Assessing the Quality of Outpatient Pain Care and Opioid Prescribing in the Military Health System

Short abstract

Pain conditions are the leading cause of disability among active-duty service members. RAND researchers conducted an assessment of outpatient care for acute and chronic pain, including opioid prescribing, delivered by the Military Health System (MHS). This research offers the most comprehensive examination to date of the quality and safety of pain care in the MHS and its alignment with evidence-based clinical practice guidelines.

Abstract

Pain conditions are the leading cause of disability among active-duty service members. Given the significant implications for force readiness and service member well-being, the Military Health System (MHS) has made it a strategic priority to provide service members with the highest-quality treatment for pain conditions.

RAND researchers assessed MHS outpatient care for acute and chronic pain, including opioid prescribing. The assessment involved developing a set of 14 quality measures designed to assess aspects of outpatient care for pain, including care associated with dental and ambulatory procedures, acute low back pain, chronic pain, opioid prescribing, and medication treatment for opioid use disorder. This research offers the most comprehensive examination to date of the quality and safety of pain care in the MHS and its alignment with evidence-based clinical practice guidelines. It identifies several areas of strength in pain care delivery, along with some areas for improvement, and provides recommendations to support the MHS in continuing to improve pain care for service members.

Pain is the leading cause of disability among active-duty service members. In the Army alone, recent data suggest that injuries and related musculoskeletal conditions account for more than 1 million medical encounters and approximately 10 million limited-duty days per year. And when soldiers are unable to deploy, these conditions are the most common reason (U.S. Army Public Health Center, 2018). Given the significant implications for force readiness and service member well-being, the Military Health System (MHS) has made it a strategic priority to provide service members with high-quality treatment for pain conditions. However, there has been no comprehensive assessment to date of the quality and safety of pain care in the MHS, including whether it is consistent with evidence-based clinical practice guidelines (CPGs). To address this knowledge gap and inform potential improvements, the Office of the Assistant Secretary of Defense for Health Affairs asked the RAND Corporation to assess the quality and safety of pain care and opioid prescribing in the MHS.

This study focuses on pain conditions that service members experience at much higher rates than the general U.S. population: acute pain and chronic pain, with back and joint pain being the most common. Acute pain can result from illness or trauma, such as surgery, injury, or overuse. If pain persists longer than the expected healing time or for more than 90 days—due to, for example, reinjury, delayed treatment, or inadequate management—it could become chronic. Chronic pain symptoms among service members are often comorbid with behavioral health (BH) conditions, such as posttraumatic stress disorder, major depressive disorder, and substance use disorders (Caldeiro et al., 2008; Runnals et al., 2013). Given the risk of dependence and the prevalence of opioid treatment for chronic pain, we also examined opioid prescribing practices in the MHS and medication treatment for opioid use disorder (OUD).

Developing Measures to Assess the Quality of Pain Care in the MHS

High-quality pain care is evidence-based and aligns with current CPGs. It also supports improved patient outcomes, such as symptoms, functioning, and satisfaction with care. We used administrative data on active-component service members’ health care encounters at military treatment facilities or in private-sector health care settings to characterize service members who received pain treatment between October 2017 and September 2019 and their care utilization patterns. We then applied our measures to assess aspects of the quality of care they received.¹

To assess the quality of selected outpatient pain care services in the MHS, we developed a series of quality measures—sometimes called quality metrics. In our set of quality measures, we opted to capture a range of outpatient noncancer pain care delivered to active-component service members in direct care settings and by private-sector providers under contract with TRICARE.² We grouped the resulting measures into five categories, as shown in Table 1: (1) acute pain related to dental and ambulatory procedures, (2) acute low back pain, (3) chronic pain, (4) opioid prescribing, and (5) OUD.

Table 1.

