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

项目摘要 慢性肌肉骨骼疼痛是美国老年人的主要健康负担，生活质量下降， 增加残疾，并使患者倾向于长期使用阿片类药物。慢性疼痛的一个重要原因 在老年人中，急性创伤性或非创伤性肌肉骨骼疼痛持续存在。与此相一致， 美国国立卫生研究院已经确定，减少老年人从急性到慢性肌肉骨骼疼痛的转变， 优先研究。急性疼痛的有效早期治疗对于防止向慢性疼痛的转变至关重要。 疼痛，但在老年人中具有挑战性，原因有两个。首先，镇痛药的选择是复杂的， 禁忌症和高发生率的副作用和不良事件。第二，促进恢复的行为是 提供者很少向患者解释，因此，患者很少实践。共同决策， 这涉及患者和提供者之间的信息交换以支持治疗决策， 提供了一种重要的临床方法，用于提高初始管理的有效性和安全性， 老年人的疼痛拟议的研究将测试三个组成部分的干预，以支持共同的决定， 在早期恢复阶段，对于那些到急诊室（艾德）就诊的老年人， 急性肌肉骨骼疼痛第一个组成部分是一个简短的互动视频，以提高病人的知识， 关于治疗方案的自我效能，旨在促进患者之间的对话， 紧急供应商第二个组成部分是一个协议引导的电话对话（远程护理）之间的 护理经理和患者在艾德出院后48-72小时评估疼痛严重程度， 干扰日常活动，审查止痛药的使用和副作用以及促进恢复的行为，以及 讨论对病人治疗的调整第三个组成部分是与患者的沟通 初级保健提供者在远程护理呼叫之后通知他们患者的状况和治疗计划。 该项目的短期目标是测试这种干预措施的有效性，以减少从 急性至慢性肌肉骨骼疼痛，并减少长期阿片类药物使用和其他关键次要结局。 这一目标将通过一项在50岁及以上成人中进行的三组随机对照试验实现 因急性肌肉骨骼疼痛而到艾德急诊室就诊。患者将被随机分配至（1）完全干预组 （视频+远程护理+与主要提供者的通信），（2）单独视频，或（3）常规护理。主 结果将是疼痛，在艾德就诊后的一年内纵向测量。二次 结果将包括阿片类药物的使用，身体功能，镇痛副作用和不良事件，抑郁症和 焦虑症状、睡眠持续时间和质量以及1个月、3个月、6个月和12个月的医疗保健利用率。 我们还将研究干预措施是否通过促进共同决策而产生效果，并评估 干预的成本效益。这项工作的长期目标是确定和实施有效的 临床护理干预，以改善老年人急性肌肉骨骼疼痛的结果。

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.