Maisa S. Ziadni

Background: Approximately 45% of individuals taking methadone or buprenorphine have chronic pain. These medications are commonly prescribed for chronic pain or opioid use disorder (OUD). To optimize pain management as well as reduce opioid-related symptoms (eg, craving) and risks (misuse and overdose), there is a critical need for a brief, effective, and accessible pain skills intervention for this population. Objective: This single-arm study aimed to examine the feasibility and preliminary efficacy of online Empowered Relief (ER), a 1-session pain relief skills class, for individuals with chronic pain taking methadone or buprenorphine for chronic pain or OUD. Methods: A priori feasibility criteria were defined as at least 75% of enrolled participants attending the ER class and the mean satisfaction rating of at least 8 on a 0‐10 scale. Participants were recruited nationally across the United States. Out of the 69 enrolled participants, 55 attended the ER class. Self-report measures were collected at baseline, immediately post class, and at follow-up points of 2 weeks and months 1‐3. Additionally, qualitative interviews were conducted in a small sample (n=14) to obtain in-depth participant feedback. Among the class attendees, 51 participants (27/51, 52.9% female; mean age 48.6, SD 12.2, range 28‐71 years) completed at least one follow-up survey, and treatment outcomes were analyzed using repeated measures ANOVA, with missing data imputed using linear regression. This analytic sample consisted of 24 participants taking methadone and 27 participants taking buprenorphine; 43.1% (22/51) endorsed at least≥2 OUD symptoms within the past 12 months, meeting the DSM-5 ( Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]) diagnostic criteria for current OUD. Results: Feasibility was achieved with 79.7% (55/74) attendance and mean 8.6 (SD 2) ratings of treatment appraisal and satisfaction. Qualitative feedback demonstrated high acceptability of the class content and delivery, with suggestions for refinements. Repeated-measures ANOVAs and FDR-corrected post hoc tests revealed significant reductions at 1 month post-ER class (primary endpoint) in pain intensity (Cohen d =0.71), pain bothersomeness (Cohen d =0.54), and pain interference (Cohen d =0.61). At 3 months post-ER class, efficacy was maintained for pain intensity, pain bothersomeness, and pain interference (Cohen d =0.28, 0.44, and 0.48, respectively). No significant time effects were observed for pain catastrophizing, sleep disturbance, physical function, fatigue, depression, anxiety, social isolation, and opioid craving. Conclusions: This study is the first to test ER in patients taking methadone or buprenorphine for pain or OUD. Findings showed feasibility, acceptability, and preliminary evidence of treatment efficacy. Participant feedback will inform future study designs. These findings support a randomized trial to fully evaluate the efficacy and scalability of ER in this population.

Emotional Awareness and Expression Therapy (EAET) targets traumatic or conflictual emotional and interpersonal contributors to chronic pain. This qualitative study examined patients’ experiences of 4-session, group EAET conducted in an Australian tertiary pain clinic. Interviews with 10 adults who completed the therapy were analyzed via thematic analysis. Seven themes were identified. Patients noted that EAET was emotionally “challenging but worth it,” and that the group “provided strength in numbers, usually.” Although only some patients reported pain reduction, most reported that EAET was beneficial in various respects, including improving their relationship to pain (“pain takes a back seat”) and improved interpersonal and emotional functioning (“changing relationships”). Regarding therapy structure and content, patients experienced “validation in pain education,” but felt that the program was too short and needed additional care provision given its high intensity (“healing takes time” and “need for ongoing care”). All patients recommended EAET, although with some caveats, especially about format and patient readiness. This study finds that EAET is viewed as helpful by people with chronic pain, especially regarding their emotional and interpersonal functioning, and with some improvement in pain or how it is experienced. Yet, EAET is also emotionally challenging, and the 4-session version conducted here is too brief; attention needs to be given to extending its length and monitoring and responding to individual differences among patients.

