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，其中 概述了一个协调一致的计划，以改善对疼痛患者的医疗保健服务。它概述了需要更好地 监控方法，支持以患者为中心的综合疼痛管理实践，并改进访问 有效的非药物疗法(NPT)。痛苦对平民医疗保健系统的影响也是如此。 在军队和退伍军人群体中；军队卫生系统(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。 医疗监督月度报告列出了在医疗保健系统寻求医疗保健的九大原因 怀孕服务和不明确的症状。5个与肌肉骨骼有关(背部、膝盖、脚踝、手臂) 受伤或问题，剩下的最严重的情况是焦虑、情绪/调整和睡眠障碍， 在某些情况下，这可能是疼痛的共病。 本研究是R01的更新应用，以促进军事准备、阿片类药物和 非药物疼痛管理的不同早期治疗轨迹与健康状况结果相关 MHS中的战略。来自SUPIC项目的调查人员(物质使用和心理伤害战斗 R01AT008404)产生了关于慢性疼痛及其行为健康的基础知识 MHS中的共病。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 消息来源。我们调查了《不扩散核武器条约》早期利用的使用情况(两者相辅相成[例如，脊椎疗法， 针灸、脊柱手法、自我管理、跨学科疼痛计划]策略和综合 [例如，运动疗法、物理疗法、职业疗法、心理健康专科护理]战略，以及 在慢性疼痛队列中，阿片类药物的流行率很高。 SUPIC续展申请的具体目标是：目标1：(A)描述早期的轨迹 《不扩散核武器条约》和用于疼痛管理的阿片类药物疗法；(B)审查《不扩散条约》使用之间的关系(例如， 具体模式、使用轨迹)和多维结果(例如，军事准备情况、阿片类药物 利用情况、健康状况)；以及(C)调查《不扩散条约》轨迹与离散高级别会议结果之间的关系 患者的风险亚组(共患创伤后应激障碍、抑郁)和特定疼痛状况(例如，背痛、其他 肌肉骨骼、头痛)。目标2：确定设施和服务提供者级别的因素(健康的FTE可用性 职业、提及《不扩散核武器条约》或开出阿片类药物的倾向)解释了《不扩散核武器条约》和阿片类药物使用的差异 在医疗保健机构之间开处方。目标3：(A)描述苏比克军部署成员的特点 (B)确定《不扩散条约》与《不扩散条约》之间的联系 卫生部的收受情况和VHA的长期健康结果(主要影响)；和(C)确定主持人和 这些协会的调解人。 这笔续期拨款将有效地继续MHS疼痛管理方面亟需的工作 将直接告知MHS和VHA领导层的方法，并促进知情的临床和组织 改变。2013-2018年，SUPIC研究对象将扩大到所有服务分支机构的成员 (估计200万人或更多)，并扩大调查小组，以加强我们的实践知识 并促进将研究成果迅速转化为行动。来自国防和退伍军人的研究人员 美国国防部统一服务大学疼痛综合管理中心 疼痛策略卓越中心正在加入调查团队。

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.