Integrating Nonpharmacologic Strategies for Pain with Inclusion, Respect, and Equity (INSPIRE): Tailored digital tools, telehealth coaching, and primary care coordination

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PROJECT SUMMARY/ABSTRACT Chronic pain (CP) is one of the most common and debilitating medical conditions resulting in substantial morbidity, lower quality of life and tremendous health care costs. With ongoing and tragic consequences, opioids were overprescribed creating a surge in opioid use disorders and overdose deaths. Although non- pharmacologic interventions have a strong evidence base, these interventions are rarely available and expensive. The common co-morbidities of psychiatric and substance use disorders trigger further stigma and lower quality care. Subjective reports of pain symptoms and the cultural meanings ascribed to them create a situation ripe for health care disparities driven by multilevel biases on individual, provider, and systemic levels. These biases are manifested in stigmatizing language and the denial of interventions to reduce pain and alleviate suffering. Multiple studies have shown that racial and ethnic minorities with CP are especially mistreated. It is essential to accelerate the creation of hybrid CP management programs that improve access to treatments while simultaneously addressing the stigma, bias, and mistrust that further harm and isolate patients with CP. The INSPIRE CP intervention creates a hybrid blend of tailored cognitive-behavioral therapy, physical therapy, mindfulness, and pain education delivered via a trilingual mobile app and supported by a telehealth pain coach providing essential care coordination with PCPs within the EHR. PROs for pain, depression, anxiety, substance use, and a range of social risks and needs will be regularly collected, summarized in the coaching dashboard, and shared with PCPs. The intervention builds on an existing, in person pain program for marginalized patients but significantly improves reach, expands cultural and linguistic adaptations, and directly addresses multilevel bias and stigma through intensive community engagement, individual and group support, and the provision of “tech tutoring” to improve digital health literacy. The two year R61 development phase includes 3 specific aims with matched milestones: 1) creation of the digital tool and coaching protocol using intensive community engagement, 2) iterative development of educational and implementation strategies for health care staff and providers, and 3) a 3 month pilot test to further assess acceptability and feasibility. The three year R33 validation phase includes 3 additional specific aims 1) perform a pragmatic RCT with n=586 patients comparing INSPIRE to enhanced usual care, 2) analyze secondary outcomes and the treatment effects model, and 3) a mixed method evaluation of implementation outcomes using Normalization Process Theory to better design strategies for future scale.