BACKGROUND Approximately 45% of individuals taking methadone or buprenorphine have chronic pain. These medications are commonly prescribed for chronic pain or Opioid Use Disorder (OUD). To optimize pain management as well as reduce opioid-related symptoms (e.g., craving) and risks (misuse, overdose), there is a critical need for a brief, effective, and accessible pain skills intervention for this population. OBJECTIVE The objective of this single-arm study is to examine the feasibility, and preliminary efficacy of online Empowered Relief (ER), a 1-session pain relief skills class, for individuals with chronic pain taking methadone or buprenorphine for chronic pain or OUD. METHODS A priori feasibility criteria were defined as at least 75% of enrolled participants attending ER class and the mean satisfaction rating of at least 8 on a 0-10 scale. Participants were recruited nationally across the U.S. Out of the 69 enrolled participants, 55 attended the ER class. Self-report measures were collected at baseline, immediately post-class, and at follow-up points of 2 weeks, and months 1-3. Additionally, qualitative interviews were conducted in a small sample (n = 14) to obtain in-depth participant feedback. Among the class attendees, 51 participants (52.9% Female; mean age = 48.6, range: 28 – 71) completed at least one follow-up survey, and their treatment outcomes were analyzed using repeated measures ANOVA, with missing data imputed using linear regression. This analytic sample consisted of 24 taking methadone and 27 taking buprenorphine, and 43.1% endorsed at least ≥ 2 OUD symptoms within the past 12 months, meeting the DSM-5 diagnostic criteria for current OUD. RESULTS Feasibility was achieved with 79.7% attendance and M= 8.6 treatment appraisal and satisfaction ratings. Qualitative feedback demonstrated high acceptability of the class content and delivery, with suggestions for refinements. Repeated-measures ANOVAs and Bonferroni post-hoc tests revealed significant reductions at 1-month post-ER class (primary endpoint) in pain intensity (d = 0.41), pain bothersomeness (d = 0.54), and pain interference (d = 0.61). At 3-month post-ER class, efficacy was maintained for pain bothersomeness (d = 0.44) and pain interference (d = 0.), but not for pain intensity. No significant time effects were observed for pain catastrophizing, sleep disturbance, physical function, fatigue, depression, anxiety, social isolation, and opioid craving. CONCLUSIONS This study is the first to test ER in patients taking methadone or buprenorphine for pain or OUD. Findings showed feasibility, acceptability, and preliminary evidence of treatment efficacy. Participant feedback will inform future study designs. Findings support a randomized trial to fully evaluate the efficacy and scalability of ER in this population. CLINICALTRIAL NCT05057988; https://clinicaltrials.gov/study/NCT05057988 INTERNATIONAL REGISTERED REPORT RR2-10.2196/53784

Importance: Opioid misuse remains a critical public health concern, associated with increased risk of overdose, psychiatric comorbidity, and societal costs. While machine learning (ML) analyses have been used to identify features associated with opioid misuse across various clinical settings, few studies have examined both modifiable and non-modifiable features. Understanding modifiable features may inform targeted prevention and intervention strategies to reduce opioid misuse. Objective: To identify key features associated with opioid misuse severity in patients with chronic pain taking long-term prescription opioids. Design, Setting, and Participants: This analysis used data from clinical trials investigating a skills-based pain management intervention. Participants were 314 community-dwelling adults with chronic pain who were taking daily opioid medications (≥ 10 morphine-equivalent daily dose) for at least 3 months. Data was extracted from baseline assessments. Outcomes and Measures: Opioid misuse severity was assessed using the Current Opioid Misuse Measure (COMM). Thirty-six demographic and clinical features were evaluated, including PROMIS symptom domains (e.g., pain rating, pain interference, physical function, fatigue, sleep disturbance, depression, anxiety, and anger) as well as emotional ambivalence, pain catastrophizing, trauma exposure, and substance use. Results: Among the seven ML algorithms (Random Forest, XGBoost, Support Vector Regression, LASSO regression, Ridge Regression, Elastic Net, and Multilayer Perceptron), the Elastic Net model demonstrated the strongest performance, yielding the highest correlation with COMM scores (mean r = 0.61, 95% CI [0.40, 0.73]) and the lowest root mean square error (mean RMSE = 4.16, 95% CI [3.41, 4.80]). Feature ablation analysis identified anger (Δ r = 0.053), emotional ambivalence (Δ r = 0.022), pain catastrophizing (Δ r = 0.008), and fatigue (Δ r = 0.002) as the most influential features associated with the COMM scores. Shapley Additive exPlanations (SHAP) analysis confirmed that higher levels of these key features were associated with higher COMM scores. Conclusions and Relevance: Emotional factors, particularly anger, emerged as key features associated with the severity of opioid misuse. These findings suggest that interventions targeting emotion regulation, especially anger management, may reduce opioid misuse among individuals receiving long-term opioid therapy for chronic pain.

