ANNUAL OCT. 31-NOV. 2 MEETING ARLINGTON, VA Addressing th the Opioid Crisis b by y Improving Pain Management Christine Goertz, DC, PhD Vice Chancellor for Research and Health Policy at Palmer College of Chiropractic and Chief Executive Officer of the Spine Institute for Quality @ChristineGoertz November 1, 2017 #PCORI2017
ANNUAL MEETING | #PCORI2017 Ch Chri ristine Goe oert rtz, D , DC, C, Ph PhD Disc sclosu sures Relationship Company(ies) Speakers Bureau Advisory Committee Quality Insights of Pennsylvania Technical Expert Panel #’s 131, 182 Consultancy American Chiropractic Association, Healthwise, Inc., Quality Insights of Pennsylvania, RAND Corporation Review Panel Board Membership American Public Health Association, Chiropractic & Manual Therapies, Journal of Manipulative and Physiological Therapeutics, PCORI Board of Governors Honorarium Ownership Interests Prezacor, Inc. 11/5/2017 2
ANNUAL MEETING | #PCORI2017 Objec ectives es At the conclusion of this activity, participants should be able to: • Understand the nature and extent of the opioid crisis and what is known about the benefits and harms of opioids, non-opioid alternatives to pain management, and treatment for opioid use disorder • Identify evidence patients and other stakeholders need to help them make better choices about managing pain • Have a broad overview of PCORI’s investments in opioid and pain-related research and how two specific PCORI projects address evidence gaps 11/5/2017 3
ANNUAL OCT. 31-NOV. 2 MEETING ARLINGTON, VA Judy Zerzan, MD, MPH Christine Goertz, DC, PhD Aleksandra Zgierska, MD, PhD PCORI Board of Governors Colorado Department of University of Wisconsin Healthcare Financing and Healthcare Erin Krebs, MD, MPH Terrie Cowley Lynn Debar, PhD University of Minnesota The TMJ Association, Ltd Kaiser Permanente #PCORI2017
ANNUAL OCT. 31-NOV. 2 MEETING ARLINGTON, VA Overview of Opioid Crisis a and Effec ective Non e Nonpharmacol ologi ogic Trea eatment St Strategies ies for or P Pain Erin E. Krebs, MD, MPH Minneapolis VA Health Care System, University of Minnesota November 1, 2017 #PCORI2017
ANNUAL MEETING | #PCORI2017 Erin K Kre rebs Has nothing to disclose. Is speaking for herself, not for the VA or US government. 11/5/2017 6
ANNUAL MEETING | #PCORI2017 Objec ectives es At the conclusion of this activity, participants should be able to describe: • Scope of the opioid crisis and its intersection with pain management • Evidence for nonopioid pain therapies and opioid tapering • Key gaps and research needed to advance our knowledge of the comparative effectiveness of strategies to address the opioid crisis 11/5/2017 7
ANNUAL MEETING | #PCORI2017 Opioid sales Opioid overdose deaths Opioid addiction treatment admissions 11/5/2017 Paulozzi et al, MMWR 2011;60:1487–92 8
ANNUAL MEETING | #PCORI2017 The Evidence f for O Opioids in Chronic P Pain, 1 1996 11/5/2017 9
ANNUAL MEETING | #PCORI2017 Opinion of respected authorities, case reports, and expert committees Management of Opioid Therapy for Chronic Pain Working Group, March 2003 11/5/2017 10
ANNUAL MEETING | #PCORI2017 • “It is now accepted by practitioners of the specialty of pain medicine that respiratory depression induced by opioids tends to be a short- lived phenomenon, generally occurs only in the opioid-naive patient, and is antagonized by pain.” Clin J Pain. 1997 Mar;13(1):6-8. 11/5/2017 11
ANNUAL MEETING | #PCORI2017 The Evidence f for O Opioids in Chronic P Pain, 2 2016 • No study of opioid therapy versus placebo, no opioid therapy, or nonopioid therapy for chronic pain evaluated long- term (≥ 1 year) outcomes related to pain, function, or quality of life. • Most placebo- controlled randomized clinical trials were ≤ 6 weeks in duration 11/5/2017 12 Dowell D et al, MMWR 2016; 65(1);1–49
ANNUAL MEETING | #PCORI2017 Inter ertwined ed c cha hallen enges o es of the he o opi pioid crisi sis How can people prescribed high-dose opioids reduce opioid dosages and Long-term decrease risk of opioid use Chronic pain harm, while managing pain? How can people with chronic pain Opioid find the best addiction approaches to pain management for their situation? 11/5/2017 13
ANNUAL MEETING | #PCORI2017 • Prompted by White House summit on opioid crisis • Focus on alternatives to opioid therapy • Goals: Synthesize existing evidence to identify approaches with sufficient evidence (ready for use) and areas needing future research 11/5/2017 14
