PROJECT SUMMARY: Postoperative opioid prescription is an important contributor to the opioid epidemic, affecting ~4% of >50 million Americans undergoing surgery each year. The dose and duration of treatment with opioids in surgical patients is an established risk factor of opioid use disorder (OUD) and overdose deaths. Although legislation and guidelines are developed to limit opioids prescribed following surgery in the US, in 2020, opioid overdose deaths increased by 39% with worsening mental health. Mood disorders, including anxiety and depression, are risk factors for increased postoperative opioid use. Thus, innovative and effective techniques to minimize the perioperative opioid use are critical in the fight of the opioid epidemic. Cognitive behavioral intervention (CBI) has been proven to decrease acute and chronic pain as well as opioid use among surgical patients. Recently, digital applications of CBI, the dCBI, is getting traction among practitioners and patients due to ease of access via smartphones and 24/7 availability. The dCBI along with telemedicine-based therapy coaches to treat anxiety among patients with inflammatory bowel disease proved success. The availability of telemedicine-delivered digital CBI is a potential groundbreaking non- pharmacological approach to limit opioid use among surgical patients. Our proposed work is also responsive to NOT-DA-20-058 “Utilizing Telemedicine or Other Remote-Based Platforms to Develop and Support Treatments for Substance Use Disorders.” Our pilot data using dCBI in conjunction with telemedicine among moderately anxious and depressed patients scheduled for total hip and total knee arthroplasty (THA/TKA) is supportive that dCBI was effective in reducing preoperative anxiety with a trend of decreased opioid use postoperatively. Our central hypothesis is that the preoperative telemedicine-delivered dCBI will decrease perioperative anxiety, depression, and pain catastrophizing in THA/TKA patients. Preoperative dCBI will reduce severe postoperative pain, overall reduce opioid use, opioid-related complications, chronic persistent surgical pain, and persistent opioid use at 3 months after surgery. Anxiety, depression, and catastrophizing increase postoperative pain and opioid requirement by up to 50% and since dCBI reduces mood disorder symptoms, we also hypothesized that using dCBI will also reduce anxiety, depression, catastrophizing and that could represent a mechanism for decreased postoperative opioid requirements. Our team is well positioned to perform this project and will 1) quantify opioid sparing properties of dCBI i n T H A / T K A u s i n g a randomized, blinded clinical trial, 2) evaluate effects of reducing preoperative depression, anxiety and catastrophizing, and 3) determine the effects of dose/time relationship of the preoperative dCBI on opioid consumption. This research will improve surgical pain relief, safety of postoperative opioids while minimizing opioid use, dependence, and risk of OUD in millions of Americans who have painful surgeries each year, while increasing broad reach and dissemination potential via telemedicine technologies.

Project narrative: Excessive use of prescribed opioids during and after major surgery is a significant contributor to persistent opioid use, misuse and ongoing opioid epidemic, which are recently worsened by the pandemic. The proposed research has significant public health relevance because it aims to reduce surgical pain and opioid use with a promising non-pharmacological tool, digital cognitive behavioral intervention, that helps decrease anxiety and depression before surgical procedures. By proactively reducing mood disorder (anxiety, depression) severity, postoperative surgical pain, opioid use and opioid-related serious adverse effects with digital cognitive behavioral intervention, this research will enable the best-in-class post-surgical pain and opioid-related outcomes in millions of Americans undergoing painful surgeries every year while minimizing the nation's opioid epidemic burden.