ACTION: Trial of Adding Buprenorphine, CBT, and TMS to Improve Outcomes of Long-Term Opioid Therapy for Chronic Pain

Inclusion Criteria:

• Age ≥ 18yrs;

• English-speaking;

• On LTOT, defined as taking daily prescription opioid therapy for 90 days or more;

• Past week average morphine equivalent dose (MED) ≥50;

• Willing and able to complete written informed consent;

• Willing and able to use a mobile/cell phone;

• Have at least one additional risk for opioid toxicity or overdose from the followinglist:

• Taking benzodiazepines with opioids

• Substance Use Disorder diagnosis [non-tobacco; Opioid Risk Tool]

• Having ever experienced an overdose

• Current major medical problem [e.g. mod-severe liver disease, pancreatitis, chronicpulmonary disease, untreated sleep apnea, hospitalized for an acute medical issue inthe past 6 months]

• Response to Brief Pain Iinventory Item 8 <30%, suggesting less than moderatelyclinically meaningful response to pain treatment

• Co-morbid psychiatric diagnosis [Opioid Risk Tool]

• Signs of opioid misuse [any score >0 on the following COMM Items: 3, 4, 5, 9, 10, 11, 14, 15, 16]

• Opioid Risk Tool >3 or Current Opioid Misuse Measure ≥ 9

• Struggling with the following side effects from opioids [self-report]: Dizzinessand/or falls Difficult-to-manage stomach pain, nausea, constipation or GI issues,Fatigue or low energy, Sleepiness or sedation, Trouble with memory or thinkingclearly [COMM Item 1>0], Other troublesome side effect [open answer]

Exclusion Criteria:

• Known seizure disorder;

• On anti-convulsant medication;

• Known allergy to buprenorphine;

• Active moderate or severe non-opioid substance use disorder (DSMV criteria);

• Active suicidal Ideation;

• Known bipolar disorder;

• Cognitive disorder limiting ability to consent or fully participate in the BCIintervention;

• Severe medical condition (e.g. malignancy), likely to limit life expectancy or studyparticipation;

• Receiving methadone or buprenorphine treatment for OUD or pain;

• On naltrexone;

• Pregnancy;

• Currently Incarcerated;

• Hypokalemia;

• Clinically unstable cardiac or pulmonary disease;

• Taking medications that prolong QTc interval or personal/immediate family history ofLong QT Syndrome.