Pain Management in the Clinic & Community

描述（由申请人提供）：拟议的研究将使用定性方法来检查在临床环境和患者家庭社区中影响初级保健提供者和患者疼痛管理实践的因素。慢性非癌性疼痛（CNCP）影响着25%的美国成年人，是导致美国残疾和高昂医疗费用的主要原因。在安全网卫生系统中获得初级保健服务的低收入患者比有保险的患者更有可能被诊断为CNCP。有药物使用史的CNCP患者是处方阿片类止痛药的最高频率使用者，获得疼痛和心理健康专家护理的机会最少。医学研究所和美国疼痛协会得出结论，缺乏科学研究来指导初级保健提供者（pcp）的疼痛管理实践，特别是与阿片类药物滥用和意外过量相关的发病率和死亡率高的物质使用患者。Arthur Kleinman的疼痛管理人类学研究模型表明，西方临床健康实践包括个人、互动和社会结构维度，这些维度都会影响健康结果。疼痛管理实践发生在特定的和广泛不同的社会背景下：在临床中，疼痛被讨论并对生物医学做出反应；在家庭环境中，患者在日常基础上应对疼痛。通过将Kleinman的模型应用于有药物使用史的CNCP患者及其pcp，提出的定性研究将提供必要的背景观察数据，为这一高风险、研究不足的患者群体提供CNCP疼痛管理信息。具体目的是：目的1：探讨初级保健提供者的疼痛管理实践在安全网的临床设置患者谁有药物使用的历史（过去或现在）。目的2：探讨患者的疼痛管理实践在临床设置。目的3：探讨患者在家庭环境中的疼痛管理实践。这项研究将在旧金山湾区三个不同县的六个安全网诊所和患者家庭环境中进行。在目的1中，我们将进行(a)对20名pcp进行定性访谈，(b)对20名pcp与60名CNCP患者之间的疼痛管理互动进行临床观察。对于目标2，我们将进行(a)对60名CNCP患者进行定性访谈，(b)从患者的角度分析患者-提供者临床互动数据。对于Aim 3，我们将从60名参与患者中理论上选择20名样本进行基于社区的参与者观察。定性数据将转录，编码和分析使用接地理论的方法。由医学人类学家/药物使用研究员（早期首席研究员）、医生/卫生服务研究员（共同研究员）和护士/临床疼痛政策专家（共同研究员）组成的多学科研究小组将综合数据，以提高我们对CNCP管理的理解，为未来的研究和临床实践提供信息。

DESCRIPTION (provided by applicant): The proposed study will use qualitative methods to examine the factors impacting primary care providers' and patients' pain management practices in clinical settings and patients' home communities. Chronic non-cancer pain (CNCP), which affects 25% of American adults, is a leading cause of disability and exorbitant health care costs in the United States. Low income patients, who access primary care services in safety net health systems, are more likely to be diagnosed with CNCP than their insured counterparts. CNCP patients with histories of substance use are the highest frequency users of prescribed opioid pain medications with the least access to pain and mental health specialist care. The Institute of Medicine and the American Pain Society have concluded that a dearth of scientific research exists to guide primary care providers' (PCPs') pain management practices, particularly with substance-using patients at high risk for opioid misuse and morbidity and mortality associated with accidental overdose. Arthur Kleinman's model for the anthropological study of pain management suggests that Western clinical health practices encompass individual, interactive and socio- structural dimensions which all influence health outcomes. Pain management practices take place in specific and widely divergent social contexts: the clinic where pain is discussed and responded to biomedically and home environments where patients cope with pain on an everyday basis. By adapting Kleinman's model to target CNCP patients with histories of substance use and their PCPs, the proposed qualitative study will provide needed contextual, observational data to inform CNCP pain management for this high-risk, under- researched patient group. The Specific Aims are: Aim 1: To explore primary care providers' pain management practices in safety net clinical settings with patients who have a history (past or current) of substance use. Aim 2: To explore patients' pain management practices in clinical settings. Aim 3: To explore patients' pain management practices in their home environments. The study will take place in six safety net clinics and patients' home environments in three diverse San Francisco Bay Area Counties. For Aim 1 we will conduct (a) qualitative interviews with 20 PCPs and (b) clinical observation of pain management interactions between the 20 PCPs and 60 of their CNCP patients. For Aim 2, we will conduct (a) qualitative interviews with the 60 CNCP patients and (b) analyze the patient-provider clinical interaction data from the patient perspective. For Aim 3, we will conduct community-based participant observation with a theoretically-selected sample of 20 of the 60 participating patients. Qualitative data will be transcribed, coded and analyzed using grounded theory methodologies. The multidisciplinary research team, consisting of a medical anthropologist/substance use researcher (Early Stage Principal Investigator), a physician/health services researcher (Co-investigator), and a nurse/clinical pain policy expert (Co-investigator), will synthesize the data with the goal of improving our understanding of CNCP management to inform future research and clinical practice.