by Janet Aker, Military Health System

The Military Health System has shown a significant decline in prescriptions for opioids as a primary tool for pain management.

The decline in prescriptions for opioid medications – like morphine and oxycodone – highlights the success of the Defense Health Agency’s training and education programs aimed at reducing the risks linked to opioid medications.

The most dramatic decline in recent years was reported among active-duty service members, but military health data shows reductions in opioid prescriptions across the entire Military Health System including among non-active-duty beneficiaries under age 65 and non-active-duty beneficiaries 65 and over.

Military Health System patients are prescribed fewer opioids in 2021 than in 2020. (DoD image)

Opioids have been prescribed as a pain reducer for many years, but the medical community has grown increasingly concerned about their risk of addiction and potentially fatal overdoses. To reduce those risks, the MHS has mounted a force-wide effort to curtail the prescribing of opioids in favor of other effective pain management techniques.

“The MHS, like all civilian medicine organizations across the nation, has been working hard to raise awareness of the specific risks associated with opioid medications. The data indicate that our providers have integrated this into their prescribing practices,” said Kevin Galloway with the Defense and Veterans Center for Integrative Pain Management, the DOD’s center of excellence for pain management located at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.

Declines across the system

Among active-duty service members during the period from April 2017 to July 2021, military health data shows a 69% decline in prescriptions filled for opioids at a strength of 50 morphine milligram equivalents (MME) per day or more.

For beneficiaries who are not on active duty and are under the age of 65, the decline for the same period was 47%. And for non-active-duty beneficiaries 65 or older, the decline was 32%, according to data from the MHS Information Platform maintained by the Program Executive Office, Defense Healthcare Management Systems.

The MHS is also reporting fewer opioids prescribed to people in another risk category – those who are co-prescribed opioids and benzodiazepines, such as Valium or Xanax. The combination of those two types of medications can be dangerous and increase the risk of an overdose.

MHS beneficiaries who are on long-term opioid therapy – defined as taking opioids 90 days or more out of the past 180 days, also has declined.

The declines are good news, but should be seen in the context of a larger effort across the MHS to improve the quality of pain management.

“Our numbers are looking better, but the pain program is so much more than just getting the numbers down. We need to provide pain care in locations where it is needed so opioids become one of a number of options in our toolbox,” said Army Lt. Col. Lori Whitney, director of the Army Comprehensive Pain Management Program.

Why the Declines?

The lower number of prescriptions is attributed in part to the recent emphasis of non-pharmacological approaches to pain management. At the same time, new education programs for health providers and patients have increased awareness of both the risks of opioids and the complementary forms of pain management therapy.

Provider training includes:

• Emphasis on avoiding routine prescription of opioids as a first-line therapy for minor pain conditions
  Developing pain management plans that ensure patients are taking the lowest effective dose of opioids for the shortest time
  Monitoring patients’ conditions closely with the aim of risk mitigation
• “The training provides a whole array of data and data tools that allow the prescriber to compare their prescribing practices to their peers at the level of the MTF [medical treatment facility], region, and market,” Whitney said. These tools can also be used by leadership.

Patient and provider education follows the Step Care Model of pain management that was developed by the Department of Veterans Affairs, where the goals and emphasis is on the “return to function and restoration of health.”

Other interventions focus on:

• Non-opioid pain management treatments such as nonsteroidal anti-inflammatories
  Complimentary pain management techniques like chiropractic manipulation, acupuncture, and massage therapy
  Behavioral interventions such as cognitive behavioral therapy and mindfulness meditation
  Patient lifestyle components like sleep and diet

Improving the quality of pain management in the MHS has been a key priority for the Defense Health Agency in recent years. The objectives of the DHA’s pain strategy are designed to:

• Educate patients in effective self-management of pain and injury rehabilitation
  Educate clinicians regarding effective pain management and opioid safety
  Provide tools, including those through the MHS GENESIS, Carepoint, and legacy electronic health records systems to assist clinicians in evidence-based and patient-centered pain management
  Conduct pain research to continuously improve the approach to pain management

Additionally, the MHS Prescription Drug Monitoring Programs electronic database collects prescription data on controlled medications dispensed to TRICARE beneficiaries within the MHS. MHS then shares prescription drug monitoring information from military hospitals, clinics, and pharmacies with civilian health care providers and pharmacies.

“It’s important that the MHS is leading this effort in that both federal partners, such as the VA, and civilian health care teams are looking to replicate our successes,” said Dr. Christopher Spevak, an anesthesiologist and pain physician at Walter Reed National Military Medical Center in Bethesda, Maryland. Spevak leads the National Capital Region Pain Initiative and Tele-Pain Program.

Opioid Prescriptions Decline Across the Military Health System, by Janet Aker,