Treating Chronic Pain in Buprenorphine Patients in Primary Care Settings

Nearly 2.5 million individuals in the United States have opioid use disorder (OUD), with the
vast majority (2 million) reporting abuse of prescription opioids. Patients with a history of
substance use are particularly vulnerable to experiencing pain. Indeed, a large percentage of
patients with OUD who receive the effective opioid agonist treatments (OAT) buprenorphine or
methadone (MMT), report that pain preceded any use of addictive substances, and that the
primary reason for starting opioid use was to reduce pain. Among methadone patients, 37-61%
suffer from chronic pain that is often severe and interferes with daily activities.
Similarly, in studies of chronic pain in buprenorphine patients, approximately 48% of
patients report chronic pain. OAT recipients report far higher rates of chronic pain than the
wider US population.

Chronic pain has been associated with negative substance use outcomes in persons receiving
buprenorphine for opioid detoxification and in people receiving MMT. Providers may prioritize
the treatment of substance use in OUD patients, leaving the concurrent pain untreated. Lack
of treatment encourages patients to use illicit opioids for pain relief. Indeed, for persons
using buprenorphine, greater pain severity in a given week was significantly associated with
increased likelihood of opioid use in the following week.

Pain contributes to other negative outcomes. Pain is an independent risk factor for suicide
including in samples of substance use disorder patients. Further, compared to MMT patients
without pain, those with pain have significantly greater health problems and psychological
distress. Pain, poor health, and low energy are the most commonly cited reasons that OAT
patients are physically inactive. The continued physical and social problems in patients with
pain influence the perception of (lack of) treatment benefits by both patients and providers.

Duration of opioid agonist treatment (OAT) is a key predictor of long-term abstinence and
outcomes improve across a variety of domains if patients remain in care for at least one
year. Although buprenorphine is a growing ambulatory treatment, retention in care remains
problematic. Across practice sites and, despite variations in visit frequency, the 12-month
retention rate ranges from 50-80% with the majority of treatment drop-out occurring during
the first three months of treatment. Though few studies have yet examined the role of pain,
pain has been found to negatively impact buprenorphine treatment retention.

Studies estimate that approximately one third to one half of MMT and buprenorphine recipients
suffer from depression. Several studies have reported that opioid dependent patients with
chronic pain have greater depressive symptoms and a greater probability of occupational
disability compared to patients with lower level or no chronic pain. Amongst MMT patients,
higher psychiatric distress is associated with lower general functioning. Methadone
counselors report difficulty treating patients with chronic pain due in part to these
patients' co-occurring psychiatric symptoms. In the only study of antidepressant treatment
for depressed persons initiating buprenorphine, the investigators found in a secondary
analysis that pain is prevalent, interferes with functioning, and its severity plateaus after
one month of buprenorphine. Importantly, as with chronic pain, depressive symptoms have been
associated with greater likelihood of relapse to opioid use in OAT patients. The substantial
overlap of pain and depression in OAT patients suggest that functioning may improve most when
depression and pain are simultaneously treated in an integrated fashion that is
theoretically-based.

TOPPS is a type of cognitive behavioral therapy (CBT) that consists of three main components:
1) psychoeducation about pain, depression, opioid misuse, their interaction, and the
maintaining role of avoidance; 2) coaching in being an informed, activated patient; and 3)
behavioral activation with a focus on acceptance. Modern behavioral activation is idiographic
and responsive to each patient's unique environment, needs, and goals. The function of a
behavior is analyzed, and if the function is avoidance (e.g., of social contact, personal
engagement, or physical activity), the behavior is targeted for change. Patients are taught
to consider behavioral options, and to choose an option inconsistent with avoidance. There is
an implicit attitude of acceptance of thoughts and feelings, as behavior is not dependent on
changing thoughts and feelings. Behavior activation for depression focuses on helping
patients to set goals in meaningful life areas, and then to break down long-term goals into
smaller weekly goals. This process is incompatible with behavioral avoidance and instead,
encourages patients to approach meaningful life goals. Barriers that arise in achieving
short-term goals are addressed in treatment.

TOPPS focuses on the relationship of pain, depression, opioid and other substance misuse, and
functioning. It has a structured agenda, uses behavioral activation, involves explicit and
ongoing psychoeducation, and includes a BHS trained extensively in the nature of pain and
opioid misuse and relapse. Devised specifically for primary care patients receiving
buprenorphine, TOPPS is collaborative (physician, interventionist, and patient) and focuses
on depression, pain and physical symptoms in order to decrease the need to turn to substance
misuse to avoid pain, increase overall functioning and to foster patient's abilities to
achieve their long-term life goals.

Inclusion Criteria:

1. Between 18 and 65 years of age

2. Have chronic pain, defined as pain duration for at least three months with a mean
score of 5 or higher on the BPI Pain Interference Scale

3. Pain severity of 40 or higher on a Visual Analog Scale (0-100) indicating "worst pain
in the last week"

4. Previous attempt at initial steps of PCP guideline pain care: must have had at least
one trial of recommended medication (i.e. acetominophen, NSAIDS, skeletal muscle
relaxants

5. Quick Inventory of Depression Symptoms (QIDS) score of ≥ 9

6. If using an antidepressant, the dose must be stable for the previous 2 months

7. Has received buprenorphine from the current primary care provider for at least the
last three months

8. Continuing buprenorphine with no plan to taper dose for the next 12 months

9. Gives informed consent to participate in the study.

Exclusion Criteria:

1. Currently receiving cognitive behavioral therapy (CBT)

2. In a multidisciplinary pain management program

3. Expected surgery in the next 3 months

4. Pain thought to be due to cancer, infection, or inflammatory arthritis

5. Receiving injectable or implantable buprenorphine

6. Current mania

7. Lifetime diagnosis of schizophrenia or other chronic psychotic condition

8. Suicide ideation or behavior requiring immediate attention

9. SSDI or SSI claim pending

10. Self-reported pregnancy.