Healthcare use and prescription of opioids in rural residents with pain

Introduction: Chronic pain is a major public health problem. Increased healthcare utilization by individuals with pain puts enormous burden on financial and health resources. There is extremely limited understanding of psychosocial factors that affect healthcare use and prescription of opioids in individuals who experience heightened healthcare disparities associated with being African-American, having low income, and with rural residency. Health disparities research indicates that rural residency and low socioeconomic status are associated with greater self-reported pain levels. It is logical to expect then that this would be associated with increased needs for health services. However, at the same time, these very variables function as barriers in accessing health care. This disparity between greater need and limited access in turn creates greater distress. Further complicating the picture is the rapidly emerging concern about the misuse of prescription opioids in rural areas. As a result, empirical inquiry has started focusing on the variables influencing the likelihood of receiving opioid prescriptions in rural areas. The understanding of psychosocial factors affecting healthcare use and prescription of opioids in individuals who experience heightened healthcare disparities associated with being African-American, low-income, and living in rural areas remains extremely limited. The primary aim of this study was to examine the demographic and psychosocial variables that affect health services use in a rural, low-income population with chronic pain. Secondarily, the influence of these same variables on receiving prescription for opioids was examined.

Methods: Healthcare use during a 3 month period, prescription analgesics, as well as medical comorbidities were obtained from the medical records of 64 patients with chronic pain. The participants were enrolling in an upcoming psychosocial intervention offered at two rural federally qualified health centers in a south-eastern state in the USA. For the present study, these participants consented to have their medical records reviewed for the 3 months prior to beginning the intervention protocol. Additionally, the pre-treatment (baseline) assessments were used in the present analyses. Demographic information, including age, sex, and education level, as well as measures of pain intensity, depressive symptoms, pain-related disability, and pain catastrophizing were collected.

Results: The participants were rural residents in medically underserved counties, primarily female (73.4%) and African-American (67.2%), and approximately 77% reported annual household income of less than $13,000. A majority had medical comorbidities, including diabetes mellitus (46.89%), cardiovascular disorders (29.7%), chronic renal disorder (14.1%), and asthma (6.3%). Approximately 30% had a diagnosis of depression. Demographic variables such as age, sex, and ethnicity did not influence the healthcare use or prescription of opioids. Depressive symptoms uniquely influenced health services use, with higher scores predicting greater health services utilization. In addition, those with a diagnosis of depression (per medical records) and those with a higher number of medical comorbidities were more likely to receive prescription opioids.

Conclusions: This study adds to the current understanding of the factors affecting healthcare use and prescription of opioids in low-income individuals living in rural areas with chronic pain receiving treatment at federally qualified health centers. Since healthcare use was predicted by depressive symptoms and the prescription of opioids by a clinical diagnosis of depression, screening for depression is advised as part of the standard care of patients with pain, ideally with follow-up assessments and treatment of depression as necessary. Furthermore, making psychosocial interventions more available at rural healthcare centers may help in lowering psychological distress, which may have the ultimate effect of reducing opioid prescriptions for this subset of patients.