Integrated Care Models Bridge Gaps in Treating Opioid Use Disorder and Chronic Pain
核心洞察
Over half of individuals with opioid use disorder (搜索) (OUD) in the United States also live with chronic pain (搜索), yet treatment for the two conditions is largely delivered in separate settings.
Yale's IMPOWR-YOU Center is running two core clinical trials—Pain CHAMP and SC-POWR—to evaluate integrated, single-setting care for co-occurring OUD and chronic pain (搜索).
Weill Cornell Medicine researchers are mapping health systems and analyzing the costs of emergency department-initiated buprenorphine to identify and address barriers to OUD care access.
In the United States, over half of individuals with opioid use disorder (搜索) (OUD) are also living with chronic pain (搜索). Despite this overlap, treatment of OUD and chronic pain is largely provided in separate locations within the American healthcare system, and clinical research driving treatment discovery and innovation in these two areas is similarly siloed.
The IMPOWR-Yale Organizations United (YOU) Center at Yale School of Medicine has developed a robust model for engaging communities of people with lived experience of OUD and chronic pain (搜索). "Traditionally, healthcare delivery for individuals with the combined conditions of chronic pain and opioid use disorder (搜索) has meant that a patient may need to seek care in two to three locations—primary care, an opioid treatment program, and a pain specialist," said William Becker, MD, co-principal investigator at IMPOWR-YOU and professor of medicine (general medicine). "Yale has been instrumental in developing models that provide integrated care for both conditions in one setting."
Two Core Clinical Trials
The center houses two core clinical trials: Pain CHAMP (Pain Care at Home to Amplify Function) and SC-POWR (Stepped Care for Patients to Optimize Whole Recovery).
The Pain CHAMP study compares two promising interventions—pharmacist collaborative management (PCM) and PCM with cooperative pain education and self-management (COPES)—among participants receiving long-term opioid therapy. "The participants may benefit from reassessment of their opioid treatment plan due to concern for opioid misuse or OUD," said Anne Black, PhD, associate professor of medicine (general medicine) and investigator at the center.
Led by Black and Becker, the study examines opioid prescription and pain management from a specialized clinical team consisting of a pharmacist and a physician. "Once the patient is stabilized in their opioid regimen or transitioned to other treatment options, they are transferred back to continue management in primary care," Black added. "We're interested in the benefits of this approach and to what extent the addition of COPES within this model further improves patient outcomes."
The SC-POWR clinical trial aims to improve a broad range of outcomes for individuals with OUD, including retention in treatment, pain, depression, anxiety, and post-traumatic stress disorder. Situated within three opioid treatment programs operated by the APT Foundation (搜索), the study provides cognitive behavioral therapy (CBT) training to counseling staff and evaluates care outcomes among participants randomized to receive CBT from these counselors, as well as those "stepped up" to additional interventions, including stress reduction groups and exercise programs.
"Stress reduction and exercise can be helpful to manage pain and improve quality of life. Engaging patients in sustainable exercise routines can bring notable improvements; many patients are afraid that exercise will make their pain worse, but find that it brings some relief," said Barry, the principal investigator.
Community-Engaged Research
The pilot studies have also afforded early-stage investigators the opportunity to pursue small-scale projects with big potential. One such study examined patient perspectives on satisfaction with clinical care among patients using prescribed and non-prescribed opioids. The study was led by Michele Buonora, MD, MS, MSHS, assistant professor of medicine at Albert Einstein College of Medicine, when she was a postdoctoral fellow at Yale, and Christin Veasley, co-founder and director of the Chronic Pain (搜索) Research Alliance, and an individual with lived experience of chronic pain.
"Co-leading a study with someone with lived experience of chronic pain (搜索)—and guided by a diverse team of patients, veterans, insurers, clinicians, scientists, and advocates—was a transformative experience," reflected Buonora. "This approach was essential in shaping our research question into a rigorous study with rich findings and implications relevant and useful to those most impacted by our work."
