Reducing the Transition from Acute to Chronic Musculoskeletal Pain among Older Adults

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Project Summary Chronic musculoskeletal pain is a major health burden for older adults in the U.S., decreasing quality of life, increasing disability, and predisposing patients to long-term opioid use. One important cause of chronic pain among older adults is persistence of acute traumatic or atraumatic musculoskeletal pain. Consistent with this, the NIH has identified reducing the transition from acute to chronic musculoskeletal pain among older adults as a research priority. Effective early treatment of acute pain is essential for preventing the transition to chronic pain but is challenging in older adults for two reasons. First, the selection of analgesics is complicated by contraindications and high rates of side effects and adverse events. Second, recovery promoting behaviors are rarely explained to patients by providers and, as a result, rarely practiced by patients. Shared decision-making, which involves the exchange of information between patients and providers to support treatment decisions, provides an important clinical approach for improving the effectiveness and safety of the initial management of pain in older adults. The proposed study will test a three component intervention to support shared decision- making during the early recovery phase for older adults who present to the emergency department (ED) with acute musculoskeletal pain. The first component is a brief interactive video to enhance patient knowledge and self-efficacy regarding treatment options with the intent of facilitating conversations between patients and emergency providers. The second component is a protocol-guided phone conversation (telecare) between a nurse care manager and the patient 48-72 hours following ED discharge to assess pain severity and interference with daily activities, review analgesic use and side effects and recovery-promoting behaviors, and discuss adjustments to the patient's treatment. The third component is communication with the patient's primary care provider following the telecare call to inform them of the patient's condition and treatment plan. The short-term objective of this project is to test the efficacy of this intervention to reduce the transition from acute to chronic musculoskeletal pain and reduce long-term opioid use and other key secondary outcomes. This objective will be achieved via a three-arm randomized controlled trial with adults aged 50 years and older who present to the ED with acute musculoskeletal pain. Patients will be randomized to (1) the full intervention (video + telecare + communication with primary provider), (2) video alone, or (3) usual care. The primary outcome will be pain, measured longitudinally over the course of a year following the ED visit. Secondary outcomes will include opioid use, physical function, analgesic side effects and adverse events, depression and anxiety symptoms, sleep duration and quality, and healthcare utilization at one, three, six, and twelve months. We will also examine whether the intervention has its effect by promoting shared decision-making and assess the cost-effectiveness of the intervention. The long-term goal of this work is to identify and implement effective interventions into clinical care to improve outcomes for older adults with acute musculoskeletal pain.