By Mr. Ronald W Wolf (Army Medicine)January 9, 2018
Every day--the Centers for Disease Control and Prevention reports--more than 1,000 people across the U.S. are treated in emergency departments for misusing prescription opioids. More than 90 Americans die from an opioid overdose each day, a rate of more than 40,000 per year.
While those numbers from the civilian community should sober everyone, opioid abuse among soldiers is a critical matter of concern for the Army and Army Medicine as well.
The leading reason for use of opioid prescriptions is pain, an unfortunate consequence of injuries sustained during training or deployments. Army Medicine has been at the forefront of developing and implementing a strategy for pain management for more than a decade.
A great deal of progress has been made during the past ten years. In the Army, chronic use of opioids (defined as those receiving at least 90 days of opioids in a 180-day period) peaked in 2007, but then decreased 9 percent between 2007 and 2012.
From 2012 to 2016, additional measures implemented to address opioid overuse led to a further reduction of more than 19 percent in the number of Soldiers who were given one or more opioid prescriptions. The rate of chronic opioid use decreased by an additional 45 percent between these years thanks to these efforts.
The Army's improvement in opioid prescribing contrasts with the worsening trend that currently exists across our nation. What did Army Medicine do to start winning the battle against opioid abuse?
In 2010, the Army Pain Management Task Force was chartered, and this group published 109 pain management recommendations with the goal of taking a standardized approach to pain management across the DoD and Veterans Health Affairs. The following were among the recommendations made:
--Determine best practices to treat acute and chronic pain;
--Provide tools and infrastructure that support and encourage practice and research advancement in pain management;
--Integrate a culture of pain awareness, education, and proactive intervention together.
First, the task force identified changes in standards, data collection, personnel use, and other system improvements under the umbrella of best practices.
As a result of the Task Force's recommendations, the Military Health System (MHS) standardized pain management policies, surveillance, clinical capabilities and pain assessment tools. Policy changes led to a patient-centric stepped care approach that helped to empower primary care providers and improved patient rehabilitation, satisfaction, pain control and recovery.
A standardized pain assessment tool was developed to assess patients' pain score and impact on patients' daily activities (e.g., activity, mood, stress, sleep). The MHS developed a surveillance tool to monitor opioid use and prescription practices, allowing risk stratification and identification of at-risk individuals. This tool facilitates ongoing management of daily opioid use and prevention measures for opioid misuse. Periodic reassessments of MHS policies are instrumental in continued performance improvement.
Second, infrastructure, resources, and tools were evaluated and improved to make them more effective.
For example, educational support to primary care was established via a tele-mentoring program--the Extension for Community Healthcare Outcomes (ECHO) program. The ECHO program provides weekly clinical education. In addition, Primary Care Pain Champions (PCPCs)--knowledge leaders in pain management--helped coordinate pain care between the primary care setting and pain management centers. The goal of the PCPC is to maximize assets in the primary care setting and coordinate the weekly ECHO programs.
Telemedicine capabilities are also being used to bring specialty care for pain to remote locations.
Finally, it was important to synchronize changes in the culture of pain awareness and education with more proactive intervention in the medical community and among health care consumers. Patient education efforts include expectation management and consistent messaging from all patient care levels that pain does not always necessitate opioids. Examples include pain awareness month campaigns, educational flyers and videos in waiting rooms, and a focus on a healthy lifestyle. Military providers are required to complete initial and refresher training on appropriate clinical management of opioids.
Army Medicine also implemented the Comprehensive Pain Management Program (CPMP) which provides a comprehensive pain management plan and education by utilizing state-of-the-science modalities and technologies to advance pain medicine and provide optimal quality of life for all patients with acute and chronic pain.
The CPMP uses a stepped care model for pain management ensuring that the appropriate level of pain care, including opioid alternatives, are available and delivered to patients. It continually strives to provide alternatives to opioid therapy through holistic, complementary and integrative medicine therapies at all levels of the medical continuum of care. In 2016, over 125,000 clinical visits were provided at the interdisciplinary pain management centers supporting active duty troops under the CPMP.
These therapies include interventional medicine, physical therapy, occupational therapy, chiropractic, nutrition, medical massage, acupuncture, and movement therapy such as yoga and tai chi. In October 2016, to improve access, continuity, and quality, the Army began relocating and integrating substance use disorder clinical care with behavioral health clinics, including embedded behavioral health teams.
In 2017, the Army revised several policies to advance pain management services, including an operations order and concept of operations for the CPMP and an executive order requiring a profile for every opioid prescription and allowing for the transfer of vital duty-related information from provider to commander.
Integrating substance use disorder clinical care treatment into the Behavioral Health System of Care improves outcomes for soldiers and family members through earlier detection and intervention. With opioid abuse--prescription or otherwise--and other substance use disorders, the Army Medicine response is patient-centered and evidence-based.
Army Medicine has established five intensive outpatient programs to deliver care to soldiers who require more treatment than a standard outpatient clinic. These intensive outpatient programs improve care integration, increase the opportunity for command involvement, and provide earlier access to higher level care.
Army Medicine continues to collect data to monitor and modify efforts. The Health of the Force Program--and its associated report--provides a standardized health assessment tool that aligns with others performed nationally. We know, for example, from the 2016 report:
--50 percent of active duty soldiers experienced one or more injuries at an average rate of 1.4 injuries per soldier. Clearly pain can result from these injuries;
--20 percent of active duty soldiers had a diagnosed behavioral health disorder;
--4 percent had a diagnosed substance abuse disorder.
Army Medicine aims to continue to intervene with soldiers identified as high-risk for opioid abuse. Nevertheless, that gains have been made in opioid management within the Army are reflected in data that show incidence of opioid use disorder is lower in the Army at 0.26 percent (FY 2016 data) compared to 0.9 percent of the U.S. adult population.
The 2017 Army Medicine policy for naloxone allows pharmacists to screen and dispense naloxone to any patient at high risk. A patient lookup tool currently being piloted at several facilities sends risk alerts directly from an opioid registry to the pharmacist for a targeted interaction. Three pharmacy quality alliance opioid safety measures (concurrent use of opioids and benzodiazepines; use of opioids at high dosage; use of opioids from multiple providers) allow a comparison against commercial healthcare systems. These efforts are moving Army Medicine forward from a safety and surveillance perspective to shaping the healthcare provider's approach and prescribing habits.
There is still much to learn regarding pain, traumatic brain injury, post-traumatic stress disorder, and the stress of deployment and their effects on soldiers and their families.
Army Medicine continues the fight against opioid overuse. The Army and Army Medicine looks forward to developing and sharing ideas for best practices concerning opioid management with the nation as it struggles with this epidemic.