PROJECT SUMMARY/ABSTRACT The opioid epidemic has not spared the hemodialysis population. Rates of chronic pain and opioid use are higher among patients treated with hemodialysis than in the general Medicare population and are comparable to rates for individuals with liver cancer. In a survey of symptoms among patients receiving hemodialysis, bone and joint pain was among the most prevalent (approximately 50%) and most bothersome symptoms reported. In addition, pain was associated with lower health-related quality of life and higher likelihood of depressive affect, abbreviated dialysis sessions, emergency department (ED) encounters, hospitalizations, and mortality. Recent studies using Medicare Part D prescription data found that over 60% of dialysis patients received at least one prescription for an opioid medication over the course of 1 year. Unfortunately, this widespread use of opioid medications is not benign; patients receiving opioids are at higher risk of hospitalization or ED encounters for altered mental status, falls, and fractures, and all-cause mortality. Despite the pervasive use of opioid analgesics in the dialysis population and the substantial risks they engender, their efficacy is limited in treating common chronic pain conditions, and most patients receiving long- term opioid therapy continue to experience severe pain and functional limitations. Furthermore, although studies in the general chronic pain population have identified successful interventions to manage pain and improve functional status, few studies have addressed this pressing problem in the dialysis population. Because patients receiving maintenance hemodialysis are encumbered by a unique combination of treatment burden, comorbid conditions, and psychosocial challenges, strategies that may be effective in non-dialysis populations may not provide benefit in the dialysis population. Further, given the diversity and complexity of challenges faced by patients with chronic pain receiving maintenance hemodialysis, individualized care approaches are likely to be especially important in this population. To simultaneously address problems related to chronic pain and opioid use in the U.S. hemodialysis population, we propose to evaluate tailored, patient-centered interventions to manage pain and reduce opioid use. Specifically, we propose to randomly assign patients in a 1:2:2 fashion to one of three groups over a 12- month study period: 1) pain care management (PCM), including collaborative opioid taper support, non-opioid medication management, and care coordination, versus 2) PCM plus an on-line pain self-management program (PSM) that incorporates cognitive behavioral training and is delivered during dialysis sessions, versus 3) control with medication review and education. We also propose to evaluate the effectiveness of offering buprenorphine. We will randomly assign participants in both active treatment arms to being offered buprenorphine rotation versus continued standard opioid taper support without the option of buprenorphine.

PROJECT NARRATIVE Patients on hemodialysis report a high prevalence of chronic pain and are more likely than others to receive long-term opioid therapy. However, they may also be at higher risk of adverse events related to opioid treatment. We propose a randomized trial to investigate the efficacy of pain care management and pain self-management interventions in reducing opioid dosing and improving pain in patients on hemodialysis.