The COVID-19 pandemic arrived as another major health crisis was already plaguing the United States: An epidemic of opioid-related overdose and death. Measures to limit the spread of COVID-19 are creating conditions that can worsen both chronic pain and opioid use disorders and create barriers for obtaining treatment for these conditions.
At Kaiser Permanente Washington Health Research Institute, researchers are exploring virtual care for people who need help with chronic pain and opioid use disorder—work that is especially critical during the COVID-19 pandemic.
“Chronic pain limits life and work activities for at least 1 in 10 adults,” says Lynn DeBar, PhD, MPH, KPWHRI senior investigator. Dr. DeBar, with Senior Investigators Katharine A. Bradley, MD, MPH, and Karen J. Sherman, PhD, MPH, is leading 3 randomized controlled trials funded by a total of more than $15 million from the National Institutes of Health HEAL Initiative, for Helping to End Addiction Long-term.
"The three NIH HEAL projects we are carrying out give us a tremendous opportunity to improve care for people with chronic pain and/or opioid use disorders,” says Dr. DeBar. Two KPWHRI HEAL studies focus primarily on virtual care, which is increasingly an option at Kaiser Permanente. Members can get help from home, for example, using a phone or secure email, instead of visiting a clinic. During the pandemic, up to 90% of Kaiser Permanente Washington care became virtual.
MI-CARE. The project called “More Individualized Care: Assessment and Recovery through Engagement” is led by Drs. Bradley and DeBar. MI-CARE is launching this fall as a pilot at Kaiser Permanente Washington and clinics in Indiana, one of the states hardest hit by the opioid crisis, Dr. DeBar says.
Although primary care providers can prescribe two medications for opioid use disorders, buprenorphine and injectable naltrexone, they seldom do, partly because of clinical and administrative burdens. In addition, many people with opioid use disorder also have low mood or depression, chronic pain, and other complicating conditions. MI-CARE’s innovation is testing collaborative care that supports primary care management of opioid use disorder and depression simultaneously, along with other complicating conditions.
The MI-CARE collaborative care approach brings a nurse care manager supervised by behavioral health experts to support primary care teams in treating their patients with opioid use disorder and depression. The nurse care manager works virtually in a centralized manner, supporting patients and primary care teams throughout the Kaiser Permanente Washington region. The MI-CARE nurse care manager and consulting experts can carefully monitor patients’ response to treatment for each condition and provide personalized feedback and recommendations to primary care teams to individualize and improve the quality of care.
MI-CARE is timely for several reasons, says Dr. DeBar. COVID-19 may be increasing mental health and substance use disorders, and is complicating patients’ ability to get needed care for these conditions. Increasingly, behavioral health conditions are being managed in primary care and many health systems including Kaiser Permanente are looking towards broader use of collaborative care. In these ways, MI-CARE fits well with current care trends. If effective, MI-CARE could provide a scalable, realistic approach to supporting frontline primary care teams in providing high-quality care for opioid use disorders, depression, and complicating conditions.
RESOLVE. This project is designed to test scalable, pragmatic approaches to chronic pain that don’t rely on medications. Led by Dr. DeBar, RESOLVE is grounded in evidence (including her PPACT study) that in-person cognitive behavioral therapy can help patients manage their pain effectively without opioids. The goal of CBT is helping patients build skills to change their day-to-day activities and ways of understanding and responding to feelings and thoughts related to their pain. This may help them better cope with and manage their pain. However, many people, especially in medically underserved and rural areas—and others in the COVID-19 era—have difficulty accessing in-person CBT for pain. RESOLVE therefore seeks to improve access to CBT-based treatment for chronic pain using telehealth, an approach of great interest to patients and health care providers.
The RESOLVE trial will compare 2 types of telehealth-delivered CBT-based treatment for chronic pain: virtual visits with a health coach over video or telephone and an established, web-accessed, CBT-based program. The study goal is to find out who does best with which treatment and if these treatments improve outcomes for patients compared to usual care. Like MI-CARE, this is a multisite study in 3 regions of Kaiser Permanente (Washington, Northwest, and Georgia) and Essentia Health in Minnesota, Wisconsin, and North Dakota where many patients live in rural areas.
“RESOLVE was designed to serve people with barriers to accessing proven treatments for pain by providing visits via phone and online,” says Dr. DeBar. Like MI-CARE, RESOLVE adapted to care changes that came with COVID-19 by adding videocalls to the phone option. Video could help patients and providers make more personal connections and share visual materials, says Dr. DeBar.
BackInAction. This project tests the effectiveness of acupuncture for chronic low back pain for people age 65 and older. BackInAction is led by Drs. Sherman and DeBar with sites in Kaiser Permanente Washington and Northern California regions, Sutter Health in Northern California, and the Institute for Family Health/Mt. Sinai in New York. Evidence suggests that acupuncture is effective for chronic low back pain for younger patients, but little evidence supports the treatment in older patients.
The study began with focus groups and interviews with older adults with back pain. After one session was held in-person, as planned, those elements were conducted virtually, says Dr. Sherman. Findings emphasized the importance of participants knowing their acupuncturists and being assured that steps will be taken to minimize COVID-19 risks.
Based on those findings, Dr. Sherman says, the study will start a pilot project in Olympia, Washington with safety measures such as giving participants N95 masks, the most protective type of face covering. The guiding principle, Dr. Sherman says, is “to do what’s needed so providers and patients are safe and feel comfortable with their care.”
Like health care workers everywhere, the HEAL researchers and their study teams and partners are adapting and finding new ways to serve patients’ broad-based needs during the COVID-19 pandemic.
“At Kaiser Permanente,” says Dr. Bradley, “we’re innovative. It’s part of testing practical approaches to evidence-based treatment in real-world primary care.”
--by Chris Tachibana
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