Quality Measures to Assess Pain Care

Measure Topic	Quality Measure	Observed Care
Acute pain related to procedures
Opioids and dental procedures	Dental procedures for opioid-naïve patients who initially received short-acting opioids and no more than a 1-day supply or no opioids	FY 2019
Opioids and ambulatory procedures	Ambulatory procedures for opioid-naïve patients who initially received short-acting opioids and no more than a 5-day supply or no opioids	FY 2019
Acute low back pain
NSAIDs/NPT without opioids	Opioid-naïve patients with acute low back pain who received NSAIDs or any NPT within 3 months and no opioids	FY 2019
Stepped care	Opioid-naïve patients with acute low back pain who received nonopioids or any NPT within 3 months and no opioids or opioids only after nonopioids or NPT	FY 2019
No initiation of benzodiazepines	Opioid-naïve patients with acute low back pain not currently taking benzodiazepines who did not initiate benzodiazepines (≥7 days) within 3 months	FY 2019
Chronic pain
NPT	Patients with chronic pain who received any NPT within 12 months	FYs 2018 and 2019
Nonopioid medication/NPT	Patients with chronic pain who received any nonopioid medication or NPT within 12 months	FYs 2018 and 2019
Opioid prescribing
Opioids without concurrent benzodiazepines	Patients who received opioids who did not receive concomitant benzodiazepines (≥7 consecutive days) during the 12-month observation period	FY 2019
Lower-risk average daily dosage	Patients who received opioids and whose average daily dosage was <90 MME during the 12-month observation period	FY 2019
No advancement to LOT	Opioid-naïve patients who received opioids who did not advance to LOT during the 12-month observation period	FYs 2018 and 2019
Naloxone in LOT at higher-risk daily dosage	Patients on LOT dispensed a daily dosage of ≥50 MME and dispensed naloxone within 3 months	FY 2019
Follow-up visit in LOT	Patients on LOT with a follow-up evaluation and management visit at least every 90 days	FYs 2018 and 2019
Urine drug testing in LOT	Patients on LOT who received drug testing at least once during the 12-month observation period	FY 2019
Opioid use disorder
Medication for OUD∗	Patients with OUD who received medication treatment for OUD during the 12-month observation period	FY 2019

NOTES: Opioid-naïve = no opioids in the previous 90 days. FY = fiscal year. NSAID = nonsteroidal anti-inflammatory drug. MME = morphine milligram equivalent. LOT = long-term opioid therapy.

^∗NQF-endorsed measure.

Across these categories, we identified only one existing measure that was compatible with our study criteria: medication treatment for OUD. This measure is also currently endorsed by the National Quality Forum (NQF).³ In developing the remaining measures, we drew on CPGs from the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD), among other sources. We also incorporated input from a panel of experts in developing and refining the measures.

One potential limitation of this research was variability in the quality, availability, and comprehensiveness of administrative data for assessing the quality of pain care. For example, administrative data might not include all types of treatment that service members received for pain conditions, including some nonpharmacologic treatments (NPTs) with a significant evidence base, such as tai chi and yoga. The data also do not include unstructured documentation from providers (i.e., chart notes). This meant that we were not able to assess patient education, informed consent regarding opioid use, patient refusals of treatment, or contraindications. Finally, it is possible that our defined focus on pain care affected the representativeness of our service member data sample, as our analyses did not include treatment of cancer pain or pain treated in inpatient settings. However, our quality measures nonetheless provide a valuable baseline for performance monitoring as the MHS continues to improve the care and support it provides to service members.

Key Findings

Applying the quality measures listed in Table 1 to administrative data highlighted several insights into the needs of service members with chronic pain and the quality of care that the MHS provides to this population. Measures reflect care received during FY 2019 or, for some measures for which longer measure eligibility periods were required, care received in FYs 2018 and 2019.

Nearly 80 Percent of Service Members with Acute Low Back Pain Received Treatment Consistent with “Stepped Care”

The MHS encourages stepped care for pain management, whereby non-invasive NPT and nonopioid medications are recommended as first-line treatments and opioid use is reserved for severe pain that has not responded to these lower-risk interventions. We found that 79 percent of service members with a new episode of low back pain received treatment consistent with stepped care, meaning that in the three months following their initial back pain visit, they received NPT or nonopioid medication prior to receiving any opioids. Overall, only 8 percent of service members who received care for acute low back pain were prescribed an opioid during our observation window.

Service Members with Chronic Pain Are a Large Population with Complex Health Care Needs

Our data indicated that nearly 100,000 service members experienced chronic pain in FY 2018, with low back pain being the most common chronic pain condition. Chronic pain was frequently comorbid with other medical and psychological conditions, with some service members having particularly medically complex needs. These “high utilizers” of care were far more likely to have a BH diagnosis and to receive psychotropic medication.

More Than 80 Percent of Service Members with Chronic Pain Received at Least Some NPT, but Few Received Some Particular Types of NPT That Are Recommended

NPT use was high among service members with chronic pain, with physical and occupational therapy being the most common, followed by exercise and chiropractic care/manipulation. Despite recommendations supporting their use, only 7 percent of service members with chronic pain received acupuncture, 3 percent received psychotherapy (with a pain diagnosis), and 2 percent received biofeedback/hypnotherapy.

Opioid Prescribing Was Largely Consistent with Recommended Guidance

In the vast majority of cases in which opioids were used to treat pain, providers followed prescribing practices that mitigated the risks of opioid misuse or dependence. For example, 93 percent of service members who were dispensed seven or more days of opioids had no concurrent use of benzodiazepines exceeding seven days. Our other findings similarly suggest that the MHS performs well on multiple metrics for assessing the safety and quality of opioid prescribing.

