Delivering high-quality pain care has long been a priority of the Military Health System (MHS). Acute and chronic pain conditions are common among U.S. service members, with about half of active-duty service members having one or more pain diagnoses, most often musculoskeletal pain (Bader et al., 2018; Reif et al., 2018). Musculoskeletal pain conditions and injuries can be disabling and are the leading cause of nondeployability among active-duty service members and, therefore, have a negative impact on force readiness (Flynn et al., 2017; U.S. Army Public Health Center, 2020). Furthermore, treating service members’ chronic pain—typically defined as pain lasting three or more months—can be complicated by the co-occurrence of other conditions, such as posttraumatic stress disorder, traumatic brain injury, and substance use disorders (Blakey et al., 2018; Lew et al., 2009).
This study presents findings and recommendations from the second of a two-phase study on pain care quality in the MHS. In the first phase, we collected and analyzed MHS administrative data to assess the quality and safety of outpatient noncancer pain care and opioid prescribing in the MHS, identifying areas of strength and opportunities for improvement (Hepner et al., 2022). The second phase of the study drew on qualitative data from interviews with military treatment facility (MTF) staff who oversee or provide pain care and service members who received pain care at MTFs. The objective was to gain a clearer picture of the real-world implications of MHS practices and policies for delivering pain care from the perspectives of MTF administrators, providers, and patients. Such qualitative data provide additional detail and context for the administrative data captured in the first phase of the study—shedding light on practice differences and effective models of care that can guide strategies to ensure that service members receive timely, high-quality pain care that supports their individual outcomes and the readiness of the force.
The findings and recommendations in this report draw on interviews with 68 MTF administrators and providers of pain care and 54 service members who were receiving care for chronic pain.1 To capture a variety of perspectives and experiences, we recruited interview participants from seven MTFs that varied by size, service branch (three MTFs located at U.S. Army installations, two at U.S. Navy installations, and two at U.S. Air Force installations), and quality of pain care, according to 11 administrative data–based quality measures.
Our interviews with staff and service member patients yielded several findings that can inform MHS efforts to implement the Phase 1 study recommendations and enhance its ongoing initiatives to improve pain care for service members.
- Nearly all providers reported assessing the severity of pain symptoms, but only approximately half said they used a structured method to assess pain severity and the impact of pain on patient functioning. Structured approaches that make use of existing MHS tools can help ensure that decisions about treatment adjustments are based on data collected in consistent ways over time.
- Nearly all providers endorsed a shared decisionmaking approach to developing a pain treatment plan. Most patients cited positive experiences with shared decisionmaking, noting that they were offered a choice of treatment options, felt that providers explained benefits and risks, or believed their providers listened to their preferences. However, most patients reported that communication between their providers was less than adequate, and nearly one-quarter felt they had been treated differently because of some aspect of their background.
- Consistent with the stepped-care model, most prescribers shared that they were reluctant to treat chronic pain with opioids and preferred nonopioid medications (e.g., oral nonsteroidal anti-inflammatory drugs) or nonpharmacologic treatment (NPT).
- Despite the availability of physical therapy and the high level of support for NPT among providers, more than three-quarters of staff reported that patients faced barriers to accessing NPT.
- Staff reported training and treatment access as the most important facilitators of high-quality pain care, whereas patients found effective treatment and patient-centered care most important.
- Staff and patients recommended prioritizing increases in treatment access and availability to improve pain care.
The following recommendations draw on both our qualitative interview findings and our analysis of MHS administrative data and pain care quality, presented in the Phase 1 study report.
