Evidence, clinical trials, systematic review, guidelines and implementation science

The Intersection of Pain and the Opioid Epidemic Across the Lifespan: Scalable Behavioral Solutions

Chronic pain and opioid use disorders have become significant and integrally related health concerns across the lifespan, affecting millions of individuals worldwide. Undertreated pain is a modifiable contributor to opioid misuse and use disorders. Developmental changes during adolescence make youth susceptible to chronic pain with continuation into adulthood, with pain being a primary driver of opioid misuse and opioid use disorders. This interprofessional panel will unravel the pain and opioid crises by presenting qualitative, longitudinal, and interventional research across adolescent, young adult, and adult populations to understand the onset, prevention, and treatment of opioid misuse in the context of pain. Dr. Rabbitts (pain physician), will present qualitative research with clinical samples of adolescents to understand perceptions and beliefs that may influence initiation of opioid misuse for pain. Dr. Voepel-Lewis (nurse scientist) will present data from parents, teens and emerging adults that explain the effectiveness (or ineffectiveness) of interventions intended to prevent opioid misuse. Dr. Darnall (psychologist) will present data from randomized trials of opioid and pain reduction strategies in adults with acute and chronic pain, and chronic pain and comorbid opioid misuse. Dr. Battaglia (psychiatrist), will lead a panel discussion on global perspectives of the intersection of pain and opioids.

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Modifiable Contributors to Initiation of Misuse of Prescription Opioids for Acute Pain During Adolescence

Adolescence is a vulnerable period when individuals are susceptible to the development of pain and substance use disorders. Opioid misuse often begins in adolescence, with rates peaking in early adulthood (7.8% of 18-25 year olds misuse opioids). Opioids prescribed for pain are a major driver of adolescent opioid misuse, with over 17% of adolescents in the US receiving an opioid prescription to each year. Indeed, adolescents report physical pain as the primary motivation for misuse. Nevertheless, opioids remain the cornerstone of acute moderate-severe pain management. Limited data are available to understand the intersection of acute pain and opioid misuse in adolescents, to inform prevention approaches. Qualitative data from a mixed clinical sample of adolescents who recently experienced injury, surgery, or critical illness, will be presented to provide insight into adolescents’ perceptions about use and misuse of prescription pain medicines which may influence risk for developing use disorders. Current work examining psychosocial factors, pain relief preferences, and expectancies as risk factors for opioid misuse following spinal fusion surgery in a large, well characterized, previously opioid-naive sample of adolescents enrolled an ongoing RCT will be discussed. Findings will identify targets for intervention to reduce lifetime burden of resulting opioid use disorders.

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Targeting Pain and Pain Relief Values to Prevent Prescription Opioid Misuse Among Emerging Adults

This speaker will present quantitative data that help to explain how pain often motivates the initiation of opioid misuse during adolescence and how early onset behavior contributes to later opioid use disorder. She will describe her own research findings which demonstrate how pain and the need or preference to relieve pain contributes to legitimate opioid use, prolonged use and risky behaviors such as retention of left-over opioids and opioid misuse. Dr. Voepel-Lewis will discuss findings from her randomized controlled trials on how educational and behavioral interventions with adolescents and young adults and with parents can mitigate risky opioid behaviors and what factors serve to thwart or moderate the success of such interventions. Finally, Dr. Voepel-Lewis will highlight findings that suggest better ways to prevent opioid misuse in the face of acute or persistent pain among youth.

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Effective and Scalable Behavioral Interventions for Acute and Chronic Pain in Adults with Opioid Use and Misuse

Dr. Darnall and team have completed numerous randomized trials in adults with results supporting specific scalable behavioral interventions for opioid and pain reduction. Scalable solutions are needed to provide ‘whole person’ pain care to the 1 in 3 who are living with ongoing pain of some type, and the hundreds of millions of people undergoing surgery each year. Published evidence will be presented for brief and digital interventions for acute and chronic pain, and new NIDA-funded research applying app-based treatment in adults with comorbid opioid misuse. These interventions are being applied internationally: the single-session pain relief skills class (“Empowered Relief”; 2 hrs) is active in 15 countries with 7 language translations. An acute pain version of Empowered Relief is being delivered in adult and adolescent perioperative settings in the U.S. and the U.K., and Cleveland Clinic Spine Surgery integrated Empowered Relief into standard care for spine surgery patients. We may envision how brief, scalable and effective behavioral treatment for pain may transform surgical and chronic pain care with low-burden, low-cost home-based options. A highlight will be discussion of active and national NIDA-funded research applying app-based Empowered Relief that is tailored to meet the needs of people with opioid misuse.

