Delivering Exceptional Pain Care to Service Members

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Pain is the leading cause of disability among active-duty service members. Given the widespread potential impact of pain on military readiness and ability to deploy, providing high-quality treatment to service members with pain conditions is a strategic priority for the Military Health System (MHS).

MHS administrative records from fiscal years 2018 and 2019 show that, in the vast majority of cases in which opioids were used to treat pain, providers followed prescribing practices that mitigated the risk of opioid misuse or dependence.

• Concurrent use of opioids and benzodiazepines has been associated with an increased risk of overdose and death, and less than 10 percent of service members were co-prescribed opioids and benzodiazepines concurrently for seven or more days.
• Higher dosages of opioids are associated with an increased risk of harm, including both nonfatal and fatal overdose. Also, higher doses do not necessarily improve pain symptoms. Nearly all service members (98 percent) who were dispensed opioids had an average daily dosage below levels of highest risk. Updated U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) clinical practice guidelines emphasize using effective nonopioid treatments before opioids, and if opioids are prescribed, there is a need for continued patient reassessment and monitoring of patient risks.
• Less than 1 percent of opioid-naïve service members who were dispensed opioids progressed to long-term opioid therapy (LOT) within 12 months. LOT has multiple risks, including substance use disorder, overdose, suicide behaviors, and increased all-cause mortality.

These findings suggest that the MHS performs well on multiple metrics assessing the safety and quality of opioid prescribing. The Centers for Disease Control and Prevention (CDC) emphasizes the need for careful assessment and management of each patient with pain — specifically, the risks and benefits of nonopioid therapies as first-line treatment before initiating opioids. This effort is known as the stepped-care model. When opioids are used, they should be prescribed at the lowest effective dosage, with regular patient monitoring.

• Opioids with no concurrent benzodiazepines for ≥7 days = 93%
• Opioids average daily dosage <90 MME (morphine milligram equivalent) = 98%
• Opioids average daily dosage <50 MME (morphine milligram equivalent) = 81%
• Opioid-naïve service members dispensed opioids who did not advance to LOT (long-term opioid therapy) = 99.6%

NOTES: MME = morphine milligram equivalent. Previous VADoD and CDC clinical practice guidelines strongly recommended against daily opioid dosages above 90 MME and acknowledged the increased risk and need for monitoring at daily dosages of 50 MME. Updated guidelines do not focus on specific dosages but emphasize the importance of considering alternative treatments to opioids and individualized patient assessment and monitoring when opioids are used.

In interviews, most MHS prescribers expressed a reluctance to treat chronic pain with opioids, preferring nonopioid medication (e.g., oral NSAIDs) or nonpharmacologic treatment (NPT) as initial treatments, consistent with the stepped-care model. One prescriber admitted, "If I get a new patient that is on opioids, I will do my damnedest to find another provider in the clinic that prescribes opioids to have them see [the patient]." Providers would benefit from additional training and support, including in safely tapering off LOT for patients when appropriate.

The use of NPT is consistent with the stepped-care model, which promotes evidence-based pain care and minimization of opioid use. Patients whose pain is not responsive to primary or secondary treatment, including NPT, can be referred to specialty pain management clinics. Among service members with chronic pain (defined as pain lasting three or more months), 81 percent received at least one visit for a recommended NPT.

• Among those with acute low back pain, 79 percent received treatment consistent with stepped care. Specifically, in the three months following patients' initial back pain visits, they received NPT or nonopioid medication prior to receiving opioids.
• Physical and occupational therapy was the most common type of NPT that service members received, followed by guided exercise and chiropractic care. However, other types of recommended NPT were underutilized in the MHS, including acupuncture, psychotherapy for pain (i.e., cognitive behavioral therapy), and biofeedback.

• Physical/occupational therapy = 75%
• Guided exercise = 55%
• Chiropractic/osteopathic manipulation = 47%

There is evidence supporting the effectiveness of these therapies, but they were received infrequently

• Acupuncture = 7%
• Psychotherapy (with pain diagnosis) = 3%
• Biofeedback/ hypnotherapy = 2%

NOTE: An individual service member could have received more than one type of NPT.

More than three-quarters of administrative leadership and providers who provide pain care cited the limited availability of NPT as a barrier to broader use, and more than one-half described it as the biggest barrier to integrating these treatments into pain care. One provider explained, "Everybody's fighting for that physical therapy." Many providers made few referrals to chiropractic care and acupuncture because of limited availability at military treatment facilities and a lack of TRICARE reimbursement in the private sector. Other common barriers included inadequate staffing and long wait times for NPT appointments. The MHS should assess the availability and wait times for NPT appointments and routinely monitor timely access to NPT.

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Topics

• Health Care Quality Measurement
• Lower-Back Pain
• Military Health and Health Care
• Opioids
• Pain Management