PROJECT SUMMARY Over 20.3 million adults in the U.S. are estimated to have a substance use disorder (SUD); and, an estimated 2 million Americans have had an opioid use disorder (OUD) involving prescription opioids and about 600,000 have had an OUD involving heroin. The number of overdose deaths from illicit opioids including heroin and synthetic opioids has tripled from 2011 to 2015 in the U.S. Among the more than half-million adults entering addiction treatment for prescription opioid abuse every year, 50%-60% report co-morbid chronic pain and 80% report that pain triggers relapse. Individualized/self-stigma among adults with substance abuse has been shown to lead to delayed recovery, increased relapse and reduced treatment-related attendance. Stigma may induce significant burden on patients with OUD and chronic pain and there may be unique characteristics of stigma for this population due to the overlap between medical treatment and substance abuse. Multiple sources of stigma may be imposed including internalized/self-stigma as well as intragroup/peer-to-peer (“horizontal”) stigma whereby peers impose stigma upon each other based on the type and severity of past drug use (e.g., “hard” vs “soft” users,” “functional addicts” vs. “junkies”). Furthermore, stigma could be “vertical” in that stigma may be enacted by health care providers or by treatment center staff and, this “vertical” sigma may also hinder recovery. However, there is notably a lack of research and related assessment tools to measure these multidimensional facets of stigma, particularly in patients with OUD and chronic pain. Moreover, there have been no prior intervention programs that target multidimensional stigma in adults with OUD and chronic pain. Importantly, the current COVID-19 pandemic may exacerbate stigma and its effects since outbreaks are known to result in intense fear and anxiety leading to significant stigma and implicit biases that can compromise care. Thus, in response to the Notice of Special Interest on Administrative Supplements to Support Strategies to Reduce Stigma in Pain Management and OUD and Treatment (NOT-OD-20-101) and, utilizing an underlying multidimensional model of stigma, we propose to take a mixed-methods approach to expanding our Parent R61 (AT010806) to include evaluation of internalized/self-stigma, anticipated/expected stigma and enacted stigma using existing standardized surveys and, to describing horizontal intragroup/peer-to-peer) and vertical (provider/treatment center staff-to-patient) stigma in individuals with OUD and pain as well as other SUD in residential drug treatment centers at multiple sites. In addition, we propose to integrate the quantitative and qualitative information to help inform modifications to the psychotherapy component (I-STOP) of our Parent R61 intervention, which would then also target multidimensional stigma in patients with OUD and chronic pain. The program could be adapted for use in outpatient and inpatient drug treatment programs to help enhance recovery even in the face of the numerous challenges imposed by the COVID-19 pandemic.

PROJECT NARRATIVE Over 20.3 million adults in the U.S. are estimated to have a substance use disorder (SUD) and, about 2 million Americans have had an opioid use disorder (OUD) involving prescription opioids and about 600,000 have had an OUD involving heroin. Exercise has been shown to reduce substance cravings, depression and anxiety as well as improve other symptoms of withdrawal; and, exercise at higher intensities may improve pain in patients with chronic pain. However, most drug treatment programs do not currently offer structured exercise programs; thus, we propose to evaluate the feasibility and effects of integrating exercise with targeted psychotherapy for comorbid addiction and pain as an adjunctive treatment to medication assisted treatment in patients with an OUD and pain enrolled in residential drug treatment programs.