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Panel Discussion: Global Perspective on How Other Countries Can Learn from the Trajectory of the Opioid Epidemic in North America

Dr Battaglia will act as a discussant of the three presentations (Rabbitts, Voepel-Lewis, Darnall). In tying the 3 presentations together, he will emphasize how chronic pain and mental health issues constitute risk factors for the opioid epidemic, and how adolescence and youth are critical windows of both risk and opportunity. The latter include prevention, and treatment of adolescent youth (Rabbitts) and education and intervention at the family-wide level (Voepel-Lewis). When moving into adult and clinical samples (Darnall), specific scalable behavioral interventions for opioid and pain reduction become necessary, including brief and digital interventions for acute and chronic pain. Dr Battaglia will also bring a more global perspective, considering how other countries can learn from the trajectory of the opioid epidemics in North America, followed by leading a group discussion.

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Clinical Aspects of Tapering Opioids for Chronic Non-Cancer Pain. Presentation of Research Results from UK, US and Canada

The panel will discuss three large research projects related to opioid tapering for chronic non-cancer pain in the UK, US and Canada. Dr. Harbinder Sandhu will show the results of the randomized controlled trial of opioid tapering in the UK (iWotch trial). Dr. Mark Sullivan will discuss the NIDA-funded STRIPE trial which is testing pain self-management training and medication support for opioid taper. Dr. Andrea Furlan will discuss the results of the online opioid self-assessment program (Opioid SAP) among Canadian physicians, nurse practitioners, and medical students.

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What Physicians Don’t Know That They Don’t Know About Opioid Prescribing

Dr. Furlan will describe a study conducted with 639 opioid prescribers in Canada that identified areas of knowledge gaps in prescribing opioids for chronic non-cancer pain. Participant scores improved significantly in all six assessment areas of the Online Opioid SAP, most notable in (i) tapering opioids safely and effectively to the lowest possible dose at 51% knowledge increase and, (ii) prevention of opioid use disorder and overdose at 41% knowledge increase from baseline pre-test.

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Improving the Wellbeing of Opioid Treated Chronic Pain (I-WOTCH): Results of a UK Randomised Controlled Trial

The I-WOTCH study (a pragmatic multi-centre randomised controlled trial, N=608), set out to test the effectiveness and cost effectiveness of a multicomponent intervention to reduce opioid use. Participants were people living with chronic non-malignant pain. We targeted withdrawal of strong opioids. Two primary outcomes at 12 month follow up are Patient-Reported Outcomes Measurement Information System Pain Interference Short Form (8A)) and opioid use. Secondary outcomes include quality of life (measured by the EQ-5D). In depth process evaluation and qualitative interviews were completed. The main trial analyses are complete and being written up for publication. This will be the first presentation of these important findings.

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STRIPE Trial: Pain Self-Management Training and Medication Support for Opioid Taper

Results from the STRIPE trial, funded by the US National Institute on Drug Abuse, will be presented.  This trial randomized 153 primary care patients taking long-term opioid therapy to telephonic pain coping skills training or usual care. Patients randomized to skills training were offered the option of supported opioid taper at their fourth training session. For those choosing to taper, guidance was provided to their primary care provider about opioid and non-opioid psychotropic medication doses. Primary outcomes were pain (PEG score) and opioid dose (mean daily MED) at 6 and 12 months.

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Novel Resources to Optimise Internal Validity and Reduce Risk of Bias for Pre-Clinical Study Designs: Presenting the Outputs of the European Quality In Preclinical Data (EQIPD) Consortium

Andrew Rice will summarise the generic outputs and opportunities for improving pre-clinical research quality and rigour developed by the European Quality In Preclinical Data (EQIPD) Project (https://quality-preclinical-data.eu/). He will briefly describe the nature of EQIPD, its working methods and summarise its outputs. He will then focus on two aspects which are most relevant to the aims of this workshop: 1) Novel, evidence based and user friendly experimental conduct and design guidelines for enhancing the internal validity and rigour of in vivo preclinical animal research. 2) The learning opportunities contained in the modules of EQIPD’s the open access e-learning course. Throughout the presentation the speaker will lay the seeds for a fruitful audience-led discussion.

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