Trajectories of non-pharmacologic and opioid health services for pain management in association with military readiness and health status outcomes: SUPIC renewal

摘要/摘要 2016年，美国卫生与公众服务部发布了《国家疼痛战略》， 概述了一项协调计划，以改善疼痛患者的医疗保健服务。它概述了需要更好地 监测方法，支持以患者为中心的综合疼痛管理实践，并改善访问 有效的非药物治疗（NPT）。疼痛对平民医疗保健系统的影响反映在 在军队和退伍军人群体;军事卫生系统（MHS）和退伍军人健康 与平民相比，行政管理（VHA）人群的慢性疼痛患病率更高。 医疗监督月报确定了在MHS寻求护理的前九个原因， 怀孕服务和不明症状。5例与肌肉骨骼（背部、膝关节、踝关节、手臂）相关 受伤或问题，其余的主要问题是焦虑，情绪/调整和睡眠障碍， 在某些情况下可能是疼痛的合并症。 本研究是一个更新R 01应用程序，以提高对军事准备，阿片类药物， 与非药物疼痛管理的不同早期治疗轨迹相关的健康状况结局 MHS中的策略。SUPIC项目（物质使用和心理伤害战斗）的调查人员 R 01 AT 008404）已经产生了关于慢性疼痛及其行为健康的基础知识 MHS中的合并症。我们已经建立了一个全面的，纵向的陆军成员数据库 返回部署包括他们的MHS和VHA健康遭遇/索赔数据和其他几个数据 源我们调查了早期使用《不扩散核武器条约》的情况（两者相辅相成[例如，脊椎按摩， 针灸，脊柱推拿，自我管理，跨学科疼痛计划]战略和综合 [e.g.,运动疗法、物理疗法、职业疗法、心理健康专科护理]策略，以及 确定在慢性疼痛队列中阿片类药物的患病率很高。 SUPIC更新申请的具体目标是：目标1：（a）表征 用于疼痛管理的NPT和阿片样物质疗法;（B）检查NPT利用之间的关系（例如， 具体模式、利用轨迹）和多维结果（例如，军事准备，阿片类药物 （c）调查《不扩散核武器条约》的轨迹和结果在离散高风险国家的关系。 患者的风险亚组（共病PTSD，抑郁症）和特定疼痛状况（例如，背痛，其他 肌肉骨骼、头痛）。目标2：确定设施和提供者层面的因素（FTE对健康的可用性 职业，倾向于引用NPT或开阿片类药物），解释NPT使用和阿片类药物的变化 MHS设施之间的规定。目标3：（a）描述苏丹和平与安全部队部署人员的特点 在MHS中患有慢性疼痛的患者，他们过渡到VHA治疗，但没有过渡到VHA治疗;（B）确定NPT与 MHS中的接收和VHA中的长期健康结果（主效应）;以及（c）确定调节因子， 这些协会的调解员。 这项更新补助金准备有效地继续急需的工作MHS疼痛管理 将直接告知MHS和VHA领导层并促进知情的临床和组织的方法 变化SUPIC研究人群将在2013-2018年扩大到所有服务分支机构的成员 （估计有200万人或更多），并扩大调查小组，以加强我们的实践知识 并促进研究成果迅速转化为行动。国防和退伍军人研究人员 美国国防部统一服务大学综合疼痛管理中心 疼痛策略卓越中心正在加入调查小组。

Summary/Abstract In 2016, the US Department of Health and Human Services released the National Pain Strategy, which outlined a coordinated plan to improve healthcare delivery for patients with pain. It outlined the need for better monitoring methods, supporting patient-centered integrated pain management practices, and improving access to effective non-pharmacological therapies (NPT). The impact of pain in civilian health care systems is mirrored in the military and veteran populations; both the Military Health System (MHS) and Veterans Health Administration (VHA) populations have a higher prevalence of chronic pain compared to civilian populations. The Medical Surveillance Monthly Report identified the top nine reasons for seeking care in the MHS outside of pregnancy services and ill-defined symptoms. Five were related to musculoskeletal (back, knee, ankle, arm) injuries or problems and the remaining top conditions were anxiety, mood/adjustment, and sleep disorders, which in some cases could be comorbidities with pain. The present study is a renewal R01 application to advance knowledge on military readiness, opioid, and health status outcomes associated with different early treatment trajectories of nondrug pain management strategies in the MHS. Investigators from the SUPIC project (Substance Use and Psychological Injury Combat R01AT008404) have generated foundational knowledge about chronic pain and its behavioral health comorbidities in the MHS. We have established a comprehensive, longitudinal database on Army members returning deployment comprised of their MHS and VHA health encounter/claims data and several other data sources. We have investigated the use of early NPT utilization (both complementary [e.g., chiropractic, acupuncture, spinal manipulation, self-management, interdisciplinary pain programs] strategies and integrative [e.g., exercise therapy, physical therapy, occupational therapy, mental health specialty care] strategies, and identified there is high prevalence of opioid medications in the chronic pain cohort. The Specific Aims of the SUPIC renewal application are to: Aim 1: (a) Characterize early trajectories of NPT and opioid therapies for pain management; (b) examine relationships between NPT utilization (e.g., specific modalities, utilization trajectories) and multidimensional outcomes (e.g., military readiness, opioid utilization, health status); and (c) investigate the relationship of NPT trajectories and outcomes in discrete high risk subgroups of patients (comorbid PTSD, depression) and for specific pain conditions (e.g., back pain, other musculoskeletal, headache). Aim 2: Identify facility- and provider-level factors (FTE availability for health occupations, propensity to refer to NPT or prescribe opioids) that explain variation in NPT use and opioid prescribing between MHS facilities. Aim 3: (a) Describe the characteristics of SUPIC Army deployed members with chronic pain in the MHS who do and do not transition to VHA care; (b) identify associations between NPT receipt in the MHS and long-term health outcomes in the VHA (main effects); and (c) identify moderators and mediators of these associations. This renewal grant is poised to efficiently continue much needed work on MHS pain management approaches that will directly inform MHS and VHA leadership and facilitate informed clinical and organizational changes. The SUPIC study population will be expanded to members of all service branches in 2013-2018 (estimated at 2 million or more) and the investigative team is expanded to strengthen our practical knowledge and facilitate rapid translation of research findings into action. Researchers from the Defense & Veterans Center on Integrative Pain Management at the Uniformed Services University, the Department of Defense’s Center of Excellence on pain strategies are joining the investigative team.