Understanding Barriers to OUD Care
Researchers at Weill Cornell Medicine are taking an interdisciplinary approach to understanding the barriers between impacted Americans and access to OUD care. More than 806,000 Americans have died from opioid overdose since the opioid epidemic began in the 1990s. Effective OUD treatments exist, and ensuring that patients can access care remains essential to tackling the crisis.
Substance use disorder treatments have not historically existed as integrated parts of mainstream medical care. For patients with mental or physical health conditions in addition to OUD, this separation may result in structural barriers to receiving care, according to Kayla Tormohlen, senior research associate in population health sciences at Weill Cornell and research director of the Cornell Health Policy Center.
"Thinking about all these different aspects that we as humans deal with…if you have to get your substance use disorder treatment here, your mental health disorder treatment here [and] your general medical care somewhere else, that creates barriers to care," Tormohlen said.
In the case of OUD, medications like buprenorphine, methadone and naltrexone reduce opioid cravings and have existed for decades. However, methadone, for example, must be dispensed through an opioid treatment program outside of a typical clinical setting, according to the Substance Abuse and Mental Health Services Administration.
Tormohlen leads a project studying integrated health systems alongside Beth McGinty, chief of the Division of Health Policy and Economics at Weill Cornell and a founding director of CHPC. The ongoing project—conducted through the National Institutes of Health's HEAL Data2Action Program, which supports research aimed at mitigating the opioid crisis—maps health systems to provide a visual representation of how substance use disorder treatments, including OUD treatments, operate within the system's context.
"There's really this idea around coordinated management of whole person health in which OUD is co-managed alongside other comorbidities such as mental illness and chronic pain (搜索)," Tormohlen said.
Analyzing the Costs of OUD Care Integration
Through its partnership in the Center for Health Economics of Treatment Interventions for Substance Use Disorders, HCV and HIV (CHERISH), Weill Cornell also approaches OUD care integration through an economic lens, studying its associated costs, benefits and outcomes.
"We have a limited amount of money, so how do we most efficiently allocate that money to have the biggest impact?" asked Prof. Bruce Schackman, population health sciences, the director of CHERISH.
A recent study led by Danielle Ryan, senior research coordinator in population health sciences, in collaboration with CHERISH affiliates analyzed the costs of implementing emergency department-initiated buprenorphine, which is one way that OUD care can be integrated into mainstream healthcare. Unlike methadone, buprenorphine is an OUD treatment that does not require participation in an opioid treatment program.
ED-initiated buprenorphine refers to buprenorphine treatment that is begun in the ED of a medical facility and followed by referral to ongoing care, according to the NIH. While a 2015 study found that starting buprenorphine care in the ED was associated with an increase in OUD patients continuing to receive care, implementing this care comes with logistical and systemic barriers, including the preparedness of ED physicians for treating OUD.
To better understand how these barriers might be addressed, Ryan's paper broke down the cost of an implementation strategy in which experts guide EDs in the integration of these new practices. Researchers created a budget impact tool for stakeholders to understand potential costs of integrating buprenorphine care into the ED.
With opioid overdose fatalities decreasing nearly 27% between 2023 and 2024, Schackman discussed how the focus of research around opioid use may shift away from overdose towards other aspects of OUD. "We want to … keep the focus on what works so that we continue to see that trend go down," Schackman said, "but [we] also understand that fatal overdoses are only one aspect of the challenges for people who use drugs."
Looking Forward
Center investigators note that the trials are approaching completion, and that planning for further research, informed by the trial findings, is in progress. The findings from five pilot studies and two clinical trials will be made available to the broader IMPOWR Research Network in early 2027, enabling other institutions and researchers conducting similar work to access the data.
"The progress that the IMPOWR Network has made in addressing common but understudied conditions is palpable. The collaborations will continue and result in better science and improved treatments for years to come," said David A. Fiellin, MD, professor of medicine (general medicine), of emergency medicine, and of public health, and co-principal investigator of IMPOWR-YOU.