More Educated Patients Less Likely to Receive Pain Meds

UNC researchers have found that the higher the education level of patients treated in emergency departments (ED) following motor vehicle accidents, the less likely they were to receive an opioid pain medication. In these surprising results, 10 percent of patients with a graduate degree received an opioid, compared to 54 percent of patients with less than a high school education. The study authors had hypothesized the reverse – that if there is a disparity in pain treatment, those with lower socioeconomic status (SES) would receive less pain medication.

The study was published online ahead of print March 2, 2012, in the journal Pain by a team of researchers from eight sites in four other states, plus at UNC. It was led by UNC emergency physicians Timothy Platts-Mills, MD, and Samuel McLean, MD, MPH, who is also vice chairman of research, Department of Anesthesiology.

According to Platts-Mills, study participants with less education had higher rates of pain and distress and these differences partly explained why less educated patients received more opioids. However, even after adjusting for pain and distress, more educated patients were still less likely to receive opioids. Platts-Mills and McLean don’t know why there was such a large difference across education level, but they have several theories they hope to explore in future research.

“In an educated patient, the initial conceptualization of neck pain after a motor vehicle collision may be ‘that hurts a lot, but is going to heal up in a few weeks.’ In a less-educated patient, the interpretation may be, ‘I think something is broken or ruined in there.’ The same injury might be a lot more threatening and concerning,” said Platts-Mills.

Other contributing factors, added Platts-Mills, may be different levels of underlying stress in people with lower SES that is exacerbated by motor vehicle accidents. For example, someone with more resources may know they can rent a car while waiting for repairs or vehicle replacement by insurance. Meanwhile someone with fewer resources may fear job loss from lack of transportation or significantly negative economic impact from meeting an insurance deductible or loss of a car.

“Increasing evidence suggests an important relationship between life stress and susceptibility to pain, and much of Dr. McLean’s work is focused on understanding the mechanisms that underlie this relationship,” said Platts-Mills.

Another factor, said Platts-Mills, may be differing levels of access to health care.

“We definitely don’t fully understand the whole picture. Perhaps, less educated people want to be validated by the physician and therefore request a prescription. Or perhaps educated patients are declining opioids.” Also, he noted that someone with higher SES may know they can always go back to the doctor later and get a prescription if they have ongoing pain, while someone with lower SES may not have that option so want to get a prescription while they can in the ED.

Platts-Mills is currently conducting similar observational studies to understand pain and pain management in older adults and has done previous work along those lines supported by an NC TraCS pilot grant.

“Regardless of the cause, the results highlight the value of conducting prospective observational studies in which detailed phenotypic information is collected," he said. "There have been at least 20 prior studies of determinants of opioid use in the ED, but none identified the relationship with education. Most of these studies were performed retrospectively using administrative data sets which did not contain this important covariate.”

All patients underwent structured interviews in the ED and reported pain on a 0-10 pain scale.

Platts-Mills is a KL2 Scholar in the second year of a three-year career development award which provides 75 percent protected research time, mentoring and coursework designed to develop him into an independently funded researcher. The KL2 program is administered by the North Carolina Clinical and Translational Sciences (NC TraCS) Institute, whose mission includes training the next generation of biomedical scholars. McLean is Platts-Mills’ mentor.

“This is a fantastic opportunity for me to learn research methods and work closely with a mentor and other investigators here at UNC, and I enjoy it tremendously,” said Platts-Mills. He is earning a Master’s of Science in Clinical Research through the UNC Gillings School of Global Public Health during the program.