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

by Kimberly A. Hepner, Carol P. Roth, Tisamarie B. Sherry, Ryan K. McBain, Teague Ruder, Charles C. Engel

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Research Questions

  1. To what extent does outpatient care for acute and chronic pain in the MHS align with evidence-based clinical practice guidelines, including for opioid prescribing?
  2. What steps can the MHS take to improve the pain care and support service members' readiness?

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 report 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.

Key Findings

  • Nearly 80 percent of service members with acute low back pain received treatment consistent with "stepped care," a model that recommends less-intensive treatments prior to prescribing opioids.
  • Service members with chronic pain are a large population with complex health care needs, with nearly 100,000 service members experiencing chronic pain in a given year.
  • More than 80 percent of service members with chronic pain received at least some nonpharmacologic therapy, but few received some recommended types.
  • Opioid prescribing was largely consistent with recommended guidance.
  • Rates of naloxone dispensing for service members on higher-risk daily opioid dosages were low.
  • Few service members with opioid use disorder received recommended medication treatment.
  • Providers at military treatment facilities were more likely than TRICARE-contracted private-sector providers to adhere to opioid-prescribing recommendations after dental and ambulatory procedures.

Recommendations

  • Select a set of high-priority quality measures to routinely monitor pain care in the MHS and report the findings.
  • Increase delivery of recommended nonpharmacologic therapies for pain to support the consistent implementation of the stepped-care model in the MHS.
  • Assess the health care utilization patterns of "high-need" service members with chronic pain and evaluate the implications for care delivery.
  • Increase naloxone dispensing to service members with higher-risk opioid use to help prevent overdose.
  • Increase medication treatment for service members with opioid use disorder.
  • Update opioid prescribing guidance for post-procedure pain to increase its specificity and ensure that it aligns with current evidence-based practice guidelines.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Developing a Pain Care Measure Set

  • Chapter Three

    Analytic Methods

  • Chapter Four

    Acute Pain Related to Procedures

  • Chapter Five

    Acute Low Back Pain

  • Chapter Six

    Chronic Pain

  • Chapter Seven

    Opioid Prescribing

  • Chapter Eight

    Medication for Opioid Use Disorder

  • Chapter Nine

    Findings and Recommendations

  • Appendix A

    Technical Specifications for Quality Measures

  • Appendix B

    Key Cross–Measure Domain Definitions

  • Appendix C

    Comorbidity and Health Care Utilization Among Service Members with Chronic Pain, by Pain Condition

  • Appendix D

    Opioid Prescribing

  • Appendix E

    Assessing Pain During Clinical Care

This research was sponsored by the Office of the Assistant Secretary of Defense for Health Affairs and conducted within the Forces and Resources Policy Center of the RAND National Security Research Division (NSRD).

This report is part of the RAND Corporation Research report series. RAND reports present research findings and objective analysis that address the challenges facing the public and private sectors. All RAND reports undergo rigorous peer review to ensure high standards for research quality and objectivity.

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