Many pain specialists oppose the use of opioids to treat chronic non -malignant pain syndrome (CPS) due to concerns about addiction and the failure of many patients to evidence functional improvements. Others advocate the use of opioids when non- pharmacologic approaches fail or when quality of life will be improved. While most providers lack the expertise to provide """"""""integrated"""""""" care to patients with CPS and co-occurring addiction, those with proficiency in both domains believe that this co-morbidity can be managed effectively with opioids so long as special procedures for dispensing medications for monitoring for illicit drug use are implemented. With this in mind, we are proposing a Stage 1 study to develop and pilot test """"""""Medication Adherence Therapy"""""""" (MAT). MAT is designed to enhance opioid adherence in pain patients with a history of prescription drug abuse for whom opioids are, nevertheless, clinically indicated. MAT """"""""blends"""""""" elements of MET and CBT with specific adherence strategies including patient education, self-monitoring, and behavioral contracting. Together, these adherence strategies will comprise """"""""Adherence Therapy"""""""" (AT), a comparison treatment which approximates best practices treatment as usual. At issue is whether adding the additional psychotherapeutic elements included in MAT (i.e., MI and CBT) improves outcomes over those for patients who receive AT only. During Phase 1 (months 1-18), we will complete drafts of the MAT and AT manuals and will pre- pilot these on 18 patients with CPS and opioid abuse (12 MAT and 6 AT). All cases will be video-taped for review by the therapy development team consisting of the PI, Co-Investigators, and consultants. Videotapes will also be used to help identify the unique aspects of MAT. Based on the results of the pre-pilot, we will revise the manuals and begin development of the adherence/competence scales. During Phase 2 (months 19-24), we will train 3 interventionists each in MAT and AT. The interventionists will be medical/rehabilitation staff who interact with these patients in medical settings as opposed to trained mental health personnel. Each interventionist will receive 2 training cases; training cases will be used to provide practice and determine therapist competence. Training will consist of didactic presentations, review of videotaped training cases, feedback, and clinical supervision. Trainees will also role-play situations they may encounter during the pilot study. During Phase 3 (months 25-42), we will conduct a pilot study comparing MAT to AT. The pilot study will in involve 30 patients with CPS and opioid abuse who are randomized to either MAT or AT. Trainees who demonstrated competence with their training cases will serve as the interventionists for the pilot study. During Phase 4 (months 42-48), the data from the pilot study will be analyzed and prepared for presentation/publication. We will estimate the effect size of the difference between MAT and AT and will then make a decision about whether MAT shows sufficient promise to warrant further testing in a State 2 study.
| Haller, Deborah L; Acosta, Michelle C (2010) Characteristics of pain patients with opioid-use disorder. Psychosomatics 51:257-66 |
| Bethea, Angela R; Acosta, Michelle C; Haller, Deborah L (2008) Patient versus therapist alliance: whose perception matters? J Subst Abuse Treat 35:174-83 |
| Acosta, Michelle C; Eissenberg, Thomas; Nichter, Mimi et al. (2008) Characterizing early cigarette use episodes in novice smokers. Addict Behav 33:106-21 |