Recommendation 1. Increase Integration of Effective Nonpharmacologic Treatment
Recommendation 1a. Increase Access to Effective Nonpharmacologic Treatment
NPT is a recommended first-line treatment option for chronic pain and is central to the MHS's implementation of a stepped-care model of pain treatment. More than three-quarters of staff described the limited availability of NPT as the biggest barrier to integrating these treatments into pain care. It is critical that MTFs ensure that staffing and appointment availability are adequate to meet demand for these treatments. In our interviews, providers were more likely to mention integrating certain types of NPT, such as behavioral health care or psychotherapy, for pain compared with the proportion of patients who reported receiving these NPTs. These findings highlight the need to increase access to NPT, particularly to underutilized, recommended types of NPT. Innovative approaches may have the potential to increase access to NPT and could include on-demand access to physical therapy for chronic pain patients, more unit-embedded NPT providers, making telehealth appointments (e.g., for cognitive behavioral therapy for chronic pain) more widely available or expanding service members’ access to NPT through private-sector providers, and designating a staff member at each MTF to serve as an expert in treatment options and to support NPT integration and coordination. The MHS should assess whether there is adequate availability of the types of providers necessary to ensure timely access to NPT.
Recommendation 1b. Monitor Access to Nonpharmacologic Treatment as Part of a Comprehensive Strategy to Improve the Quality of Pain Care
Ongoing monitoring of access and quality of care is essential to improving pain care in the MHS and can be used to ensure that care is delivered equitably across the patient population. Both phases of this study consistently found that service members received certain types of NPT (e.g., physical therapy) much more often than other types of NPT that were also recommended by the pain care research literature, such as acupuncture and psychotherapy associated with a pain diagnosis (Hepner et al., 2022). Using pharmacy data, the MHS monitors several metrics related to opioid prescribing at MTFs and by private-sector providers that contract with TRICARE (U.S. Department of Defense, 2021). Perhaps because of this ongoing monitoring, the MHS performs quite well across most metrics related to appropriate opioid prescribing. There is an opportunity to similarly expand these monitoring and improvement efforts to NPT integration. Phase 1 of this study generated several quality metrics related to monitoring NPT delivery (Hepner et al., 2022). There is an opportunity for the MHS to incorporate NPT into its ongoing efforts to standardize and track pain care. Doing so would help the MHS monitor access to specific types of NPT.
Recommendation 2. Identify Barriers to Broader Use of the Defense and Veterans Pain Rating Scale
The Defense and Veterans Pain Rating Scale (DVPRS) is the standard pain scale to be used by all providers (primary care and specialty) in MTFs to screen and assess for pain in adolescent and adult patients during each visit. Based on the intensity of pain, the DVPRS guides the assessment of pain's impact on the service member's functioning. The MHS has rolled out the DVPRS to providers, yet our findings suggest that continued support is needed to increase use of the DVPRS. Specifically, only half of providers reported using a structured method to assess the impact of pain on patient functioning and response to treatment. The reasons for the lack of use of the DVPRS to assess the impact of pain on functioning are unclear, and further work is needed to understand the specific barriers impeding broader implementation of the DVPRS. It is possible that providers could benefit from additional education on the use of the DVPRS and its value. In addition, the DVPRS should be feasible to use and easily accessible in the medical record. The current transition to GENESIS—the MHS's new electronic medical record—provides an opportunity to continue to promote the use of structured and longitudinal evaluations of outcomes of treatment and to provide other pain treatment decision support. The use of the DVPRS for standardized pain care assessment may also help to ensure that the pain care provided to service members is equitable.
Recommendation 3. Expand Provider Education on Effective Treatment Options and Appropriate Opioid Prescribing
Increasing provider training in targeted areas is a strategy that may help support the MHS in its ongoing quality improvement efforts. Staff endorsed the value of access to provider training and consultative support for pain care and recommended increased access to provider training and improved provider awareness of pain treatment options. To support this need, MHS should ensure that providers have protected time to attend training and that pain champions have time to support their providers.2 MHS could also leverage existing programs, such as Project Extension for Community Healthcare Outcomes (ECHO), to achieve this aim.3 Providers may benefit from MTF-specific guidance on available types of NPT, how patients can be referred, and whom to contact when faced with access challenges. Furthermore, providers may need additional training on appropriate opioid prescribing with an emphasis on how to prescribe for limited indications rather than solely on avoidance of prescribing. Most interviewed providers indicated some level of uncertainty and discomfort with prescribing opioids and, therefore, may benefit from additional guidance on when it is appropriate to prescribe opioids to treat service members with acute or chronic pain and how to manage service members on long-term opioid therapy (LOT), including how to safely titrate patients off LOT, particularly given the risks of overdose and suicide risk with rapid titrations (U.S. Food & Drug Administration, 2019). Additionally, providers should be educated on when referrals to specialists should be made for complex opioid treatment cases based on a stepped-care model.
