Optimizing the value of pain management in knee OA patients with comorbidities

指导我们研究的广泛目标是进行分析，为临床医生提供重要的见解 和决策者优化膝关节OA疼痛管理，同时减少OA患者的阿片类药物使用， 主要合并症，包括精神健康障碍和病态肥胖。 症状性膝关节骨关节炎（OA）影响超过1400万美国人，每年造成270亿美元的损失。 医疗支出。膝关节OA疼痛作为伤害性疼痛的传统观点受到了不断发展的挑战。 有证据表明，神经系统的改变往往会导致致敏和神经病样症状。许多 OA患者有包括抑郁症在内的合并症，抑郁症导致膝关节疼痛加重并使疼痛复杂化 管理，特别是关于阿片类药物的使用。药物的疗效有限，部分原因是 并不适合疼痛机制。肥胖，特别是病态肥胖， 药物和手术OA疼痛管理。疼痛机制的多样性和 合并症已经开始将膝关节OA重新定义为由多种表型组成的综合征，其中， 单一的治疗策略并不适用于所有人。 多种疼痛表型和合并症给OA疼痛管理带来的挑战， “我们所知”和“我们所做”之间的差距进一步加剧了类阿片流行病的威胁。' 虽然基于疼痛表型的药物治疗、体重管理和运动的疗效已被证实， 在随机对照试验中，这些方法尚未转化为常规护理。PA对于控制OA疼痛至关重要， 但大多数OA患者不活动。强有力的证据表明，锻炼和体育活动（PA） 有效的止痛药物，但实施锻炼计划是由于缺乏 基础设施和资金。尽管有强有力的证据表明， 对合并症的OA患者有效。有效性证据不足以促进 将这些方案落实到临床实践中。执行需要投资;和知识 这些计划的成本效益和预算影响将有助于将研究结果转化为 日常临床管理。 决策分析是一种重要的方法论，有助于评估已经实施的项目的价值。 证明是有效的。我们建议使用经过验证的膝关节OA计算机模拟模型（OAPol）， 通过评估三种主要治疗策略的价值，缩小证据与实践之间的差距， 合并症的膝关节OA患者的疼痛管理：1）根据疼痛进行定制疼痛管理 表型，以优化药理学方案; 2）病态肥胖者的体重管理，以改善 以OA为重点的治疗的结果;和3）PA程序作为非药物性疼痛减轻方案。

The broad objective guiding our research is to conduct analyses that will provide critical insights to clinicians and decision makers to optimize knee OA pain management while reducing opioid use in persons with OA and major comorbidities including mental health disorders and morbid obesity. Symptomatic knee osteoarthritis (OA) affects over 14 million Americans and accounts for $27 billion/year in healthcare expenditures. Traditional views of knee OA pain as nociceptive have been challenged by evolving evidence that nervous system alterations often result in sensitization and neuropathic-like symptoms. Many OA patients have comorbidities including depression, which leads to worse knee pain and complicates pain management, especially regarding opioid use. Medications are only modestly efficacious, in part because they are not tailored to pain mechanisms. Obesity, especially morbid obesity, further complicates both pharmacologic and surgical OA pain management. The diversity of pain mechanisms and frequency of comorbidities have begun to reframe knee OA as a syndrome comprised of multiple phenotypes, wherein a single treatment strategy does not fit all. The challenges in OA pain management posed by multiple pain phenotypes and comorbidities, coupled with the threat of the opioid epidemic, are further exacerbated by the gap between `what we know' and `what we do.' While the efficacy of pain phenotype-based pharmacotherapy, weight management and exercise have been established in RCTs these approaches have not translated to routine care. PA is essential to managing OA pain, yet most OA patients are inactive. Strong evidence suggests that exercise and physical activity (PA) are as effective as analgesic medications, but implementation of exercise programs is hindered by lack of infrastructure and funds. Comorbidities augment the risk of physical inactivity, despite strong evidence that PA is efficacious in OA patients with comorbidities. Evidence of efficacy is not sufficient to facilitate the implementation of these programs into clinical practice. Implementation requires investment; and knowledge of the cost-effectiveness and budgetary impact of these programs will help to translate research findings into day-to-day clinical management. Decision analysis is an important methodology that helps to evaluate the value of programs that have been shown to be efficacious. We propose to use a validated computer simulation model of knee OA (OAPol) to narrow the gap between evidence and practice by assessing the value of three major therapeutic strategies in managing pain in knee OA patients with comorbidities: 1) tailored pain management according to pain phenotypes to optimize pharmacologic regimens; 2) weight management in morbidly obese persons to improve outcomes of OA-focused treatments; and 3) PA programs as non-pharmacologic pain reduction regimens.