Developing and pilot testing an intervention to increase opioid tapering in primary care

ABSTRACT With the career goal of becoming an independent investigator, Hector R. Perez, MD, MS, describes a mentored research project and specific career development plan which will prepare him to develop and test interventions to improve health outcomes among patients taking opioid pain relievers (OPRs) for chronic pain. Use of OPRs for chronic pain is widespread in primary care settings despite consistent evidence of harm for this clinical indication. Guidelines recommend reducing or discontinuing (tapering) OPRs when risks exceed benefits, such as for patients taking high-dose OPRs with poorly controlled pain. However, there are numerous barriers to initiating and maintaining OPR tapers in primary care settings, including the concern that patients will elect to seek care elsewhere and not be retained in primary care. This project seeks to increase OPR tapering in primary care in a select group of high risk patients by implementing a protocol-based tapering intervention (TapPro) that provides patient and provider support, delivered by a nurse within a primary care setting. Using the Social Cognitive Theory as a framework, the intervention will be developed based on tapering guidelines by the Washington State Agency Medical Directors? Group and adapted based on qualitative interviews with patients and primary care providers (PCPs). This proposal aims to: 1) identify barriers to and facilitators of OPR tapering among patients with high OPR dose and among PCPs, 2) develop a protocol-based tapering intervention (TapPro) to increase tapering in primary care that addresses barriers and facilitators of OPR tapering, and 3) test the feasibility and preliminary efficacy of TapPro versus standard of care (SOC) in a pilot RCT of 60 patients taking high-dose OPRs (?100 mg morphine-equivalent daily dose) with persistent chronic pain. Our primary feasibility outcome is retention in primary care, defined as the number of PCP follow-up visits during the 6-month intervention. Our primary efficacy outcome is any change in OPR dose over time during the 6-month intervention. We hypothesize that TapPro will be associated with similar retention in primary care and a greater OPR dose reduction compared to SOC. Through completion of the proposed research and career development plan, Dr. Perez will gain skills in research methods to study OPR use for chronic pain, advanced qualitative methods, the design and conduct of randomized controlled trials, and the statistical analysis of complex longitudinal data. The proposed research will lead to an R01 application to test TapPro in a large randomized controlled trial. Together, these activities will be instrumental in advancing Dr. Perez?s goal to become an independent investigator.