Recommendation 4. Explore the Feasibility and Impact of Allowing Extended Visit Length for Primary Care Appointments for Patients with Complex Pain Needs
Staff members identified inadequate appointment length as the most common overarching barrier to delivering evidence-based pain care. Staff explained that the standard appointment length of 15 to 20 minutes was generally inadequate, particularly for patients with complex pain care needs. Providers discussed needing more time during the visit to obtain patient buy-in, provide education, and discuss treatment options. Nearly one-quarter of staff members recommended that appointments for chronic pain patients be longer. Patients discussed the need for longer appointments to allow time to have their concerns addressed as part of the development of a treatment plan. Twenty-minute appointment times are often too short to manage preventive care and chronic medical conditions (Yarnall et al., 2003). Inadequate time may lead to further clinician burnout (Linzer et al., 2009) and potentially poorer quality of care (Linzer et al., 2015) and reduced patient satisfaction (Howie et al., 1991). The MHS should explore the potential impact and feasibility of defining an enterprisewide appointment standard that allows for a small number of complex patient appointments in primary care that would be longer than the standard appointment length of 20 minutes. Additionally, the MHS may consider expanding patient visit time by involving nurses or case managers as part of the visit for patients with chronic pain. These providers could support the primary clinician in patient pain assessment, education, and referrals.
Recommendation 5. Improve Patient Experience in Receiving Care for Chronic Pain, and Ensure Pain Care Is Equitable
Patients identified several positive aspects of their care for chronic pain received from the MHS, including shared decisionmaking, being offered a choice of treatments, learning about risks and benefits of treatment options, and feeling that their provider listened to their preferences. However, patients report less favorable perceptions of coordination of care between their providers, and nearly one-quarter felt they had been treated differently because of some aspect of their background (e.g., age or rank). These findings suggest that the MHS can continue to improve patient experience in receiving pain care and ensure that the care is delivered equitably. In addition, patients voiced a desire for more awareness of treatment options, including NPT and techniques for pain self-management. Interestingly, patients recommended increasing use of diagnostic imaging, such as magnetic resonance imaging, a perspective that is generally not consistent with recommendations in clinical practice guidelines. Increasing provider training and patient education materials would support providers in sharing evidence-based guidance on appropriate use of NPT and the role and timing of imaging in pain care. The MHS should also ensure that care is delivered equitably, particularly given persistent disparities in pain care in the United States (Hoffman et al., 2016; Institute of Medicine, 2001; Meghani, Byun, and Gallagher, 2012). Using stratified reporting, quality metrics can be used to examine variations in pain care (Fiscella, Burstin, and Nerenz, 2014; Health Research & Educational Trust, 2014; Jha and Zaslavsky, 2014; Meghani et al., 2012; Simon et al., 2015). Should care vary by patient characteristics, these variations should be investigated for potential causes and quality improvement strategies implemented to minimize variation. Providers and patients both referred to tensions between receiving appropriate treatment for pain and fulfilling military duties. Patient experience could be improved by directly addressing these tensions, such as through improving access to on-demand NPT or making it easier to schedule appointments around military training and work schedules. Some aspects of military culture may be associated with stigma toward service members who seek treatment for pain.
Our interviews with MTF staff and service members receiving treatment for chronic pain provided valuable context for the findings on pain care quality drawn from MHS administrative data in the first phase of this study. Administrative data capture patterns of care, offer insights into the extent to which service members receive evidence-based care, and are essential to measuring the quality of pain care in the MHS. Qualitative data provide a more nuanced picture of how the MHS organizes to provide pain care, how policies and guidance are implemented in practice, how patients experience pain care, and facilitators and barriers to high-quality pain care. The findings and recommendations in this study highlight areas for improvement and suggestions for innovation to ensure that the MHS continues providing timely, high-quality pain care that supports service members’ outcomes and the readiness of the force.