Racial, ethnic disparities observed in opioid access among older patients dying of cancer
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Researchers identified substantial racial and ethnic disparities in access to prescription opioids among older patients with cancer nearing end of life, according to study results published in Journal of Clinical Oncology.
The disparities persisted over time and socioeconomic variables did not appear to mediate them, researchers noted.
Rationale and methods
Most research on cancer pain-management inequities occurred before recognition of the full scope of the opioid crisis and establishment of regulations to curb opioid prescribing, Andrea C. Enzinger, MD, oncologist in the department of medical oncology at Dana-Farber Cancer Institute, said in a press release.
“Over the past decade, there has been a seismic shift in prescribing practices and sharp declines in access to these medications for patients with cancer,” Enzinger said in the release. “But we know very little about the current state of disparities in access in this environment of increased regulation, and about the magnitude of disparities among patients with terminal cancer.”
For this reason, researchers sought to examine racial and ethnic disparities and trends in opioid prescription orders between 2007 and 2019 among 318,549 Medicare recipients (mean age, 77.6 years; 86% white, 9% Black and 5% Hispanic) with poor-prognosis cancers and nearing the end of life.
Researchers also assessed disparities in urine drug screening among these patients.
Findings
Compared with white patients, Black patients and Hispanic patients had a lower likelihood of receiving any opioid (Black patients, 4.3 percentage points; 95% CI, 4.8 to 3.6; Hispanic patients, 3.6 percentage points; 95% CI, 4.4 to 2.9) and long-acting opioids (Black, 3.1 percentage points ; 95% CI, 3.6 to 2.8; Hispanic, 2.2%; 95% CI, 2.7 to 1.7).
Black patients also received lower daily doses of opioids (10.5 morphine milligram equivalents per day [MMED]; 95% CI, 12.8 to 8.2), followed by Hispanic patients (9.1; 95% CI, 12.1 to 6.1), and lower total doses (210 MMEs; 95% CI, 293 to 207), followed by Hispanic patients (179; 95% CI, 217 to 142), compared with white patients.
Of note, researchers found that Black patients had a higher likelihood of undergoing urine drug screening (0.5 percentage points; 95% CI, 0.3-0.8) than any other race/ethnicity.
“We were unable to determine the causes of the inequities, but our findings of inequities in urine drug testing hint toward racial bias and discrimination,” Enzinger told Healio. “Structural racism likely plays a role in the observed findings.”
Limitations of the study included the assessment of opioid prescription refills and not unfulfilled prescriptions, lack of examination of opioid prescriptions on hospice, and that the findings only represent Medicare beneficiaries and are likely conservative estimates of prescribing disparities, researchers noted.
Implications
Concerted efforts are needed to address the various potential causes of inequities identified in the study, and will likely need to target patients, providers, insurance companies, pharmacies and state-level policies to reduce barriers and promote equitable access, Enzinger told Healio.
“Our team is doing more research to try to understand whether these findings extend to other populations, such as younger patients and those with commercial insurance, as well as those in other stages in cancer care,” Enzinger said. “We are additionally planning follow-up studies to examine mechanisms and understand the most potent drivers of inequities in opioid pain management, so that we can then design interventions that have the greatest chance of making a difference.”
References:
- Enzinger AC, et al. J Clin Oncol. 2023;doi:10.1200/JCO.22.01413.
- Study finds racial inequities in access to opioids among older patients with cancer near end of life (press release). Available at: www.dana-farber.org/newsroom/news-releases/2023/study-finds-racial-inequities-in-access-to-opioids-among-older-patients-with-cancer-near-end-of-life. Published Jan. 10, 2023. Accessed Jan. 10, 2023.
For more information:
Andrea C. Enzinger, MD, can be reached at andrea_enzinger@dfci.harvard.edu.
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