Background: Few personalized behavioral treatments are available to reduce the risk of prescription opioid–related harm among patients with chronic noncancer pain. Objective: We aimed to report on the second phase of the co-design of a digital brief intervention (BI) based on patient and health professional preferences. Methods: Eligible patients with chronic noncancer pain (n=18; 10 women; mean age 49.5, SD 6.91 y) from public hospital waitlists and health professionals (n=5; 2 women; mean age 40.2, SD 5.97 y) from pain and addiction clinics completed semistructured telephone interviews or participated in focus groups exploring BI preferences, needs, and considerations for implementation. Grounded theory was used to thematically analyze the data. Results: We identified 5 themes related to intervention content from patient reports: relevance of the biopsychosocial model and need for improved awareness and pain psychology education; nonpharmacological strategies and flexibility when applying coping skills training; opioid use reflection and education, with personalized medication and tapering plans; holistic and patient-inclusive assessment measures and feedback; and inclusion of holistic goals targeting comfort and happiness. Five themes related to the process and guiding principles were identified: therapist guided; engaging features; compassionate, responsive, person-centered care; a digital solution is exciting, maximizing reach; and educate and normalize system and policy challenges. Finally, 5 themes were reflected in the health professionals’ reports: digital health use is rare but desired; digital health is useful for patient monitoring and accessing support; patient motivation is important; a digital BI app is likely beneficial and at multiple care points; and safe medication use and managing pain goals. The reported barriers from health professionals were intervention intensity, potential costs, and patient responsiveness; factors facilitating the implementation were the alignment of digital BIs with clinical models, a stepped-care approach, and feedback. Conclusions: This co-design study identified key content areas, guiding principles, enabling factors, and barriers from both patients and health professionals to guide the development of digital BIs. The knowledge gathered should inform future iterations of co-designing digital BIs for the population most at risk of the harmful effects of opioid medications.

