Opioids and Adjuvants for Pain in Nursing Home Residents with Cancer

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 DESCRIPTION (provided by applicant): Nearly 1/3rd of Medicare beneficiaries with cancer will receive care in a nursing home (NH). Our preliminary work revealed that among NH residents with cancer, 28.3% had daily pain with 13.5% experiencing severe pain and 61.3% with moderate pain. Opioid use was common for those with daily pain, despite the potential for significant adverse effects such as insomnia, depression, constipation and cognitive impairment. The extent to which adjuvants to analgesia may be used to improve the level of analgesia and ultimately reduce opioid dosage has not been explored in this vulnerable population. The proposed work uses a contemporaneous dataset to provide longitudinal descriptions of the management of pain in newly admitted NH residents with cancer. We propose merging elements of the following existing databases: the Minimum Data Set (MDS), Medicare eligibility and claims data (Part A, B & D), and the Certification and Survey Provider Enhanced Reporting (CASPER) system. Using state of the art analytic methods such as marginal structural models, the specific aims are to: 1) Describe the pattern of analgesic use in terms of "morphine equivalents", route of administration, and use of adjuvants to analgesia in patients newly admitted to NHs with cancer and to compare the level of daily pain, analgesia use, and adjuvant use as a function of age, gender, race/ethnicity and level of cognitive impairment.; 2) Evaluate the extent to which pharmacologic management of pain including the uptake of adjuvants to analgesia intensifies over time in NH residents with cancer; and 3) Quantify the association between adjuvants to pain medication and reduction of opioid dose and potential adverse effects (e.g. constipation). The National Cancer Institute is interested in pursuing clinical research to evaluate the role of adjuvants to chronic pain management (PA-14-225). The proposed exploratory work is a necessary precursor prior to design of an RO1 for the NH context. No studies have attempted to characterize the longitudinal experience of pain and use of opioids and adjuvants in NH residents with cancer. Evaluation of the changes in pain, pharmacologic pain treatments, use of adjuvants and outcomes in a contemporaneous national dataset of NH residents with cancer will form the basis of a scientifically sound larger randomized controlled experiment of the use of adjuvants in pain management in NH settings.