Stopping the opioid epidemic: Priority research at KPWHRI

KPWHRI continues to lead in helping patients find safe, effective ways to manage chronic pain

About 1 in 10 adults have pain that limits work and life activities. As U.S. opioid prescriptions for chronic pain increased in the early 2000s, followed by a rise in use of heroin and powerful synthetic opioids such as fentanyl, Kaiser Permanente Washington Health Research Institute scientists pioneered research on opioids. The overarching theme of this work, initiated by Senior Investigator Michael Von Korff, ScD, now retired, is safely managing chronic pain. 

“We need accessible, effective treatment for pain, so people don’t get started on prescription opioids, which so often lead to addiction,” says KPWHRI Senior Investigator Lynn DeBar, PhD, MPH. “We also need ways to help people with opioid use disorders reduce their doses or stop taking opioids.”

Dr. DeBar leads studies that focus on helping people manage their chronic pain to improve their daily function and quality of life. As health care systems and insurers, physicians and patients, and politicians and policy experts ask how to solve the opioid crisis, KPWHRI investigators are working on practical answers. Our projects to improve care for chronic pain and opioid use disorders include:

HEAL studies

The National Institutes of Health Helping to End Addiction Long-term (HEAL) Initiative funds research on scientific solutions to the national opioid crisis. The goal of the initiative is improving treatment for chronic pain, curbing opioid use disorder and overdose, and achieving long-term recovery from opioid addiction. Many interventions studied in KPWHRI HEAL projects are particularly suitable for telemedicine.

• More Individualized Care: Assessment and Recovery through Engagement (MI-CARE) is led by Dr. DeBar and Senior Investigator Kathy Bradley, MD, MPH. This $12.8 million pragmatic trial is testing phone-based nurse care management for opioid use disorder and depression at Kaiser Permanente Washington and clinics in Indiana. Collaborating institutions include Regenstrief Institute/University of Indiana, University of Washington, University of New Mexico, Kaiser Permanente Northwest Center for Health Research, and Boston Medical Center. The goals are helping primary care patients to begin and sustain treatment with medications for opioid use disorder and to improve their depression symptoms.
• Tailored nonpharmacotherapy services for chronic pain: Testing scalable and pragmatic approaches (RESOLVE). Dr. DeBar leads this 5-year project on the effectiveness, costs, and factors for providing cognitive behavioral therapy for chronic pain online and through virtual visits (by video and/or phone). In-person CBT is effective for high-impact pain and does not involve use of drugs such as opioids. RESOLVE focuses on CBT delivered by telehealth methods that do not require in-person visits and are designed to provide more robust services for people in medically underserved and rural areas.
• Pragmatic trial of acupuncture for chronic low back pain in older adults. KPWHRI Senior Investigator Karen Sherman, PhD, and Dr. DeBar lead this 4-year pragmatic randomized trial on the effectiveness, costs, and factors for providing acupuncture to older adults with low back pain. The study has 4 diverse sites: Kaiser Permanente Washington, Kaiser Permanente and Sutter Health in Northern California, and the Institute for Family Health in New York. Evidence from this work will inform Medicare coverage decisions and help physicians and patients decide on treatment.

