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

Eligibility 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 following list:
• * Taking benzodiazepines with opioids
• * Substance Use Disorder diagnosis \[non-tobacco; Opioid Risk Tool\]
• * Having ever experienced an overdose
• * Current major medical problem \[e.g. mod-severe liver disease, pancreatitis, chronic pulmonary disease, untreated sleep apnea, hospitalized for an acute medical issue in the past 6 months\]
• * Response to Brief Pain Iinventory Item 8 \<30%, suggesting less than moderately clinically 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 \[self-report\]: Dizziness and/or falls Difficult-to-manage stomach pain, nausea, constipation or GI issues, Fatigue or low energy, Sleepiness or sedation, Trouble with memory or thinking clearly \[COMM Item 1\>0\], Other troublesome side effect \[open answer\]
• * 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 BCI intervention;
• * Severe medical condition (e.g. malignancy), likely to limit life expectancy or study participation;
• * 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 of Long QT Syndrome.