Rates of Naloxone Dispensing for Service Members on Higher-Risk Daily Opioid Dosages Were Low, and Few Service Members with OUD Received Medication Treatment

Naloxone co-prescribing is recommended to reduce the risk of overdose among at-risk patients prescribed opioids for pain. Only 8 percent of service members on LOT regimens who were dispensed opioids at a daily dose of 50 MME or higher were also dispensed naloxone rescue (nasal spray or autoinjector) within three months. This low rate highlights a potentially serious safety and quality concern. Among service members with a diagnosis of OUD in FY 2019 in our study population, only 22 percent received any recommended medication for OUD in that same year. Few received one of the medications with the strongest recommendations for OUD treatment (i.e., 8 percent received buprenorphine; 3 percent received injectable naltrexone).

Direct Care Providers Were More Likely Than Private-Sector Providers to Adhere to Opioid-Prescribing Recommendations After Dental and Ambulatory Procedures

Following dental and ambulatory procedures, the Defense Health Agency (DHA) recommends either not prescribing opioids or prescribing an initial limited supply of short-acting opioids.⁴ Almost half of the dental procedures and more than 80 percent of ambulatory procedures in our data met DHA recommendations, although this varied by procedure, and there was greater adherence among direct care providers than among private-sector providers.

Recommendations and Policy Implications

The observations generated by our analyses supported six recommendations to better align chronic pain care with the needs of service members and in support of force readiness.

Recommendation 1. Select a Set of High-Priority Pain Care Quality Measures to Monitor and Report Routinely

Continually measuring the quality of pain care is essential to determining whether patients receive recommended care and for providing ongoing feedback to providers to improve care. We used a large set of measures to assess pain care, but the MHS might want to select a smaller set to monitor the quality of specific aspects of pain care on an ongoing basis, establish benchmarks, and track the impact of quality-improvement efforts.

Recommendation 2. Increase Delivery of Recommended NPTs for Pain to Support Consistent Implementation of the Stepped-Care Model

By prioritizing NPT and nonopioid medications, with opioids reserved for unresponsive severe pain, the MHS is already promoting a model of stepped care for pain management. However, it should maximize the availability and awareness of NPT, as well as provider and service member awareness of the potential benefits of NPT, and work to address barriers to the use of these treatments.

Recommendation 3. Assess the Utilization Patterns of “High-Need” Service Members with Chronic Pain and Implications for Care Delivery

The population of service members with chronic pain is vast and diverse, with subsets with comorbid BH conditions and with other complex medical needs. This latter group, identified as high utilizers, merits further study. Depending on what these analyses reveal, the MHS might want to examine whether there is a need to strengthen its programs targeting medically complex service members to improve care, outcomes, and readiness for this population.

Recommendation 4. Increase Naloxone Dispensing to Service Members with Higher-Risk Opioid Use

However small the share of service members receiving long-term or high-risk opioid treatment, the low rates of naloxone prescribing for this population across the MHS could pose a patient safety risk. There are several approaches that the MHS could consider to build on its existing efforts to increase naloxone dispensing to service members at risk of opioid overdose. However, any solution will need to account for the fact that a large proportion of service members receiving LOT get all or the majority of their care from private-sector providers.

Recommendation 5. Increase Medication Treatment for Service Members with OUD

Service members with OUD are at risk for increased morbidity and mortality. Due to military policies on drug use and substance use disorders, service members diagnosed with OUD are likely to be subsequently separated from the military (Army Regulation 600-85, 2020). However, it is essential that these service members initiate recommended treatment as soon as their condition is diagnosed. The MHS should ensure that these service members are offered medication treatment for OUD and track the rates of receipt of this recommended treatment. Furthermore, transition assistance programs should support separating service members by connecting them with a prescribing provider to ensure continuity of care.

Recommendation 6. Update Opioid Prescribing Guidance for Procedures to Improve Specificity and Appropriateness of Guidance

Current guidelines for prescribing opioids for acute pain (related to procedures or not) tend to broadly suggest an initial maximum days of supply of opioids (Dowell, Haegerich, and Chou, 2016). However, studies have shown that most patients receive more opioid tablets than they ultimately need for post-procedure pain control (Hartford et al., 2019; Hill et al., 2017; Maughan et al., 2016; Wojahn et al., 2018). Creating procedure-specific recommendations for opioid types and quantities or dispensed MMEs could minimize initial over- or underprescribing and help identify areas for quality improvement. These recommendations could be provided to contracted private-sector providers to help standardize prescribing practices across MHS care settings.

Conclusions

The pervasive impact of pain on military readiness and ability to deploy has made the provision of high-quality pain care a strategic priority for the MHS. This study offers the most comprehensive examination to date of the quality and safety of pain care in the MHS and its alignment with evidence-based CPGs. The measures that we developed to assess different aspects of pain care provide a valuable baseline for performance monitoring as the MHS continues to improve the care and support it provides to service members with acute and chronic pain.