Integrating Nonpharmacologic Strategies for Pain with Inclusion, Respect, and Equity (INSPIRE): Tailored digital tools, telehealth coaching, and primary care coordination

项目总结/摘要 慢性疼痛（CP）是最常见且最令人衰弱的疾病之一，导致大量 发病率、生活质量下降和巨大的医疗保健费用。带来了持续的悲剧性后果， 类阿片处方过量，造成类阿片使用障碍和过量死亡激增。虽然非- 药物干预有很强的证据基础，这些干预很少可用， 贵了精神疾病和药物使用障碍的常见并发症引发了进一步的污名化， 低质量的护理。 疼痛症状的主观报告及其所赋予的文化含义创造了一个成熟的环境， 个人、提供者和系统层面的多层次偏见导致的医疗保健差异。这些偏见 表现为侮辱性语言和拒绝采取干预措施以减轻痛苦。 多项研究表明，患有CP的种族和少数民族尤其受到虐待。有必要 加速创建混合CP管理计划，以改善治疗的可及性， 同时解决进一步伤害和孤立CP患者的耻辱，偏见和不信任。 INSPIRE CP干预创造了一种混合的定制认知行为治疗，物理治疗， 通过三语移动的应用程序提供治疗，正念和疼痛教育，并由远程医疗支持 疼痛教练在EHR中与PCP进行基本护理协调。疼痛，抑郁， 焦虑，物质使用，以及一系列社会风险和需求将定期收集，总结在 指导仪表板，并与PCP共享。干预建立在现有的，在人的疼痛计划， 边缘化的患者，但显着提高了覆盖面，扩大了文化和语言的适应，并直接 通过加强社区参与、个人和团体支持， 以及提供“技术辅导”以提高数字健康素养。 为期两年的R61开发阶段包括3个具体目标和相应的里程碑：1）创建 数字工具和教练协议，使用密集的社区参与，2）迭代开发 针对卫生保健工作人员和提供者的教育和实施战略，以及3）为期3个月的试点测试， 进一步评估可接受性和可行性。三年R33验证阶段包括3个额外的特定 目的：1）对586例患者进行一项实用RCT，比较INSPIRE与强化常规护理，2）分析 次要结局和治疗效果模型，以及3）实施的混合方法评价 结果使用规范化过程理论，以更好地设计未来规模的战略。

PROJECT SUMMARY/ABSTRACT Chronic pain (CP) is one of the most common and debilitating medical conditions resulting in substantial morbidity, lower quality of life and tremendous health care costs. With ongoing and tragic consequences, opioids were overprescribed creating a surge in opioid use disorders and overdose deaths. Although non- pharmacologic interventions have a strong evidence base, these interventions are rarely available and expensive. The common co-morbidities of psychiatric and substance use disorders trigger further stigma and lower quality care. Subjective reports of pain symptoms and the cultural meanings ascribed to them create a situation ripe for health care disparities driven by multilevel biases on individual, provider, and systemic levels. These biases are manifested in stigmatizing language and the denial of interventions to reduce pain and alleviate suffering. Multiple studies have shown that racial and ethnic minorities with CP are especially mistreated. It is essential to accelerate the creation of hybrid CP management programs that improve access to treatments while simultaneously addressing the stigma, bias, and mistrust that further harm and isolate patients with CP. The INSPIRE CP intervention creates a hybrid blend of tailored cognitive-behavioral therapy, physical therapy, mindfulness, and pain education delivered via a trilingual mobile app and supported by a telehealth pain coach providing essential care coordination with PCPs within the EHR. PROs for pain, depression, anxiety, substance use, and a range of social risks and needs will be regularly collected, summarized in the coaching dashboard, and shared with PCPs. The intervention builds on an existing, in person pain program for marginalized patients but significantly improves reach, expands cultural and linguistic adaptations, and directly addresses multilevel bias and stigma through intensive community engagement, individual and group support, and the provision of “tech tutoring” to improve digital health literacy. The two year R61 development phase includes 3 specific aims with matched milestones: 1) creation of the digital tool and coaching protocol using intensive community engagement, 2) iterative development of educational and implementation strategies for health care staff and providers, and 3) a 3 month pilot test to further assess acceptability and feasibility. The three year R33 validation phase includes 3 additional specific aims 1) perform a pragmatic RCT with n=586 patients comparing INSPIRE to enhanced usual care, 2) analyze secondary outcomes and the treatment effects model, and 3) a mixed method evaluation of implementation outcomes using Normalization Process Theory to better design strategies for future scale.