Background: Patients with chronic pain on long-term opioid therapy often face barriers to accessing effective nonpharmacological treatments, including the burden of multiple sessions, lack of trained clinicians, and travel time. Empowered Relief (ER), a 2-hour, single-session pain relief skills class, can improve pain and quality of life among patients with chronic pain when delivered in person or virtually. Objective: This study examined the impact of Zoom-delivered ER among people with chronic pain on long-term opioid therapy. We assessed (1) the feasibility and acceptability of Zoom-delivered ER; (2) changes in pain and opioid use outcomes at 3 and 6 months after treatment; and (3) daily associations among pain, opioid dose, and the Pain Catastrophizing Scale (PCS) before and after treatment. Methods: During the early COVID-19 pandemic, we conducted an uncontrolled pilot study of a Zoom-delivered ER among 60 adults (n=45, 76% female participants; n=52, 88% White participants) experiencing chronic pain who were receiving daily prescribed opioids (≥10 morphine-equivalent daily dose). Participants completed assessments at enrollment, before class, after class, 3 months after treatment, and 6 months after treatment. Furthermore, participants completed 2 daily assessment periods (spanning 14 consecutive days) before and after the class. We used a multilevel modeling approach to examine (1) the raw changes in PCS, average pain intensity, pain interference, and self-reported opioid dose at 3 and 6 months after treatment and (2) daily-level changes in average pain intensity and opioid dose before and after the class. Results: Of the 60 participants enrolled, 41 (68%) attended the class and 24 (59% of the 41 class attendees) reported satisfaction with the Zoom-delivered class. PCS score was significantly reduced at 3 months (β=–3.49, P=.01; Cohen d=0.35) and 6 months after treatment (β=–3.61, P=.01; Cohen d=0.37), and pain intensity was significantly reduced at 3 months (β=–0.56, P=.01; Cohen d=0.39) compared to enrollment. There were no significant reductions in pain interference or opioid dose. Across daily assessments, higher daily pain catastrophizing was associated with worse daily pain (β=.42, P<.001) and higher self-reported opioid use (β=3.14, P<.001); daily pain intensity significantly reduced after the class (β=–.50, P<.001). People taking prescribed opioids as needed trended toward decreasing their daily opioid use after the class (β=–9.31, P=.02), although this result did not survive correction for multiplicity. Conclusions: Improvements to future Zoom-delivered ER iterations are needed to improve feasibility and acceptability among people with chronic pain and daily prescribed opioid use. Despite this, findings show a promising preliminary impact of the intervention on pain outcomes. A larger randomized controlled trial of Zoom-delivered ER among this patient population is currently under way.

BACKGROUND Patients with chronic pain on long-term opioid therapy often face barriers to accessing effective nonpharmacological treatments, including the burden of multiple sessions, lack of trained clinicians, and travel time. Empowered Relief (ER), a 2-hour, single-session pain relief skills class, can improve pain and quality of life among patients with chronic pain when delivered in person or virtually. OBJECTIVE This study examined the impact of Zoom-delivered ER among people with chronic pain on long-term opioid therapy. We assessed (1) the feasibility and acceptability of Zoom-delivered ER; (2) changes in pain and opioid use outcomes at 3 and 6 months after treatment; and (3) daily associations among pain, opioid dose, and the Pain Catastrophizing Scale (PCS) before and after treatment. METHODS During the early COVID-19 pandemic, we conducted an uncontrolled pilot study of a Zoom-delivered ER among 60 adults (n=45, 76% female participants; n=52, 88% White participants) experiencing chronic pain who were receiving daily prescribed opioids (≥10 morphine-equivalent daily dose). Participants completed assessments at enrollment, before class, after class, 3 months after treatment, and 6 months after treatment. Furthermore, participants completed 2 daily assessment periods (spanning 14 consecutive days) before and after the class. We used a multilevel modeling approach to examine (1) the raw changes in PCS, average pain intensity, pain interference, and self-reported opioid dose at 3 and 6 months after treatment and (2) daily-level changes in average pain intensity and opioid dose before and after the class. RESULTS Of the 60 participants enrolled, 41 (68%) attended the class and 24 (59% of the 41 class attendees) reported satisfaction with the Zoom-delivered class. PCS score was significantly reduced at 3 months (β=–3.49, P=.01; Cohen d=0.35) and 6 months after treatment (β=–3.61, P=.01; Cohen d=0.37), and pain intensity was significantly reduced at 3 months (β=–0.56, P=.01; Cohen d=0.39) compared to enrollment. There were no significant reductions in pain interference or opioid dose. Across daily assessments, higher daily pain catastrophizing was associated with worse daily pain (β=.42, P<.001) and higher self-reported opioid use (β=3.14, P<.001); daily pain intensity significantly reduced after the class (β=–.50, P<.001). People taking prescribed opioids as needed trended toward decreasing their daily opioid use after the class (β=–9.31, P=.02), although this result did not survive correction for multiplicity. CONCLUSIONS Improvements to future Zoom-delivered ER iterations are needed to improve feasibility and acceptability among people with chronic pain and daily prescribed opioid use. Despite this, findings show a promising preliminary impact of the intervention on pain outcomes. A larger randomized controlled trial of Zoom-delivered ER among this patient population is currently under way.