Enhancing Exercise and Psychotherapy to Treat Comorbid Addiction and Pain for ImprovingAdherence to Medication Assisted Treatment in Opioid Use Disorders

项目总结 据估计，美国有超过2030万成年人患有药物使用障碍(SUD)；估计有200万美国人患有涉及处方阿片类药物的阿片使用障碍(OUD)，约60万人有涉及海洛因的OUD。从2011年到2015年，美国因海洛因和合成阿片类药物等非法阿片类药物过量死亡的人数增加了两倍。在每年因处方阿片类药物滥用而接受成瘾治疗的50多万成年人中，50%-60%的人报告患有慢性疼痛，80%的人报告疼痛会引发复发。有药物滥用的成年人中的个人化/自我羞辱已被证明导致康复延迟、复发增加和与治疗相关的就诊减少。耻辱可能会给OUD和慢性疼痛患者带来巨大的负担，由于药物治疗和药物滥用之间的重叠，这一人群可能会有独特的耻辱特征。可以施加多种污名来源，包括内在化/自我污名以及组内/点对点(“水平”)污名，即同龄人根据过去吸毒的类型和严重程度对彼此施加污名(例如，“硬”与“软”吸毒者、“功能成瘾者”与“吸毒者”)。此外，污名可能是“垂直的”，因为污名可能是由卫生保健提供者或治疗中心的工作人员制定的，这种“垂直”的印记也可能阻碍康复。然而，值得注意的是，缺乏研究和相关评估工具来衡量耻辱的这些多维方面，特别是在有OUD和慢性疼痛的患者中。此外，之前还没有针对患有OUD和慢性疼痛的成年人的多维污名的干预计划。重要的是，目前的新冠肺炎大流行可能会加剧耻辱及其影响，因为众所周知，疫情爆发会导致强烈的恐惧和焦虑，导致严重的耻辱和隐含的偏见，可能会危及护理。因此，针对《关于支持减少疼痛管理和治疗中污名的策略的行政补充措施的特别兴趣》(NOT-OD-20-101)的通知，并利用污名的基本多维模型，我们建议采用混合方法扩展我们的亲本R61(AT010806)，以包括使用现有标准化调查评估内化/自我污名、预期/预期污名和已实施的污名，并描述水平的组内/同行)和垂直(提供者/治疗中心工作人员对患者)的污名。此外，我们建议整合定量和定性信息，以帮助为修改我们的父母R61干预的心理治疗部分(I-STOP)提供信息，这也将针对OUD和慢性疼痛患者的多维污名。该计划可以调整用于门诊和住院药物治疗计划，以帮助促进康复，即使面对新冠肺炎大流行带来的众多挑战。

PROJECT SUMMARY Over 20.3 million adults in the U.S. are estimated to have a substance use disorder (SUD); and, an estimated 2 million Americans have had an opioid use disorder (OUD) involving prescription opioids and about 600,000 have had an OUD involving heroin. The number of overdose deaths from illicit opioids including heroin and synthetic opioids has tripled from 2011 to 2015 in the U.S. Among the more than half-million adults entering addiction treatment for prescription opioid abuse every year, 50%-60% report co-morbid chronic pain and 80% report that pain triggers relapse. Individualized/self-stigma among adults with substance abuse has been shown to lead to delayed recovery, increased relapse and reduced treatment-related attendance. Stigma may induce significant burden on patients with OUD and chronic pain and there may be unique characteristics of stigma for this population due to the overlap between medical treatment and substance abuse. Multiple sources of stigma may be imposed including internalized/self-stigma as well as intragroup/peer-to-peer (“horizontal”) stigma whereby peers impose stigma upon each other based on the type and severity of past drug use (e.g., “hard” vs “soft” users,” “functional addicts” vs. “junkies”). Furthermore, stigma could be “vertical” in that stigma may be enacted by health care providers or by treatment center staff and, this “vertical” sigma may also hinder recovery. However, there is notably a lack of research and related assessment tools to measure these multidimensional facets of stigma, particularly in patients with OUD and chronic pain. Moreover, there have been no prior intervention programs that target multidimensional stigma in adults with OUD and chronic pain. Importantly, the current COVID-19 pandemic may exacerbate stigma and its effects since outbreaks are known to result in intense fear and anxiety leading to significant stigma and implicit biases that can compromise care. Thus, in response to the Notice of Special Interest on Administrative Supplements to Support Strategies to Reduce Stigma in Pain Management and OUD and Treatment (NOT-OD-20-101) and, utilizing an underlying multidimensional model of stigma, we propose to take a mixed-methods approach to expanding our Parent R61 (AT010806) to include evaluation of internalized/self-stigma, anticipated/expected stigma and enacted stigma using existing standardized surveys and, to describing horizontal intragroup/peer-to-peer) and vertical (provider/treatment center staff-to-patient) stigma in individuals with OUD and pain as well as other SUD in residential drug treatment centers at multiple sites. In addition, we propose to integrate the quantitative and qualitative information to help inform modifications to the psychotherapy component (I-STOP) of our Parent R61 intervention, which would then also target multidimensional stigma in patients with OUD and chronic pain. The program could be adapted for use in outpatient and inpatient drug treatment programs to help enhance recovery even in the face of the numerous challenges imposed by the COVID-19 pandemic.