Drug overdose deaths in the US have increased exponentially, driven by opioid overdoses. Concurrently, US surveillance studies have documented increased disability prevalence among adults in midlife. People with disabilities have higher rates of opioid use disorder (OUD) but are less likely to receive treatment for it, putting them at higher risk for opioid overdose. Despite these established risks, people with disabilities remain an understudied subpopulation in the context of the opioid crisis. Much of heightened risk among the disabled population may be due to chronic pain. Many people with physical disability experience chronic pain that either drives the disability, termed “high-impact chronic pain”, or that occurs concurrently. Chronic pain is frequently managed with prescription opioids, sometimes via risky prescribing practices. In addition to chronic pain, pathways through depression or through loss of economic opportunity and its accompanying stressors may link physical disability to overdose risk. Opioid prescribing for chronic pain has been linked to increased risk of opioid overdose, but any such risk conferred by having a physical disability, disentangled from chronic pain, has not been estimated—nor has the risk associated with co-occurring physical disability and chronic pain. Moreover, the mechanisms through which disability and chronic pain operate to affect overdose risk are unknown. Availability of recommended treatments for substance use disorders (SUDs), including OUD, and chronic pain may influence the relationships, mechanisms, and the associated disparities we propose to study, but is highly variable across localities. The objectives of this project are: Aim 1) to estimate the unique and joint contributions of physical disability and chronic pain conditions to opioid overdose risk and the extent to which pain management practices mediate these relationships; Aim 2) to develop novel statistical methods to transport mediated effects from one state to another, and to apply those methods in Aim 3) to identify SUD and pain management treatment metrics that, if improved, may reduce both overall overdose risk associated with physical disability and chronic pain and disparities in overdose risk by racial/ethnic-gender subgroup. We will harness geographic variation in the delivery of SUD and pain management treatment and predict the effects that realistic improvements in delivery would have on reducing opioid overdose in this vulnerable population. The proposed research is expected to estimate the extent to which physical disability increases risk of opioid overdose, the proportion of that increased risk attributable to chronic pain and attendant risky pain manage- ment practices (versus non-chronic pain mechanisms), and the extent to which risk may be mitigated by improvements in delivering appropriate chronic pain management and SUD (including OUD) treatment. This will allow for future prevention strategies to be tailored to the particular needs and challenges faced by people with physical disabilities, with the goal of ultimately making a significant contribution to improving prescribing practices and provision of recommended treatments to reduce their risk of opioid overdose.

People with physical disabilities may be particularly vulnerable to opioid misuse and overdose, as they have a high prevalence of chronic pain due to musculoskeletal conditions and high exposure to opioid analgesics. However, disabled adults have been largely left out of research into the prevention and treatment of opioid use disorder and overdose. This project will improve understanding of the mechanisms that place low-income, disabled adults at increased risk of opioid overdose, as well as the potential for improved pain management practices and increased receipt of recommended treatments for substance use disorder and chronic pain to reduce overdose risk in this population.