Project Summary-Abstract:
The treatment of chronic non-cancer pain has largely fallen to primary care physicians who often, due to
healthcare system constraints, rely exclusively on long-term opioid therapy (LOT). Based on the adverse
consequences and inadequate evidence of effectiveness for LOT, the CDC recently developed
recommendations designed to decrease the use of LOT and the morphine equivalent dose (MED) for patients
receiving LOT. However, the majority of people receiving LOT report that opioid medication is significantly
beneficial and even critical to managing their pain. Compounding the problem is poor access to non-
pharmacologic therapies for many patients, particularly in rural and lower socioeconomic communities, due to
insurance reimbursement structures and limited availability of pain services. The importance of testing
adjunctive therapies to reduce MED was noted in NIDA’s new strategic plan as was the importance of
evaluating interventions that are scalable and, thus, more likely to be used. Chronic pain patients are
increasingly using the internet for information and support; hence an affordable and effective web-based
intervention could dramatically increase access to pain treatment. A web-based chronic pain program, the
Chronic Pain Management Program (referred to as E-health), includes multiple learning centers that train skills
such as cognitive restructuring, emotion regulation, goal setting, activity and exercise promotion, social
support, relaxation techniques, and behavioral activation. The learning activities can be completed within a 4-
month subscription period, the cost of which is $25/month. The results of two prior randomized controlled trials
(RCTs) found E-health to be efficacious in decreasing pain and medication use. While these results are
promising, they need to be replicated in a larger RCT and with patients being treated in primary care, where
the majority of chronic pain patients are treated. Specific aims for the present project are to: 1) Conduct a RCT
comparing E-health+ to treatment as usual (TAU). Four hundred patients being treated with =20 mg/day MED
for chronic pain at primary care practices within one of two healthcare systems will be randomized in a 1:1 ratio
to TAU or to TAU plus E-health (E-health+). TAU will consist of LOT from a primary care physician; MED and
physician visits will be tracked through the electronic health record (EHR). TAU will be further characterized
using the Assessment of Chronic Illness Care, which assesses the degree to which a practice uses six
strategies that encourage high-quality care. Participants will complete assessments at baseline, the end of the
4-month E-health treatment period, and at 6 months post-treatment. 2) Test our conceptual model of E-health’s
mechanisms of change, including hypothesized mediators (i.e., pain self-efficacy, coping strategies, knowledge
about pain/opioid therapy, and stress) and moderators (neurocognitive function: executive function and verbal
learning ability) of E-health’s impact on decreasing MED and pain intensity.