The National Institutes of Health (NIH) intends to establish an Integrative Management of chronic Pain and OUD for Whole Recovery (IMPOWR) network consisting of clinical research centers, which will be supported by a single Coordination and Dissemination center. This network is intended to create multidisciplinary team science collaborations to develop effective interventions, best models of care for delivery of services, and sustainable implementation strategies for access to quality care for complex patients with chronic pain (CP) and opioid use disorder (OUD) or opioid misuse. The network will be part of the NIH’s Helping to End Addiction Long-term (HEAL)SM Initiative to speed the development and implementation of scientific solutions to the national opioid public health crisis. The NIH HEAL Initiative will bolster research across NIH to (1) improve treatment and prevention of opioid misuse and opioid use disorder and (2) enhance pain management.
This FOA seeks applications for a single Coordination and Dissemination Center for the IMPOWR network. Key responsibilities include coordination and communication to support the research centers within this network and other HEAL funded projects of relevance to CP and OUD/misuse, data harmonization on common data elements, providing educational infrastructure, stakeholder and patient engagement and information dissemination, and creating novel tool assessments.This FOA runs in parallel with a companion FOA that seeks applications to develop collaborative research projects on approaches, models, delivery, and implementation of care for co-occurring chronic non-cancer pain and OUD/misuse (RFA-DA-21-030).
The ongoing opioid epidemic and the chronic pain (CP) crisis represent significant public health problems with unmet needs. The opioid epidemic was fueled by three waves of opioid use: (1) the overprescribing of prescription opioids to manage pain; (2) the increased use of illicit opioids, such as heroin; and (3) the increased number of overdose deaths involving powerful synthetic opioids, like fentanyl. As a result, an estimated 2 million individuals have an opioid use disorder (OUD), and to date, approximately 450,000 people have died from an overdose involving prescription or illicit opioids. In addition, nearly 10 million Americans misuse opioids, using them differently than prescribed or for the euphoric effects of the drug, which may elevate the risk for developing OUD. More than 50 million Americans suffer from chronic pain, and approximately 20 million individuals have severe CP that interferes with life or work activities. CP treatment and loss of productivity are estimated to cost $635 billion annually in the United States. Both opioid over-prescribing and restrictions on opioid prescribing have led to unintended consequences for many who have CP. People with pain may rely on opioids for pain relief in the absence of other effective treatments, and some turn to misuse or to illicit drug use for pain relief as health care professionals reduce or eliminate access to opioids for pain management. In addition, a subset of individuals with OUD may go on to develop acute or chronic pain. As a consequence, too many people suffer from both CP and OUD. These complex patients often do not respond well to current treatments for pain or OUD, face challenges of stigma, and often have limited or no access to quality care. Evidence-based integrated treatments and models of care that are effective and accessible for patients with co-occurring conditions are urgently needed.
Care for patients who have co-occurring CP and OUD may be further complicated by additional comorbid mental health or substance use disorders. A significant number of individuals self-medicate for pain with alcohol and/or have Alcohol Use Disorder. Furthermore, the prevalence of General Anxiety Disorder and Major Depressive Disorder is high among individuals with co-occurring OUD and CP. Patients who have co-occurring mental health or substance use diagnoses often have worse pain outcomes and may complicate effective management of comorbid CP and OUD. For this reason, the development of integrated treatments, integrated care delivery models, and implementation strategies should not ignore these comorbidities and opportunities may exist to attend to these psychiatric comorbidities in order to treat the whole patient.
Health care services for patients with both CP and OUD are fragmented in the United States. Providers in pain clinics and primary care clinics have evidence-based pain management treatments for patients with CP, such as opioid or non-opioid medications, interventional treatments, and non-pharmacological pain management strategies. They also have tools to assess and monitor patient responses to opioid analgesics, compliance with treatment agreements to assure safe and effective opioid prescription use, and monitor behaviors indicative of misuse while managing their pain. However, if a patient exhibits opioid misuse, the patient may be discharged from a pain clinic or a primary care clinic and referred to substance use or OUD treatment programs. While skilled at treating OUD, these programs often lack the expertise and resources to manage co-occurring CP. Healthcare providers lack tools and treatment guidelines and therefore, experience great difficulty treating patients with co-occurring CP and OUD. There is limited research on how to effectively and concurrently treat a patient’s CP and OUD. For example, there is a lack of evidence regarding which medications and/or dosages can be used safely and effectively to treat these patients. There also is a lack of evidence about how best to integrate and dose pharmacotherapies with non-pharmacological behavioral approaches and complementary interventions to treat patients with CP and OUD. The overall goal of these companion FOAs is to develop, evaluate, disseminate, and implement patient-centered and integrated treatments and models of care that are safe, effective, and accessible to complex patients with both CP and OUD.
While challenging, strategies can be pursued to safely and effectively respond to the needs of this complex patient population. Opportunities exist to leverage the effective treatment modalities targeting CP or OUD alone by integrating them to address the needs of individuals with both conditions. Medications for OUD (MOUDs; e.g. buprenorphine, methadone, and naltrexone) can effectively treat OUD and are often used in combination with behavioral approaches to improve treatment adherence and recovery outcomes. Pharmacological treatments and complementary medicine approaches such as mindfulness, cognitive behavioral therapy, acupuncture, exercise, and physical therapy can be effective for treating CP. Despite scientific evidence for effectiveness of such approaches for OUD or pain, we have little knowledge of how best to leverage, integrate, and deliver these treatments for co-occurring CP and OUD/misuse. Access to quality care for many, especially underserved populations, who have CP or OUD presents even greater challenges for care delivery to people with both conditions. Effort is needed to address the barriers that lead to fragmented health care delivery for CP and OUD. Best models for integrated care and best approaches to implementation need to be explored and evaluated to maximize sustained access to quality care. Bringing together scientists, patients, and practitioners with the appropriate expertise to develop data-driven best practices to manage CP and OUD is an important part of the formula needed to improve the health of this population.
This FOA seeks applications for a single Integrative Management of chronic Pain and OUD for Whole Recovery (IMPOWR) Coordination and Dissemination Center. This FOA runs in parallel with a companion FOA that seeks applications for multidisciplinary and collaborative research centers to develop, evaluate and implement effective patient-centered and integrated approaches to treat complex patients with CP can OUD and to evaluate best delivery models and implementation strategies for access to quality care (IMPOWR Research Centers: RFA-DA-21-030). The Coordination and Dissemination Center is expected to develop a communication plan, enhance collaboration and coordinate activities across the network and with relevant NIH initiatives (e.g., NOT-MH-21-005, and other HEAL programs on pain and OUD). The center will develop, evaluate and provide essential shared assessment tools and facilitate harmonization of data collected across the network. It also will develop and support educational activities in support of the program goals. This initiative encourages innovative, multidisciplinary approaches.
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