Association Between Facility-Level Utilization of Non-pharmacologic Chronic Pain Treatment and Subsequent Initiation of Long-Term Opioid Therapy

  • Evan P. Carey
  • Charlotte Nolan
  • Robert D. Kerns
  • P. Michael Ho
  • Joseph W. Frank
Original Research



Expert guidelines recommend non-pharmacologic treatments and non-opioid medications for chronic pain and recommend against initiating long-term opioid therapy (LTOT).


We examined whether veterans with incident chronic pain receiving care at facilities with greater utilization of non-pharmacologic treatments and non-opioid medications are less likely to initiate LTOT.


Retrospective cohort study


Veterans receiving primary care from a Veterans Health Administration facility with incident chronic pain between 1/1/2010 and 12/31/2015 based on either of 2 criteria: (1) persistent moderate-to-severe patient-reported pain and (2) diagnoses “likely to represent” chronic pain.

Main measures

The independent variable was facility-level utilization of pain-related treatment modalities (non-pharmacologic, non-opioid medications, LTOT) in the prior calendar year. The dependent variable was patient-level initiation of LTOT (≥ 90 days within 365 days) in the subsequent year, adjusting for patient characteristics.

Key results

Among 1,094,569 veterans with incident chronic pain from 2010 to 2015, there was wide facility-level variation in utilization of 10 pain-related treatment modalities, including initiation of LTOT (median, 16%; range, 5–32%). Veterans receiving care at facilities with greater utilization of non-pharmacologic treatments were less likely to initiate LTOT in the year following incident chronic pain. Conversely, veterans receiving care at facilities with greater non-opioid and opioid medication utilization were more likely to initiate LTOT; this association was strongest for past year facility-level LTOT initiation (adjusted rate ratio, 2.10; 95% confidence interval, 2.06–2.15, top vs. bottom quartile of facility-level LTOT initiation in prior calendar year).


Facility-level utilization patterns of non-pharmacologic, non-opioid, and opioid treatments for chronic pain are associated with subsequent patient-level initiation of LTOT among veterans with incident chronic pain. Further studies should seek to understand facility-level variation in chronic pain care and to identify facility-level utilization patterns that are associated with improved patient outcomes.


chronic pain practice variation health care delivery health services research 



comlementary and integrative health


physical therapy/occupational therapy


non-steroidal anti-inflammatory drugs


Sample size across all years, N = 858,199

Adjusted rate ratios and 95% confidence intervals for initiation of long-term opioid therapy during year following chronic pain index date. Adjusted estimates generated using a quasi-Poisson general linear model.

Model 1 adjusted for patient age at index date, gender, race/ethnicity, calendar year of index date, rurality of patient residence, pain diagnoses (back pain, neck, and other joint pain), mental health diagnoses (depression, anxiety, post-traumatic stress disorder, bipolar disorder), substance use disorder diagnoses (alcohol use disorder, opioid use disorder, other substance use disorder), Charlson’s comorbidity index, facility rurality, and facility complexity.


Model 2 adjusted for all Model 1 variables plus each of 10 facility-level pain treatment modality variables, categorized as quartiles.


Authors’ contribution

All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; and final approval of the version to be published.


This work was supported by the Department of Veterans Affairs, Quality Enhancement Research Initiative (QUE 15-468). Dr. Frank was supported in part by VA Health Services Research & Development Career Development Award (HSR&D CDA 15–059). Dr. Kerns was supported in part by a VA Health Services Research & Development Center of Innovation (CIN 13-047). The funding sources had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US Government.

Compliance with ethical standards

Prior presentations

This manuscript has not been previously published and is not under consideration in the same or substantially similar form in any other peer-reviewed media. This work will be presented as a poster at the upcoming VA HSR&D/QUERI meeting on July 18–20, 2017, in Washington, DC.

Conflict of interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2018_4324_MOESM1_ESM.docx (21 kb)
ESM 1 (DOCX 21 kb)


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Copyright information

© Society of General Internal Medicine (outside the USA) 2018

Authors and Affiliations

  • Evan P. Carey
    • 1
  • Charlotte Nolan
    • 1
  • Robert D. Kerns
    • 2
    • 3
  • P. Michael Ho
    • 1
    • 4
  • Joseph W. Frank
    • 1
    • 5
  1. 1.Center of Innovation for Veteran-Centered and Value-Driven CareVA Eastern Colorado Health Care SystemDenverUSA
  2. 2.Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of InnovationVA Connecticut Healthcare SystemWest HavenUSA
  3. 3.Departments of Psychiatry, Neurology and PsychologyYale UniversityNew HavenUSA
  4. 4.Division of CardiologyUniversity of Colorado School of MedicineAuroraUSA
  5. 5.Division of General Internal MedicineUniversity of Colorado School of MedicineAuroraUSA

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