Psychophysiological Disorders and Pain Medication Prescription Among Internal Medicine Outpatients

| February 15, 2010 | 0 Comments

Dear Editor:

Psychophysiological disorders are physical disorders with psychological overlays. Because the proportion of psychological overlay is always variable, these types of disorders can be challenging to treat in primary care settings—particularly with regard to the management of any associated pain symptoms. In the following cross-sectional study, we examined various relationships between eight self-reported psychophysiological disorders and recorded prescriptions for analgesic medications during the preceding four weeks.

Participants comprised male and female subjects between the ages of 18 and 65 years who presented for outpatient treatment in an internal medicine resident-provider clinic. Participants were recruited as clinical demands allowed (i.e., the sample was one of convenience). Exclusion criteria were cognitive, medical, psychiatric, 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 of whom agreed to participate, for a response rate of 97.6 percent.

The sample for analysis consisted of 21 men and 59 women (N=80) who ranged in age from 17 to 74 years (M=45.58, SD=14.74). The large majority were Caucasian (89.9%), followed by African-American (6.3%), Hispanic (2.5%), and Native-American (1.3%). With regard to educational achievement, 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 achieved a bachelor’s degree, and 7.6 percent had attained a graduate degree.

Each participant completed a survey booklet that initially explored demographic information (e.g., age, gender, race, completed education) and then explored a history of having ever been diagnosed with one of the following psychophysiological disorders: chronic fatigue syndrome, fibromyalgia, temporomandibular joint syndrome, irritable bowel syndrome, chronic pain, rheumatoid arthritis, multiple chemical sensitivities, and migraine headaches. We then examined the medical records for analgesic prescription during the preceding four weeks. Analgesic prescriptions were coded as narcotic analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), and “other” (e.g., gabapentin, duloxetine, pregabalin). When present, narcotic analgesic prescriptions were converted to morphine equivalents to compare participants’ prescription. All participants signed a consent form for participation. The project was approved by the institutional review boards of both the community hospital and university.

With regard to results, we initially examined the individual psychophysiological disorders and pain prescriptions (narcotic analgesics, NSAIDs, “other” pain medications, total number of prescribed pain medications). There were statistically significant correlations between the total number of prescribed pain medications and irritable bowel syndrome (r=0.25, p<0.05), chronic pain (r=0.37, p<0.01), rheumatoid arthritis (r=0.30, p<0.01), and migraine headaches (r=0.28, p<0.01), with respondents with these disorders demonstrating a greater number of pain medications, but no associations between these disorders and narcotic analgesics, NSAIDs, or “other” pain medications. There was also a statistically significant correlation between chronic pain and narcotic analgesic dosages (r=0.35, p<0.001), in the expected direction. We then examined the number of different psychophysiological disorders and pain medication prescription. There were statistically significantly positive correlations between the number of endorsed psychophysiological disorders and “other” pain medications (r=0.28, p<0.05), as well as the number of psychophysiological disorders and total number of prescribed pain medications (r=0.39, p<0.001). However, there were not statistically significant correlations between the number of psychophysiological disorders and either narcotic analgesic dosages (r=0.10, p<.38) or prescription of a NSAID (r=0.05, p<0.67). What do these findings tell us? In this clinic, it appears that with the exception of chronic pain, narcotic analgesics are not over-represented among those with psychophysiological disorders. In addition, while the number of self-reported psychophysiological disorders demonstrated a statistically significant association with the total number of analgesic medications, this increase was not reflected in narcotic analgesic dosages or NSAID prescription. One interpretation for these data may be that as clinicians discern potentially greater psychological overlays in their patients’ symptom presentations, they refrain from narcotic analgesics and emphasize non-narcotic analgesics. These data have a number of potential limitations, including a sample of convenience (i.e., risk of sampling bias), small sample size, and the self-report nature of the data. However, few studies have examined psychophysiological disorders and their association with prescription medication patterns. These findings indicate that except for chronic pain, narcotic analgesics are not overly represented in prescribing patterns for these disorders. However, for specific disorders (i.e., irritable bowel syndrome, chronic pain, rheumatoid arthritis, and migraine headaches), there was a relatively greater number of pain medications prescribed. In addition, the number of different psychophysiological disorders predicted for a greater number of analgesics prescribed, including “other” analgesics, but not narcotic analgesics or NSAIDs. These data are reassuring both in terms of analgesic prescription in these perplexing patients as well as regarding concerns about the addiction risk of narcotic analgesics. With regards, Randy A. Sansone, MD
Professor Psychiatry and Internal Medicine, Wright State University School of Medicine, Dayton, Ohio, and Director of Psychiatry Education, Kettering Medical Center, Kettering, Ohio

Michelle Mueller, MD
Resident, Department of Internal Medicine, Kettering Medical Center, Dayton, Ohio

Amy Mercer, MD
Resident, Department of Internal Medicine, Kettering Medical Center, Dayton, Ohio

Michael W. Wiederman, MD
Professor in Psychology in the Department of Human Relations at Columbia College in Columbia, South Carolina

Category: Headache, Letters to the Editor, Mental Disorders, Mood Disorders, Neurologic Systems and Symptoms, Neurology, Pain, Past Articles, Psychiatry, Psychology

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