Trajectories of non-pharmacologic and opioid health services for pain management in association with military readiness and health status outcomes: SUPIC renewal

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Summary/Abstract In 2016, the US Department of Health and Human Services released the National Pain Strategy, which outlined a coordinated plan to improve healthcare delivery for patients with pain. It outlined the need for better monitoring methods, supporting patient-centered integrated pain management practices, and improving access to effective non-pharmacological therapies (NPT). The impact of pain in civilian health care systems is mirrored in the military and veteran populations; both the Military Health System (MHS) and Veterans Health Administration (VHA) populations have a higher prevalence of chronic pain compared to civilian populations. The Medical Surveillance Monthly Report identified the top nine reasons for seeking care in the MHS outside of pregnancy services and ill-defined symptoms. Five were related to musculoskeletal (back, knee, ankle, arm) injuries or problems and the remaining top conditions were anxiety, mood/adjustment, and sleep disorders, which in some cases could be comorbidities with pain. The present study is a renewal R01 application to advance knowledge on military readiness, opioid, and health status outcomes associated with different early treatment trajectories of nondrug pain management strategies in the MHS. Investigators from the SUPIC project (Substance Use and Psychological Injury Combat R01AT008404) have generated foundational knowledge about chronic pain and its behavioral health comorbidities in the MHS. We have established a comprehensive, longitudinal database on Army members returning deployment comprised of their MHS and VHA health encounter/claims data and several other data sources. We have investigated the use of early NPT utilization (both complementary [e.g., chiropractic, acupuncture, spinal manipulation, self-management, interdisciplinary pain programs] strategies and integrative [e.g., exercise therapy, physical therapy, occupational therapy, mental health specialty care] strategies, and identified there is high prevalence of opioid medications in the chronic pain cohort. The Specific Aims of the SUPIC renewal application are to: Aim 1: (a) Characterize early trajectories of NPT and opioid therapies for pain management; (b) examine relationships between NPT utilization (e.g., specific modalities, utilization trajectories) and multidimensional outcomes (e.g., military readiness, opioid utilization, health status); and (c) investigate the relationship of NPT trajectories and outcomes in discrete high risk subgroups of patients (comorbid PTSD, depression) and for specific pain conditions (e.g., back pain, other musculoskeletal, headache). Aim 2: Identify facility- and provider-level factors (FTE availability for health occupations, propensity to refer to NPT or prescribe opioids) that explain variation in NPT use and opioid prescribing between MHS facilities. Aim 3: (a) Describe the characteristics of SUPIC Army deployed members with chronic pain in the MHS who do and do not transition to VHA care; (b) identify associations between NPT receipt in the MHS and long-term health outcomes in the VHA (main effects); and (c) identify moderators and mediators of these associations. This renewal grant is poised to efficiently continue much needed work on MHS pain management approaches that will directly inform MHS and VHA leadership and facilitate informed clinical and organizational changes. The SUPIC study population will be expanded to members of all service branches in 2013-2018 (estimated at 2 million or more) and the investigative team is expanded to strengthen our practical knowledge and facilitate rapid translation of research findings into action. Researchers from the Defense & Veterans Center on Integrative Pain Management at the Uniformed Services University, the Department of Defense’s Center of Excellence on pain strategies are joining the investigative team.