Stopping the opioid epidemic: Priority research at KPWHRI
Opioid misuse and overdose are now a national priority. For decades, KPWHRI has worked to help patients find safe, effective ways to manage chronic pain.
Low back pain is a common reason for visiting the doctor. This is true now, as it was in the 1990s, when Michael Von Korff, ScD, senior investigator at Kaiser Permanente Washington Health Research Institute (KPWHRI), was leading studies on lower back and other common chronic pain conditions. "I saw the dramatic national increase in opioid prescriptions, with the associated increase in opioid addiction and overdose," he says, "and decided to study ways to reverse those trends."
Dr. Von Korff's pioneering work over the last three decades provides evidence for what is now called the U.S. opioid epidemic. Although the last decade's rising rate of overdose deaths involving prescription opioids has leveled off and opioid prescribing may be gradually declining, Dr. Von Korff says, "In the last five years there's been a rapid increase in fatal overdoses involving heroin and illicit fentanyl." 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.
KPWHRI leads in research on opioids and addiction treatment
KPWHRI investigators are studying how to improve care for chronic pain; supporting providers in safer approaches to managing chronic pain; and helping people with opioid use disorders. Current projects include:
- National research on primary care for chronic pain.
Senior Investigator Lynn DeBar, PhD, MPH leads the Pain Program for Active Coping & Training (PPACT) study. PPACT is a pragmatic randomized clinical trial funded by the Health Care Systems Collaboratory of the National Institutes of Health that compares usual primary care for chronic pain, including prescription opioids, to a multipronged primary care intervention. The trial involves 851 patients and 273 primary care providers across three regions of Kaiser Permanente: Georgia, Hawaii, and the Northwest. The PPACT intervention coordinates and integrates services that help patients with chronic pain adopt self-management skills and limit prescription opioid use. Dr. DeBar's research team is measuring patient-reported pain and function. They are also calculating health care system costs for medications and patient services over the study.
- Evaluating the impact of a state strategy to reduce prescription opioid use.
Supported by $5.7 million from the Patient-Centered Outcomes Research Institute (PCORI), Dr. DeBar is leading the Back on Track study to analyze the effects of a natural experiment. Oregon changed its Medicaid reimbursement to promote nondrug treatments including physical therapy, cognitive behavioral therapy, yoga, acupuncture, and massage for patients with low back pain. The new reimbursement strategy discourages prescription opioids for low back pain. Dr. DeBar's team is using electronic health record data and surveys and interviews with staff and Medicaid-insured patients at federally qualified health centers in Oregon and California to determine how the Medicaid changes affect patients’ pain severity, function, and satisfaction with care, and their use of illegal and recreational drugs.
- A nationwide pragmatic trial on increasing access to effective treatment for opioid use disorders in primary care.
Senior Investigator Kathy Bradley, MD, MPH, leads the PRimary Care Opioid Use Disorders (PROUD) treatment trial funded by the National Institute on Drug Abuse Clinical Trials Network. Based on successful pilot work, PROUD is a pragmatic trial of collaborative care for opioid use disorders.
- Implementing evidence-based team-focused approaches to safe opioid prescribing.
Researchers at the MacColl Center for Health Care Innovation at KPWHRI are applying their expertise in primary care best practices to opioid prescribing for chronic pain patients in rural clinics. Supported by the Agency for Healthcare Research and Quality and based on findings from their work on Primary Care Teams: Learning from Effective Ambulatory Practices (LEAP), researchers are studying how to sustainably and effectively implement team-based best practices for chronic pain care, including reduced opioid use. The work is led by Michael Parchman, MD, MPH, KPWHRI senior investigator and MacColl Center director.
KPWHRI also develops methods to track opioid prescribing and related adverse effects. Examples include:
- Measuring and monitoring misuse, abuse, and addiction associated with extended-release/long-acting (ER/LA) opioids.
KPWHRI Senior Investigator Denise Boudreau, PhD, co-leads a $10 million national project on measuring the extent of and identifying factors associated with harms from long-term opioid use. Her research partners are from the Health Care Systems Research Network; Veterans Affairs, Palo Alto, CA; and groups from New York and Florida from the Practice-Based Research Network. Funding is from pharmaceutical companies that manufacture opioid medications, as mandated by the U.S. Food and Drug Administration (FDA).
- Measuring the effect of opioid use during pregnancy on birth defects.
Funded by the FDA, Dr. Boudreau is determining the association between prescription opioid use during pregnancy and risk of neural tube defects.
- Developing algorithms and statistical methods for detecting and studying overdoses and deaths from ER/LA.
Jennifer Nelson, PhD, senior investigator and director of biostatistics, and Susan Shortreed, PhD, associate investigator, lead a team of KPWHRI biostatisticians in a coordinating center for a national consortium on ER/LA opioids. For this work, Dr. Nelson is applying models developed by KPWHRI for the FDA Sentinel Initiative that monitors the safety of prescription drugs in the United States.
In addition, assistant investigator David Carrell and colleagues are generating methods to mine insurance and health data to measure opioid harms, find factors that affect them, and assess the effectiveness of interventions to reduce risks from prescription opioids.
KPWHRI opioid research has influenced clinical guidelines, policy, and practice. Examples include:
- Dr. Von Korff's contributions to developing and evaluating state and national guidelines about opioid prescribing.
Dr. Von Korff led a groundbreaking 2010 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. KPWHRI and University of Washington researchers, in another 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 (then Group Health) initiative to standardize care plans for patients receiving opioids. His most recent study on opioid safety included patients as research partners to ensure their perspectives are integrated into research on chronic pain and opioid use.
- Dr. Dublin's medication safety studies on prescription opioids for older adults.
Sascha Dublin, MD, PhD, associate investigator and internal medicine physician with the Washington Permanente Medical Group, has led studies cited by researchers around the world showing that prescription opioid use by older adults does not appear to affect brain function but may increase risk of pneumonia.
"Safe chronic pain management and expanding options for nonpharmacotherapy treatment that are both feasible to use and sustainable within the clinical care environment will continue to be a focus of my research," Dr. DeBar says. "This work touches on our institute-wide priorities in chronic illness management, complementary and integrative health research, and medication use and patient safety." With opioid misuse, abuse, and addiction a major concern of clinical care teams, Dr. DeBar says, "Our research is designed to help Kaiser Permanente provide the best care possible to people with chronic pain."