Opioids and Adjuvants for Pain in Nursing Home Residents with Cancer

 描述（由申请人提供）：近1/3的癌症医疗保险受益人将在疗养院（NH）接受护理。我们的初步工作显示，在NH癌症患者中，28.3%的人每天都有疼痛，13.5%的人有重度疼痛，61.3%的人有中度疼痛。阿片类药物的使用对于那些每天都有疼痛的人来说很常见，尽管有可能产生显著的不良反应，如失眠，抑郁，便秘和认知障碍。镇痛辅助剂可用于改善镇痛水平并最终减少阿片类药物剂量的程度尚未在该弱势人群中进行探索。拟议的工作使用同期的数据集提供纵向描述的疼痛管理新入院的NH居民癌症。我们建议合并以下现有数据库的元素：最小数据集（MDS），医疗保险资格和索赔数据（A，B和D部分），以及认证和调查提供商增强报告（CASPER）系统。使用最先进的分析方法，如边际结构模型，具体目标是：1）描述新入院的癌症患者的镇痛剂使用模式，包括“吗啡等效物”、给药途径和镇痛辅助剂的使用，并比较每日疼痛、镇痛剂使用和辅助剂使用的水平，作为年龄、性别、种族/民族和认知障碍的程度。2)评估疼痛的药理学管理（包括镇痛辅助剂的摄入）在NH癌症患者中随时间推移而加剧的程度; 3）量化镇痛药物辅助剂与阿片类药物剂量减少和潜在不良反应（例如便秘）之间的相关性。国家癌症研究所有兴趣进行临床研究，以评估佐剂对慢性疼痛管理的作用（PA-14-225）。拟议的探索性工作是为NH背景设计RO 1之前的必要前提。没有研究试图描述NH癌症患者疼痛和使用阿片类药物和佐剂的纵向经历。评估疼痛的变化，药物疼痛治疗，使用佐剂和同期国家数据集的NH居民与癌症的结果将形成一个科学合理的更大的随机对照实验的基础上使用佐剂在疼痛管理在NH设置。

 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.