ANNUAL MEETING | #PCORI2017 Therapies wi with e evidence of efficacy Exercise therapies Strengthening- stretching Aerobic exercise Behavioral Yoga therapies Tai chi Manual CBT therapies ACT Massage MBSR Acupuncture Manipulation 11/5/2017 15
ANNUAL MEETING | #PCORI2017 Area eas ne needing a add dditional r rese esearch • Selecting therapies • Combining and sequencing therapies • Dose/duration of therapies • Engaging and activating patients 11/5/2017 16
ANNUAL MEETING | #PCORI2017 The e he eviden ence ce f for r opi pioids in n chr hronic pa pain, 2016 016 • Findings • Interdisciplinary pain programs and multimodal behavioral interventions may be effective in reducing opioid dose • Pain, function, and quality of life may improve during and after opioid dose reduction • Overall, very low quality of evidence 11/5/2017 17 Frank JW et al. Ann Intern Med 2017;167:181-191
ANNUAL MEETING | #PCORI2017 The e he eviden ence ce f for r opi pioids in n chr hronic pa pain, 2016 016 • Research needs include: • Studies using innovative designs to overcome research challenges (e.g., recruitment) • Testing more feasible/scalable treatment approaches • Studies to examine real-world changes in practice and policy 11/5/2017 18 Frank JW et al. Ann Intern Med 2017;167:181-191
ANNUAL MEETING | #PCORI2017 Future directi tions for r research 11/5/2017 19
ANNUAL MEETING | #PCORI2017 PC PCORI’s Investm tment i in Pain and Opioid Research Christine Goertz, DC, PhD Vice Chancellor for Research and Health Policy at Palmer College of Chiropractic and Chief Executive Officer of the Spine Institute for Quality @ChristineGoertz November 1, 2017 20 11/5/2017 20
ANNUAL MEETING | #PCORI2017 PCORI’s M Mission To help people make informed healthcare decisions and improve healthcare delivery and outcomes, by producing and promoting high- integrity, evidence-based information that comes from research guided by patients, caregivers, and the broader healthcare community. 21
ANNUAL MEETING | #PCORI2017 PCOR ORI’s R Role i in a National al H Health R Resear arch P Program am 11/5/2017 22
ANNUAL MEETING | #PCORI2017 PCOR ORI P Prior ority ty Ar Area: C Chron onic ic P Pain a and Op Opioi oid R Resea earch ch Development of Stakeholder Board Priority Area: Key Initiatives on Workshops: Chronic Pain/Opioid Pain and Opioid Crisis Define CER Questions Research 11/5/2017 23
ANNUAL MEETING | #PCORI2017 Research ch A Addressing Q Questions That M Matter Clinician What works best to safely and appropriate reduce opioid use for people with pain? Patient I’m worried about becoming dependent on opioids. How effective are nondrug options for treating pain? Health System Leader How can we improve our clinicians’ prescribing practices? Caregiver How can patients best become empowered about opioid use? 11/5/2017 24
ANNUAL MEETING | #PCORI2017 Chronic an and A Acute P Pai ain M Man anagement As o of O Oct ctober 2 2017, PC PCORI has a awarded 209 million to fund 59 studies related to chronic noncancer pain and/or opioids 11/5/2017 25
ANNUAL OCT. 31-NOV. 2 MEETING ARLINGTON, VA #PCORI2017
ANNUAL MEETING | #PCORI2017 Spanning t the C Care C Continuum Management of Treatment for Treatment Education and Prevention Long-term Opioid Opioid Use Alternatives Communication Use Disorder 11/5/2017 27
ANNUAL MEETING | #PCORI2017 PCORI’ I’s T Targeted O Opioid I Initiatives 11/5/2017 28
ANNUAL MEETING | #PCORI2017 Strategies t to P Prevent U Unsafe Prescr cribing i in Primary Care a among Patients w with A Acu cute o or C Chronic P Pain Objective of this PFA : Funds and Duration: • Prevent unsafe opioid prescribing while ensuring adequate pain management • $30 million originally utilizing: available (direct and indirect) • health system or payer strategies • Up to $5 million in total • patient and provider communication direct costs per project interventions addressing benefits and • Projects should be harms of treatments completed within 3 years 11/5/2017 29
ANNUAL MEETING | #PCORI2017 Clinical S Strategies for Managing a and R Reduci cing Long-Term U Use f for C Chronic Pain Objective of this PFA : Funds and Duration: • Identify clinical strategies for managing • A total of $40 million pain while: (direct and indirect) • Up to $10 million in total • Reducing or eliminating long-term opioid use direct costs per project • Projects should be • Limiting dose escalation completed within 3-5 years 11/5/2017 30
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