Dear Editor:

Patients on medical disability are not uncommon, particularly in primary care settings. From the perspective of psychiatric consultation/liaison, we examined pain medication prescription patterns among outpatients with a history of medical disability versus those without.

Participants were men and women, ages 17 or older, who presented for routine outpatient treatment in a resident-provider internal medicine clinic. The sample was one of convenience. Exclusion criteria were cognitive (e.g., dementia), medical (e.g., severe illness), psychiatric (e.g., psychosis), and/or intellectual impairment that would preclude the successful completion of a survey booklet, as well as patients who had not been registered in the clinic during the preceding four weeks. A total of 82 patients were approached; 80 agreed to participate (response rate of 97.6%).

The sample consisted of 21 men and 59 women (N=80), ranging in age from 17 to 74 years (mean [M]=45.58, standard deviation [SD]=14.74). Most participants were Caucasian (89.9%), followed by African American (6.3%), Hispanic (2.5%), and Native American (1.3%). With regard to education, 20.3% percent had not graduated high school; 41.8 percent had graduated high school but had not attended college, 21.5 percent attended some college but had not earned a degree, 8.9 percent had a bachelor’s degree, and 7.6 percent had a graduate degree.

During assigned clinic times, two resident physicians recruited participants from their clinical caseloads. Participants signed a consent form to enable us to review their medical records for pain medication prescriptions during the preceding four weeks. Participants also completed a survey booklet.

In the survey booklet, we initially explored demographic information and then asked, “Have you ever been on medical disability?” We then examined the medical records of each participant during the preceding four weeks with regard to pain medication prescriptions. Pain medication prescriptions were coded as narcotic analgesics (when present, the narcotic analgesic was converted to daily morphine equivalents), nonsteroidal anti-inflammatory drugs (NSAIDs), and “other” (e.g., gabapentin, pregabalin, duloxetine, amitriptyline). We also calculated the total number of individual pain medications prescribed per participant. This project was approved by the institutional review boards of both the community hospital and the university.

Twenty-five (31.3%) participants reported having ever been on medical disability. Participants with a history of medical disability were older (M=51.96, SD=9.43) than participants without a history of medical disability (M=42.74, SD=15.83), F(1,76)=7.00, p<0.01, but there were no statistically significant relationships between medical disability and sex or education. Compared to participants who had never been on medical disability, those who had had a statistically significantly greater number of prescriptions for pain medications (M=1.36, SD=1.00 vs. M=0.62, SD=0.81, F(1,78)=12.56, p<0.001), were more likely to have a prescription for a narcotic medication (64.0% vs. 34.5%, c2(1)=6.06, p<0.02), and had a statistically significantly greater number of prescriptions for “other” pain medications (M=0.52, SD=0.63 vs. M=0.15, SD=0.41, F(1,78)=9.86, p<0.002), but were not more likely to have a prescription for a NSAID (20.0% vs. 12.7%, c2(1)=0.71, p<0.40). For those prescribed a narcotic medication (n=35), there were no differences between those patients with a history of medical disability versus those without and the amount of the narcotic prescribed in morphine equivalents (M=72.03, SD=83.02 vs. M= 80.92, SD=124.10, F(1,33)=0.06, p<0.81). Our findings suggest that individuals with medical disability histories are more likely to be prescribed a greater number of pain medications, narcotic analgesics, and “other” pain medications, but not higher rates of NSAID prescriptions or higher daily doses of narcotics—all suggesting that patients with histories of medical disability are clinically characterized by pain. This patient/medication profile may be useful for psychiatrists on consultation/liaison services. With regards, Randy A. Sansone, MD; Michelle Mueller, MD; Amy Mercer, MD; and Michael W. Wiederman, PhD

Dr. Sansone is a Professor in Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Drs. Mueller and Mercer are residents in the Department of Internal Medicine at Kettering Medical Center in Dayton, Ohio; and Dr. Wiederman is a Professor in Psychology in the Department of Human Relations at Columbia College in Columbia, South Carolina.