Fibromyalgia diagnosis and treatment receipt in the U.S. military health system

Abstract: Introduction: Meta-analytic findings and clinical practice guidance recommend pharmacological (e.g., pregabalin, duloxetine, and milnacipran) and non-pharmacological (e.g., exercise and sleep hygiene) interventions to reduce symptoms and improve quality of life in people living with fibromyalgia. However, some of these therapies may lack robust evidence as to their efficacy, have side effects that may outweigh benefits, or carry risks. Although the annual prevalence of fibromyalgia in active duty service members was estimated to be 0.015% in 2018, the likelihood of receiving a fibromyalgia diagnosis was 9 times greater in patients assigned female than male and twice as common in non-Hispanic Black than White service members. Therefore, the primary goal of this retrospective study is to examine co-occurring conditions and pain-management care receipt in the 3 months before and 3 months after fibromyalgia diagnosis in active duty service members from 2015 to 2022. Materials and Methods:Medical record information from active duty service members who received a fibromyalgia diagnosis between 2015 and 2022 in the U.S. Military Health System was included in the analyses. Bivariate analyses evaluated inequities in co-occurring diagnoses (abdominal and pelvic pain, insomnia, psychiatric conditions, and migraines), health care (acupuncture and dry needling, biofeedback and other muscle relaxation, chiropractic and osteopathic treatments, exercise classes and activities, massage therapy, behavioral health care, other physical interventions, physical therapy, self-care management, and transcutaneous electrical nerve stimulation), and prescription receipt (anxiolytics, gabapentinoids, muscle relaxants, non-opioid pain medication, opioids, selective serotonin and norepinephrine inhibitors, and tramadol) across race and ethnicity and assigned sex. Pairwise comparisons were made using a false discovery rate adjusted P value. Results: Overall, 13,663 service members received a fibromyalgia diagnosis during the study period. Approximately 52% received a follow-up visit within 3 months of index diagnosis. Most service members received a co-occurring psychiatric diagnosis (35%), followed by insomnia (24%), migraines (20%), and abdominal and pelvic pain diagnoses (19%) fibromyalgia diagnosis. At least half received exercise classes and activities (52%), behavioral health care (52%), or physical therapy (50%). Less commonly received therapies included other physical interventions (41%), chiropractic/osteopathic care (40%), massage therapy (40%), transcutaneous electrical nerve stimulation (33%), self-care education (29%), biofeedback and other muscle relaxation therapies (22%), and acupuncture or dry needling (14%). The most common prescriptions received were non-opioid pain medications (72%), followed by muscle relaxers (44%), opioids (32%), anxiolytics (31%), gabapentinoids (26%), serotonin-norepinephrine reuptake inhibitor (21%), selective serotonin reuptake inhibitors (20%), and tramadol (15%). There were many inequities identified across outcomes. Conclusion: Overall, service members diagnosed with fibromyalgia received variable guideline-congruent health care within the 3 months before and after fibromyalgia diagnosis. Almost 1 in 3 service members received an opioid prescription, which has been explicitly recommended against use in guidelines. Pairwise comparisons indicated unwarranted variation across assigned sex and race and ethnicity in both co-occurring health conditions and care receipt. Underlying reasons for health and health care inequities can be multisourced and modifiable. It is unclear whether the U.S. Military Health System has consolidated patient resources to support patients living with fibromyalgia and if so, the extent to which such resources are accessible and known to patients and their clinicians.