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Patients with head and neck cancer may be at risk for opioid misuse
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Patients with oral and oropharyngeal cancer appeared likely to receive opioids for pain management during treatment, and a significant number continued to use them 3 and 6 months later, according to a study published in Otolaryngology-Head and Neck Surgery.
“We felt like it was a long-term problem for some of our head and neck patients, but we didn’t know how much of a problem,” Jessica D. McDermott, MD, investigator at University of Colorado Cancer Center and assistant professor at CU School of Medicine, said in a press release. “You shouldn’t need opioids at the 6-month point.”
In the retrospective, population-based study, McDermott and colleagues used the SEER-Medicare database to identify 976 individuals aged 66 years or older treated for nondistant metastatic oral cavity and oropharynx cancer between 2008 and 2011.
Researchers used national drug codes and generic names to identify opioids documented in Medicare Part D prescription drug claims. They estimated time on opioids based on prescription fill dates and supply received.
Initial opioid use and use at 3 months and 6 months served as the study’s primary outcome, with univariate and multivariable logistic analyses conducted to establish risk factors for use.
Results showed 811 patients (83%) received prescriptions for opioids during treatment. Of these patients, 150 (15.4%) continued to have opioid prescriptions 3 months after treatment ended, and 68 (7%) had opioid prescriptions 6 months after treatment.
The use of opioids during treatment appeared associated with prescriptions before treatment (OR = 3.28; 95% CI, 2.11-5.12) and was least likely to be related to radiation treatment alone (OR = 0.35; 95% CI, 0.18-0.68).
Patients who continued opioid use 3 months and 6 months after treatment tended to be younger and unmarried and have lower incomes.
Patients with higher T tumor stages (T3-T4) had a greater likelihood of continued opioid use at 3 months (OR = 2.64; 95% CI, 1.48-4.71). Those less likely to remain on opioids at 3 months included patients aged 70 to 74 years (OR = 0.7; 95% CI, 0.41-1.17) and those aged 75 years or older (OR = 0.39; 95% CI, 0.23-0.67).
Patients prescribed opioids prior to treatment appeared at greater risk for continued opioid use at 3 months (OR = 3.84; 95% CI, 2.45-5.91) and at 6 months (OR = 3.56; 95% CI, 1.95-6.5) after treatment, as did patients who used tobacco (3 months, OR = 2.23; 95% CI, 1.06-4.71; 6 months, OR = 3.84; 95% CI, 1.44-10.24).
Researchers noted that those prescribed oxycodone as their initial opioid appeared least likely to continue opioid use at 3 months (OR = 0.33; 95% CI, 0.17-0.62) and at 6 months (OR = 0.26; 95% CI, 0.1-0.67).
“We don’t know why this is the case, but we think that maybe patients know the word ‘oxycodone’ and are more aware of the potential for addiction than they might be if prescribed a less well-known drug or one they consider less dangerous, like hydrocodone,” McDermott said in the press release.
McDermott hypothesized that because the risk for opioid misuse is higher in younger patients and the SEER-Medicare database includes data from mostly older patients, the actual number of patients misusing opioids may be higher than the current study suggests.
She noted that the goal of the current study is to better understand opioid dependence in this population and find strategies to help patients.
“If a patient needed opioids for pain, I wouldn’t keep them away, but especially if they have risk factors, I might counsel them more about the risks [for] addiction and misuse, and keep an eye on it,” she said in the press release. – by Jennifer Byrne
Disclosures: The researchers report no relevant financial disclosures.
Perspective
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John Pang, MD
This valuable study examined the risk for acute and chronic opioid use in a large cohort of patients undergoing treatment for oral and oropharynx cancer. The authors were interested in a primary outcome of opioid use between treatment start date and 3 months after treatment, as well as secondary outcomes of continued opioid use at the 3-month and 6-month posttreatment marks.
Eighty-three percent of patients received an opioid prescription during the treatment period, compared with 15.4% exhibiting continued use at 3 months and 7% exhibiting continued use at 6 months. The authors appropriately used multivariable logistic regression to control for confounders and found that pretreatment opioid use was significantly associated with increased likelihood of opioid use during and after treatment — both at 3 and 6 months posttreatment. Tobacco use also appeared correlated with opioid use at 3 and 6 months. Interestingly, use of oxycodone was associated with one-third of the risk for opioid use at 3 months and one-quarter of the risk for opioid use at 6 months, compared with hydrocodone.
This study’s strength is in its large sample size compared with prior studies of patients with head and neck cancer and opioid use, which allowed authors to adhere to strict eligibility criteria. They did find a lower incidence of opioid use at 3 months than two prior studies that had smaller populations. One of these studies was restricted to surgery patients exclusively, in which more than 99% of patients received an opioid prescription after surgery. It may very well be that surgery and a de facto opioid prescription carries a greater long-term risk than nonsurgical therapy with opioids given on an as-needed basis.
It cannot be overemphasized that opioids have not been shown to be effective for chronic pain, and, thus, the perception that a patient on opioids is a patient with adequately controlled pain is of questionable accuracy.
The author’s findings add credence to the growing body of literature that has identified patients who are at risk for chronic opioid use — those with prior opioid use and tobacco use, among other risk factors. When providers prescribe opioids to patients as “something for the pain” before they start treatment, they should know they are increasing the likelihood of chronic use two- to fourfold. We must be cognizant that between 1 in 7 to one-half of patients with head and neck cancer will develop long-term use. Increasingly, the evidence suggests that patients with identifiable risk factors for chronic use should have a tailored and multimodal analgesic regimen in place prior to starting treatment.
References:
Lee JS, et al. J Clin Oncol. 2017;doi:10.1200/JCO.2017.74.1363.
Pang J, et al. JAMA Otolaryngol Head Neck Surg. 2017;doi: 10.1001/jamaoto.2017.0582.
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