-the-Art Conference on Strategies to Improve Opioid Safety. Journal of general internal medicine. 2020 Dec 1; 35(Suppl 3):983-987.
6. Frank JW, Carey E, Nolan C, Hale A, Nugent S, Krebs EE. Association Between Opioid Dose Reduction Against Patients' Wishes and Change in Pain Severity. Journal of general internal medicine. 2020 Dec 1; 35(Suppl 3):910-917.
7. Krebs EE, Clothier B, Nugent S, Jensen AC, Martinson BC, Goldsmith ES, Donaldson MT, Frank JW, Rutks I, Noorbaloochi S. The evaluating prescription opioid changes in veterans (EPOCH) study: Design, survey response, and baseline characteristics. PLoS ONE. 2020 Apr 22; 15(4):e0230751.
8. Becker WC, Frank JW, Edens EL. Switching From High-Dose, Long-Term Opioids to Buprenorphine: A Case Series. Annals of internal medicine. 2020 Jul 7; 173(1):70-71.
9. Nunes NS, Chandran P, Sundby M, Visioli F, da Costa Gonçalves F, Burks SR, Paz AH, Frank JA. Therapeutic ultrasound attenuates DSS-induced colitis through the cholinergic anti-inflammatory pathway. EBioMedicine. 2019 Jul 1; 45:495-510.
10. Midboe AM, Martino S, Krein SL, Frank JW, Painter JT, Chandler M, Schroeder A, Fenton BT, Troszak L, Erhardt T, Kerns RD, Becker WC. Testing implementation facilitation of a primary care-based collaborative care clinical program using a hybrid type III interrupted time series design: a study protocol. Implementation science : IS. 2018 Nov 29; 13(1):145.
11. Kennedy LC, Binswanger IA, Mueller SR, Levy C, Matlock DD, Calcaterra SL, Koester S, Frank JW. "Those Conversations in My Experience Don't Go Well": A Qualitative Study of Primary Care Provider Experiences Tapering Long-term Opioid Medications. Pain medicine (Malden, Mass.). 2018 Nov 1; 19(11):2201-2211.
12. Rabin BA, McCreight M, Battaglia C, Ayele R, Burke RE, Hess PL, Frank JW, Glasgow RE. Systematic, Multimethod Assessment of Adaptations Across Four Diverse Health Systems Interventions. Frontiers in public health. 2018 Apr 9; 6(102):102.
13. Becker WC, Bair MJ, Picchioni M, Starrels JL, Frank JW. Pain Management for Primary Care Providers: A Narrative Review of High-Impact Studies, 2014-2016. Pain medicine (Malden, Mass.). 2018 Jan 1; 19(1):40-49.
14. Frank JW, Lovejoy TI, Becker WC, Morasco BJ, Koenig CJ, Hoffecker L, Dischinger HR, Dobscha SK, Krebs EE. Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review. Annals of internal medicine. 2017 Aug 1; 167(3):181-191.
15. Nugent SM, Dobscha SK, Morasco BJ, Demidenko MI, Meath THA, Frank JW, Lovejoy TI. Substance Use Disorder Treatment Following Clinician-Initiated Discontinuation of Long-Term Opioid Therapy Resulting from an Aberrant Urine Drug Test. Journal of general internal medicine. 2017 Oct 1; 32(10):1076-1082.
16. Busse JW, Craigie S, Juurlink DN, Buckley DN, Wang L, Couban RJ, Agoritsas T, Akl EA, Carrasco-Labra A, Cooper L, Cull C, da Costa BR, Frank JW, Grant G, Iorio A, Persaud N, Stern S, Tugwell P, Vandvik PO, Guyatt GH. Guideline for opioid therapy and chronic noncancer pain. CMAJ: Canadian Medical Association Journal = Journal De L'Association Medicale Canadienne. 2017 May 8; 189(18):E659-E666.
17. Lovejoy TI, Morasco BJ, Demidenko MI, Meath TH, Frank JW, Dobscha SK. Reasons for discontinuation of long-term opioid therapy in patients with and without substance use disorders. Pain. 2017 Mar 1; 158(3):526-534.
18. Frank JW, Levy C, Matlock DD, Calcaterra SL, Mueller SR, Koester S, Binswanger IA. Patients' Perspectives on Tapering of Chronic Opioid Therapy: A Qualitative Study. Pain medicine (Malden, Mass.). 2016 Oct 1; 17(10):1838-1847.

Journal Other

1. Frank JW, Binswanger IA. Commentary on Rhee & Rosenheck (2019): Buprenorphine prescribing for opioid use disorder in medical practice - can office-based out-patient care address the opiate crisis in the United States?. [Letter to the Editor]. Addiction (Abingdon, England). 2020 Apr 1; 115(4):786-787.

Center Products

1. Frank JW, Gilmartin HM. Pain Management and Opioid Safety. https://www.hsrd.research.va.gov/news/podcasts/listen.cfm?ID=28; 2018 May 4. Available from: https://www.hsrd.research.va.gov/news/podcasts/listen.cfm?ID=28.

DRA: Substance Use Disorders, Health Systems
DRE: Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: Utilization
MeSH Terms: none