{"doi":"10.14444/8804","title":"Billions Spent, Few Saved: Rethinking National Institutes of Health HEAL Initiative in Light of Dopaminergic Alternatives to the Opioid Trap","abstract":"BACKGROUND: Despite >$3.2 billion invested across >1,800 projects by NIH's HEAL Initiative, scalable solutions for chronic pain and opioid use disorder remain limited. Continued reliance on opioid-replacement therapies often suppresses reward circuitry without restoring its neurobiology. OBJECTIVE: and to propose pragmatic clinical and policy steps for translation. APPROACH CONCEPTUAL MODEL: We synthesize evidence that chronic pain and addiction share hypodopaminergic mechanisms (Reward Deficiency Syndrome). We highlight precision nutraceuticals (amino-acid precursors + enkephalinase inhibitors) aimed at restoring dopamine homeostasis-especially in genetically vulnerable patients identified by the Genetic Addiction Risk Severity (GARS) test-and position them within ERAS 2.0 as adjuncts to peripheral analgesia. KEY POINTS/RECOMMENDATIONS: (1) Initiate dopaminergic repletion ~2 weeks preoperative to 4 weeks postoperative, layered with local anesthetic strategies. (2) Incorporate GARS-guided risk stratification and track MMEs, pain, function, mood/craving, LOS, and 90-day opioid persistence. (3) Prioritize multicenter pragmatic RCTs and registries with mechanistic endpoints. (4) Improve funding transparency and link HEAL-like investments to clinical outcomes dashboards. CLINICAL SIGNIFICANCE: We challenge the clinical status quo and call on spine surgeons and pain specialists to integrate dopaminergic repletion protocols within a precision-prehabilitation framework that offers a low-risk, non-opioid pathway to reduce suffering, enhance recovery, and decrease opioid dependence in spine surgery. LEVEL OF EVIDENCE: 5 (Expert Opinion). The model integrates neurobiology, early translational signals, and policy levers to guide hypothesis-generating implementation.","journal":"The International Journal of Spine Surgery","year":2025,"id":581427,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":0,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.9573,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2025-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":460951,"name":"Kenneth Blum","orcid":"0000-0001-6727-803X","position":1,"is_corresponding":false},{"id":1489392,"name":"Morgan P. Lorio","orcid":"0000-0003-1623-2095","position":2,"is_corresponding":false},{"id":1245129,"name":"Sergio L. Schmidt","orcid":"0000-0001-7654-5507","position":3,"is_corresponding":false},{"id":1439172,"name":"Rossano Kepler Alvim Fiorelli","orcid":"0000-0001-5236-0903","position":4,"is_corresponding":false},{"id":1245127,"name":"Kai‐Uwe Lewandrowski","orcid":"0000-0001-7842-2914","position":0,"is_corresponding":true}],"reference_count":0,"raw_metadata":null,"created_at":"2026-07-19T02:58:47.357782Z","pmid":"41249063","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}