Opioid regulations may result in poorer pain management for people with terminal cancer
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Opioid use among people dying of cancer declined substantially from 2007 to 2017, according to study results published in Journal of Clinical Oncology.
Pain-related ED visits among this population increased during the same period, suggesting end-of-life pain management may be worsening, researchers concluded.
“The opioid crisis in the United States prompted regulators, health care providers and insurers to enact a variety of measures to curb the inappropriate prescribing of these medications,” Andrea C. Enzinger, MD, medical oncologist and member of the population sciences department at Dana-Farber Cancer Institute, said in an institution-issued press release. “[Although] these efforts have had their intended effect of reducing overall rates of opioid prescribing in the past decade, our findings indicate that the restrictions may be inadvertently depriving patients with advanced cancers of medicines they need to control their pain near the end of life.”
Enzinger and colleagues used Medicare Part D data to examine trends in opioid prescriptions filled and opioid potency (morphine milligram equivalents per day) among people with cancer near the end of life, which researchers defined as the 30 days before death or hospice enrollment. Investigators also used administrative claims to evaluate trends in pain-related ED visits.
The analysis included 270,632 Medicare beneficiaries aged 66 years or older who died with poor-prognosis cancers between 2007 and 2017. The most common diagnoses included lung cancer (34.2%), colorectal or anal cancer (8.4%), pancreatic cancer (8.1%), breast cancer (6.6%) and prostate cancer (6.6%).
The percentage of individuals who received at least one opioid prescription near the end of life declined from 42% in 2007 to 35.5% in 2017 (relative percent difference [RPD], 15.5%). The percentage who received at least one long-acting opioid prescription declined from 18.1% to 11.5% during that same period (RPD, 36.5%).
The total amount of opioids prescribed per person near end of life — averaged across those who did and did not receive an opioid — declined 38% during the study period, from 1,075 morphine milligram equivalents per person to 666 morphine milligram equivalents per person.
Mean daily dose fell by 24.5%, from 85.6 morphine milligram equivalents per person to 64.6 morphine milligram equivalents per person.
The percentage of patients with pain-related ED visits increased from 13.2% (95% CI, 12.7 to 13.6) in 2007 to 19.9% (95% CI, 19.4 to 20.4) in 2017 (RPD, 50.8%).
Sensitivity analyses revealed similar declines in opioid utilization in the 60-day and 90-day periods prior to hospice or death. This observation suggests secular trends in hospice utilization did not confound trends in opioid access, researchers wrote.
“Opioids are the cornerstone of managing moderate to severe cancer pain,” Enzinger said. “Yet we know that undertreatment of cancer pain is a major problem in the U.S., and many patients with advanced-stage cancers only receive mild analgesics, which are completely inadequate for the very severe pain that they experience. Opioid regulations may exacerbate the heartbreaking problem of undertreatment of cancer pain at the end of life.”
References:
Enzinger AC, et al. J Clin Oncol. 2021;doi:10.1200/JCO.21.00476.
Dana-Farber Cancer Institute. Study finds signs of worsening pain management for patients with terminal cancer. www.dana-farber.org/newsroom/news-releases/2021/study-finds-signs-of-worsening-pain-management-for-patients-with-terminal-cancer/ Published July 22, 2021. Accessed Oct. 3, 2021.
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