Guiding Aging Long-Term Opioid Therapy Users Into Safer Use Patterns

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ABSTRACT Patients on long-term opioid therapy are aging and now face magnified risk of harm with continued high-dose opioid use. These increased risks are due to age-related changes in drug metabolism, multi-morbidity, and polypharmacy. The dominant approach to mitigate these risks is to screen for aberrant patient opioid behaviors, with assessments like the Current Opioid Misuse Measure (COMM), so that clinicians can pre-empt misuse early through review of contractual opioid agreements or by lowering patient dosages. By focusing on opioid misuse alone, this strategy encourages forced opioid tapering that is associated with opioid overdose and mental health crisis. Many persons have mental health, trauma-related or polysubstance use disorders that need to be addressed. Directing clinician attention to the comorbid conditions associated with opioid misuse may promote safer and more effective care. Such an approach provides a broader understanding of the pain experience and may help address the reasons why patients use or misuse opioids. The specific aims are: (1) to develop a simple experimental approach for the collection of clinical pain data and for assessing, preventing, and managing pain in later life through the electronic health record; and (2) to assess the comparative effectiveness of PainTracker, a set of questions that targets a broad range of problems associated with pain, in a randomized controlled trial. Using the electronic health record, patient portal, and patient-reported outcome capabilities, we will develop programming logic for a randomized experimentation platform wherein two or more versions of pain surveys may be delivered to patients (Aim 1). We will use this system to evaluate PainTracker, delivered to half of the sample (2,579 patients). The primary outcome is patient referral rate to non-opioid care (e.g., mental and behavioral health care, antidepressant prescribing, physical therapy, and sleep medicine). Secondary outcomes will include prescription quantities for opioids, non-opioid pain medications, benzodiazepines and antidepressants. Assuming 2,579 patients per condition, there is an 80% chance to detect differences between groups that have a 25% vs 29% referral rate, assuming a significance level of 0.05 and a two-sided test. Each Chronic Opioid Use Registry participant that meets the inclusion criteria will: (i) be assigned to one of two conditions involving patient surveys (Pain Tracker + COMM or COMM alone1); (ii) be prompted 3 times to complete the survey; and (iii) receive a score also delivered to their physician's inbox in Epic®. This supplemental proposal is in response to NOT- AG-22-005 which seeks applications that "improv[e] the understanding of mechanisms underlying pain experience with aging". It aims to improve the health of persons with pain on long-term opioid therapy by identifying appropriate assessments to better address their pain experience and problems in their lives.