Opioids and Adjuvants for Pain in Nursing Home Residents with Cancer

 描述(由申请人提供)：近三分之一患有癌症的联邦医疗保险受益人将在疗养院(NH)接受治疗。我们的初步工作显示，在患癌症的NH居民中，28.3%的人每天都有疼痛，13.5%的人经历重度疼痛，61.3%的人有中度疼痛。阿片类药物的使用在那些有日常疼痛的人中很常见，尽管可能会出现失眠、抑郁、便秘和认知障碍等严重的不良反应。在这一弱势人群中，止痛辅助剂可以在多大程度上改善止痛水平并最终减少阿片类药物的用量还没有得到探索。这项拟议的工作使用同期的数据集来提供新入院的NH癌症患者疼痛管理的纵向描述。我们建议合并以下现有数据库的元素：最低数据集(MDS)、联邦医疗保险资格和索赔数据(A、B和D部分)以及认证和调查提供者增强型报告(CASPER)系统。使用最先进的分析方法，如边际结构模型，具体目的是：1)描述NHS新入院的癌症患者在止痛方面的“吗啡等效物”、给药途径和辅助药物的使用模式，并比较日常疼痛、止痛使用和辅助药物使用的水平与年龄、性别、种族/民族和认知障碍水平的函数关系。2)评估在NH癌症患者中，疼痛的药物管理，包括对止痛辅助剂的吸收随着时间的推移而加强的程度；3)量化止痛药辅助剂与减少阿片类药物剂量和潜在不良反应(如便秘)之间的关系。国家癌症研究所有兴趣进行临床研究，以评估佐剂在慢性疼痛管理中的作用(PA-14-225)。拟议的探索性工作是在为NH环境设计RO1之前的一个必要的先导。还没有研究试图描述NH癌症患者的纵向疼痛体验以及阿片类药物和佐剂的使用情况。在全国癌症患者的同期数据集中，对疼痛的变化、药理疼痛治疗、辅助剂的使用和结果进行评估，将形成一项科学合理的更大规模的随机对照试验的基础，该试验在NH环境中使用辅助剂进行疼痛控制。

 DESCRIPTION (provided by applicant): Nearly 1/3rd of Medicare beneficiaries with cancer will receive care in a nursing home (NH). Our preliminary work revealed that among NH residents with cancer, 28.3% had daily pain with 13.5% experiencing severe pain and 61.3% with moderate pain. Opioid use was common for those with daily pain, despite the potential for significant adverse effects such as insomnia, depression, constipation and cognitive impairment. The extent to which adjuvants to analgesia may be used to improve the level of analgesia and ultimately reduce opioid dosage has not been explored in this vulnerable population. The proposed work uses a contemporaneous dataset to provide longitudinal descriptions of the management of pain in newly admitted NH residents with cancer. We propose merging elements of the following existing databases: the Minimum Data Set (MDS), Medicare eligibility and claims data (Part A, B & D), and the Certification and Survey Provider Enhanced Reporting (CASPER) system. Using state of the art analytic methods such as marginal structural models, the specific aims are to: 1) Describe the pattern of analgesic use in terms of "morphine equivalents", route of administration, and use of adjuvants to analgesia in patients newly admitted to NHs with cancer and to compare the level of daily pain, analgesia use, and adjuvant use as a function of age, gender, race/ethnicity and level of cognitive impairment.; 2) Evaluate the extent to which pharmacologic management of pain including the uptake of adjuvants to analgesia intensifies over time in NH residents with cancer; and 3) Quantify the association between adjuvants to pain medication and reduction of opioid dose and potential adverse effects (e.g. constipation). The National Cancer Institute is interested in pursuing clinical research to evaluate the role of adjuvants to chronic pain management (PA-14-225). The proposed exploratory work is a necessary precursor prior to design of an RO1 for the NH context. No studies have attempted to characterize the longitudinal experience of pain and use of opioids and adjuvants in NH residents with cancer. Evaluation of the changes in pain, pharmacologic pain treatments, use of adjuvants and outcomes in a contemporaneous national dataset of NH residents with cancer will form the basis of a scientifically sound larger randomized controlled experiment of the use of adjuvants in pain management in NH settings.