MUSE, STRIPE, PROUD, and more

• Medication Use, Safety, and Evidence. The MUSE project is co-led by Senior Investigator Denise Boudreau, PhD, and Bobbi Jo Yarborough, PsyD, of Kaiser Permanente Northwest. MUSE is a U.S. Food and Drug Administration postmarketing requirement study funded by pharmaceutical companies that manufacture extended-release/long-acting opioid medications. The aims are to estimate the prevalence, incidence, and risk factors of misuse, abuse, and opioid use disorder among patients using long-term opioid therapy. MUSE is the first large, U.S.-based study to determine these important estimates using validated and robust measures of problematic opioid use. Research partners are from the Health Care Systems Research Network; Veterans Affairs, Palo Alto, CA; and New York and Florida Practice-Based Research Networks. MUSE will have direct implications on FDA policies around opioid prescribing and risk-mitigation strategies. 
• Strategies to Improve Pain and Enjoy Life. The STRIPE study is co-led by Dr. Boudreau and Mark D. Sullivan, MD, PhD, from the University of Washington. STRIPE is a pragmatic randomized trial funded by the National Institute on Drug Abuse to determine the effects of a pain self-management and optional opioid-taper support intervention, compared to usual care, on opioid dose and pain. If the intervention can reduce opioid doses and improve quality of life for patients while not increasing their pain, it could be used by care systems to improve pain management and reduce problematic opioid use.  
• PRimary care Opioid Use Disorders treatment. The PROUD trial is led by Dr. Bradley and Andrew Saxon, MD, VA Center of Excellence in Substance Abuse Treatment and Education, and funded by the National Institute on Drug Abuse Clinical Trials Network. The primary objective of this pragmatic implementation trial is evaluating whether implementing the Massachusetts Model of collaborative care for management of opioid use disorders in primary care increases opioid use disorder treatment with buprenorphine or naltrexone compared to usual care.
• The PROUD intervention has 3 strategies: 1) Intervention clinics hire a nurse care manager employed and supervised by the health care system; 2) Experts at Boston Medical Center, who developed the MA Model, train and supervise them; and 3) Intervention clinics have three primary care providers with waivers to prescribe buprenorphine who treat opioid use disorder in primary care. Participating health care systems are Kaiser Permanente Washington, Henry Ford Health System in Michigan, Montefiore Medical Center in New York, MultiCare Health System in Washington, University of Miami Health System, and Harris Health System in Texas. Other collaborators are University of Washington, Kaiser Permanente Northwest and Kaiser Permanente Colorado.
• Back on Track. This study, led by Dr. DeBar and funded by the Patient-Centered Outcomes Research Institute, analyzes the effects of changes to Oregon’s Medicaid expanded coverage for nondrug treatments for back and neck pain. The changes allow reimbursement for nondrug services such as physical and behavioral health therapy, acupuncture, and chiropractic care. Dr. DeBar’s team is studying how these changes affect health services provided to patients, their satisfaction with the services, and the impact on their pain and functioning. Back on Track participants include staff and Medicaid-insured patients at federally qualified health centers in Oregon and California.
• Pain Program for Active Coping & Training. The PPACT pragmatic randomized clinical trial was led by Dr. DeBar. This study compared usual primary care for chronic pain to an intervention that offered multiple treatment approaches. The trial was funded by the Health Care Systems Collaboratory of the National Institutes of Health and involved 3 Kaiser Permanente regions: Georgia, Hawaii, and the Northwest. The PPACT intervention was designed to coordinate and integrate services that help patients use self-management skills for chronic pain and limit prescription opioid use. The study follows up on PPACT.
• Other opioid-related research includes projects by Dr. Boudreau to study associations between opioid use and outcomes such as suicide, overdose, and cancer; and work by Senior Investigator Sascha Dublin, MD, PhD, supported by the FDA, on use and effects of opioids taken during pregnancy. Dr. Boudreau, with Dr. Dublin and Research Associate Gaia Pocobelli, PhD, Assistant Investigator Jennifer F. Bobb, PhD, funded by the FDA, investigated associations between neural tube defects and taking prescription opioids during early pregnancy.
• Drs. Dublin and Boudreau, with Research Associate Ben Balderson, PhD, and KPWHRI Affiliate Researchers Elizabeth Phelan, MD, MS, Shelly Gray, PharmD, MS, AGSF, and Zachary Marcum, PhD, PharmD, are collaborating on STOP FALLS, funded by the Centers for Disease Control and Prevention (CDC). This project reaches out to doctors and patients to help older adults reduce or stop use of potentially harmful medications including opioids. 

Impact

KPWHRI opioid research has influenced clinical guidelines, policy, and practice.

• Six Building Blocks. The 6BB program is a team-based approach to helping primary care clinics improve management of patients with chronic pain who are on long-term opioid therapy. The 6 building blocks are key focus areas—from leadership support to measuring success—for clinics in the program. Development of 6BB was led by Senior Investigator Michael L. Parchman, MD, MPH. Clinics using the program have lower numbers of patients receiving opioids for chronic pain and fewer on high doses, so Dr. Parchman’s team, supported by the Washington State Department of Health, using funds from the CDC, is offering the program to diverse settings throughout the state.
• Learning Health System. The LHS program brings KPWHRI and the Kaiser Permanente Washington care delivery system together to design, implement, and evaluate initiatives to benefit members, care teams, and communities. One example is the LHS Integrated Pain Management pilot—a partnership with 3 clinics in the Tahoma District southeast of Seattle to develop and evaluate a primary care-based pain management program to improve whole-person care for people with chronic pain. The goal is improving quality of life, functioning and overall health by providing safe alternatives to opioids including evidence-based, nondrug treatments for chronic pain. The program is led by KPWHRI Senior Investigator and Kaiser Permanente Washington Senior Associate Medical Director for Research and Translation Paula Lozano, MD, MPH, with Kaiser Permanente physician Annie Chun, MD.
• Dr. Von Korff led a ground-breaking study linking higher doses of medically prescribed opioids to increased overdose risk among people with chronic pain. The results are cited in policy papers from the Centers for Disease Control and Prevention, the U.S. National Academies, and the World Health Organization, among others. The work influenced Washington state guidelines and a Kaiser Permanente initiative to increase the safety of noncancer opioid use. A highly cited study led by Dr. Von Korff showed the guidelines led to a reversal of the trend toward increased opioid prescribing. Dr. Von Korff also collaborated on a Kaiser Permanente initiative to standardize care plans for patients receiving opioids and has included patients as research partners to ensure their perspectives are integrated into research on chronic pain and opioid use.

KPWHRI is an excellent place for research on chronic pain and opioids, Dr. Boudreau says: “We can see a complete picture over time because of our excellent data, large and stable population, and relationships with providers, leadership, and patients.” These features are the foundation for studies that are robust and relevant to clinical practice and policy, as KPWHRI works toward practical, effective, patient-centered ways to treat opioid use disorders and chronic pain.