Altering The Transition From Acute to Chronic Pain (ATTAC-Pain)
Altering The Transition From Acute to Chronic Pain (ATTAC-Pain)
The current way that pain is treated after trauma and injury is problematic. Most often pain
 after trauma is treated with opioids (ex. Percocet® or Vicodin®) or anti-inflammatories (ex.
 ibuprofen). Both of these medications can cause side effects and opioids have been related to
 the development of addiction. In addition, there are not any treatments that prevent pain
 from going on to become persistent (last beyond it is supposed to) or chronic (lasting 3
 months or longer).

 Chronic pain is an enormous problem and there an urgent need to find both alternatives to
 opioid pain medications and medications that prevent pain from becoming chronic. The
 ATTAC-Pain (Altering The Transition from Acute to Chronic Pain) study proposes to examine
 whether duloxetine (a medication that is marketed for depression, anxiety, and specific types
 of pain conditions), can reduce acute and chronic pain among adults who come to the emergency
 department (ED)with muscular pain (such as neck pain after a car accident or low back pain).
 Investigators will enroll 60 patients who come to the ED. Patients will be eligible if they
 report moderate to severe muscular pain (such as pain in the back, neck, or shoulders).
 Consenting patients will be randomized to receive duloxetine 30mg, duloxetine 60mg, or
 placebo (2/3rd chance of being in one of the duloxetine groups). The study team will follow
 patients for six weeks and collect information on pain outcomes and use of pain medications.
 Investigators aim to determine if duloxetine can (1) reduce acute pain symptoms following the
 ED visit, (2) prevent the transition to persistent pain (having pain 6 weeks after the
 initial ED visit), and (3) decrease opioid use following a motor vehicle collision (MVC). The
 results of this study will ultimately help determine if duloxetine can be used as a
 non-opioid pain treatment option that reduces acute pain and prevents the transition to
 chronic pain. This in turn can improve recovery, reduce opioid use and its consequences, and
 decrease health care costs.
There is an urgent need for new non-opioid pain management options to prevent the development
 of chronic musculoskeletal pain in patients experiencing acute pain and injury. Investigators
 propose to address this unmet need by intervening at the point when pain is still acute with
 pain management that is intended to alter the mechanisms involved in the transition from
 acute to chronic pain. The proposed study, "Altering The Transition from Acute to Chronic
 Pain (ATTAC-Pain): A randomized clinical trial of duloxetine for the treatment and prevention
 of musculoskeletal pain," will examine the ability of duloxetine to improve pain outcomes in
 individuals presenting to the emergency department (ED) with acute musculoskeletal pain.
 Investigators will enroll a total of sixty participants. Eligible patients who consent to the
 study will: be randomized in the ED, receive a dose of study drug (duloxetine 30mg,
 duloxetine 60mg, or placebo) in the ED, and be discharged from the ED with a two week supply
 of study drug. Following discharge, the patient will receive follow-up assessments via
 internet-based surveys and phone to monitor for adverse events and evaluate patient outcomes.
 The patient will also return to the study site for an in-person follow-up interview 6 weeks
 after their initial ED visit. The study team will recruit participants at the Rhode Island
 Hospital and the Miriam Hospital EDs. The results of this study will be used as basis for a
 potentially high impact large-scale trial examining an important new non-opioid pain
 treatment option that reduces acute pain and prevents the transition to chronic pain. This in
 turn can improve recovery, reduce opioid use and its sequelae, and decrease health care
 costs.
Inclusion Criteria:

 -  generally in good health, are between the ages of 18 and 65, present to the ED with
 acute (present for <7 days) musculoskeletal pain, and have a current pain score of >4
 without a history of pain in the past month.

 Exclusion Criteria:

 -  Musculoskeletal pain lasting > 7days

 -  ED pain score <4

 -  Chronic pain: Pain present on most days of the week, with an average score >1 in past
 month, in the same location as presenting pain

 -  Clinically unstable

 -  Fracture (except fracture of the phalanges)

 -  Substantial soft tissue injury†

 -  Hepatic failure (acute or chronic)

 -  Renal failure (acute or chronic)

 -  Coronary artery disease, including previous myocardial infarction, Angina,
 percutaneous transluminal coronary angioplasty, etc.

 -  History of glaucoma

 -  Previous congestive heart failure

 -  History of seizure disorder

 -  History of mania or psychotic disorder

 -  History of suicidal ideation

 -  Prisoner

 -  History and behavior indicates, in the investigator's judgment, that the participant
 would likely be noncompliant with the study

 -  Any other condition that, in the investigator's judgment, would indicate that the
 patient in unsuitable for the study (e.g. might interfere with the study, confound
 interpretation, or endanger patient)

 -  Does not have a telephone

 -  Does not have regular internet access and email address

 -  Unable to speak and read English

 -  Blood pressure reading(s) in ED that, when considered in the context of patient past
 and current history, in the investigator's judgment exceeds acceptable level

 -  Currently taking a monoamine oxidase inhibitor (MAOI)

 -  Currently taking medication with substantial interaction with duloxetine (Table 1).

 -  Breastfeeding

 -  If female, either not postmenopausal (having menses within past year), or, if
 childbearing potential, positive pregnancy test prior to randomization and not using a
 medically acceptable form of contraception

 -  Exceeds acceptable chronic daily opioid use prior to MVC*

 -  Previously on duloxetine

 -  Previous allergic reaction to duloxetine

 -  Antidepressant use within 2 weeks of study start (4 week if Prozac)

 -  Allergy to lactose

 -  Intoxicated