Persistent opioid use common among adolescents, young adults after sarcoma treatment
Click Here to Manage Email Alerts
Adolescents and young adults with sarcoma prescribed opioids for pain often continued using those substances after treatment completion, according to study results published in Cancer.
Approximately two-thirds of adolescents and young adults (AYAs) received prescriptions for opioids during cancer treatment. Nearly one-quarter of AYAs who used opioids during sarcoma treatment met criteria for new persistent opioid use after completing cancer therapy.
“Opioid use was expectedly high, given that most of these patients undergo intense multimodal treatment,” Melissa P. Beauchemin, PhD, RN, CPNP-PC, CPON, director of the NCI-Community Oncology Research Program at Herbert Irving Comprehensive Cancer Center at Columbia University and assistant professor at Columbia University School of Nursing, told Healio. “In our study, Medicaid insurance, bone tumors compared with soft tissue sarcomas, and concurrent lorazepam use were associated with new persistent use.”
Background and methodology
AYAs with sarcoma often develop acute and chronic pain due to their disease and the treatments they receive.
Prior research showed high risk for persistent opioid use after cancer therapy among previously opioid-naive older adults, according to study background.
Beauchemin and colleagues aimed to describe patterns of new persistent opioid use among AYAs treated for sarcoma. They defined persistent opioid users as previously opioid-naive patients who filled at least one opioid prescription during active therapy and at least two opioid prescriptions in the year after therapy completion.
Researchers also assessed the association between insurance type and opioid use.
Beauchemin and colleagues used the IBM Marketscan Database to identify patients aged 10 to 26 years diagnosed with sarcoma between 2008 and 2016 who had not used opioids in the period 365 days to 31 days prior to their first treatment.
Their analysis included 938 patients (55.6% men; 62% aged younger than 18 years) with an International Classification of Diseases code for sarcoma. All patients received anticancer therapy — chemotherapy, surgery and/or radiation — within 30 days of the initial diagnosis code and had continuous insurance coverage (78% commercial, 22% Medicaid) for more than 12 months prior to diagnosis and more than 12 months after their final therapy.
Twenty-nine percent of patients had a mental health diagnosis before or during the treatment period.
Key findings
A majority (64%) of patients received opioid prescriptions during sarcoma treatment.
Half (49%) of patients used opioids only during treatment.
Nearly one-quarter (23%) of those who used opioids during treatment received at least two prescriptions in the year following therapy.
Multivariable analysis showed non-soft tissue sarcoma type (Ewing sarcoma, OR = 3.23; 95% CI, 1.81-5.78; osteosarcoma, OR = 2.05; 95% CI, 1.36-3.09) and insurance type (Medicaid vs. commercial, OR = 1.74; 95% CI, 1.15-2.64) appeared associated with increased likelihood of persistent opioid use.
“Medicaid insurance may be a proxy for other social determinants of poorer health, including access to quality health care, education level and social support networks,” Beauchemin told Healio.
Patients with a mental health diagnosis exhibited a higher likelihood of persistent opioid use than those without (21% vs. 12%; P < .01). Concomitant use of lorazepam — often used as an antiemetic for chemotherapy-induced nausea — also appeared significantly associated with persistent opioid use (OR = 3.38; 95% CI, 2.26-5.05).
Implications
The results highlight an urgent need for age-appropriate education and guidance for AYAs, as well as development of novel pain management strategies to limit long-term negative effects of opioid use, researchers concluded.
Future studies should focus on managing pain among AYAs undergoing treatment while developing ways to limit or discontinue opioid use safely and early to reduce misuse, Beauchemin said.
“Psychosocial screening and targeted interventions should be developed for AYAs, including close monitoring and provision of anticipatory guidance for AYAs and their family members,” Beauchemin told Healio. “Generations of new knowledge around opioid use in AYAs, and potential strategies to mitigate long-term misuse, will help to inform development of clinical practice guidelines to support evidence-based clinical decision-making.”
For more information:
Melissa P. Beauchemin, PhD, RN, CPNP-PC, CPON, can be reached at Columbia University Mailman School of Nursing, 560 W. 168th St. 634, New York, NY 10032; email: mmp2123@cumc.columbia.edu.
Perspective
Back to Top
Kyle Neale, DO
The management of chronic pain after cancer treatment is complex. It requires a biopsychosocial approach to navigate fears of recurrence, impaired functional status, and opioid use and misuse. In the AYA cancer survivor population, it is even less well-understood. Most guidelines on chronic pain management exclude pediatric populations and robust evidence for this vulnerable survivor population is scarce.
The authors’ findings that patients with a mental health diagnosis, concomitant lorazepam use, new diagnosis of substance use during treatment or Medicaid insurance had positive associations with persistent opioid use is not surprising. What once was referred to by the euphemism “chemical coping” is now better understood as undertreated pain. Palliative health care workers are familiar with the concept of “total pain” as defined by Dame Cicely Saunders: suffering that includes physical, psychological, social, spiritual and emotional distress.
AYA cancer survivors continue to receive more opioid prescriptions than their peers who did not have cancer. Overall, the number of opioid prescriptions nationally has decreased; however, this prescribing disparity still exposes the AYA cancer survivor to increased risks for opioid-related adverse effects, including risky opioid use.
So what to do? The use of procedure-specific multimodal strategies perioperatively has been shown to reduce opioid use, total cost and hospital stays in the adult cancer population. Effectively treating pain without introducing opioids can reduce long-term risk by minimizing initial exposure.
Further education on the goal of pain management being primarily improved function and not necessarily the elimination of pain also may be helpful. This can prove difficult for clinicians who are sympathetic to the plight of their patients. I’ve been there. But I believe they will feel supported if they have access to providing their patients with robust multidisciplinary support: spiritual care, physical therapy and rehabilitation, social work and psycho-oncology. This isn’t always the case. More research will bolster our case for this approach to hospital administrations.
Collapse
Read more about
Click Here to Manage Email Alerts