Advertisement

Decreasing Trends in Opioid Prescribing on Discharge to Hospice Care

      Abstract

      Context

      There are concerns that policies aimed to prevent opioid misuse may unintentionally reduce access to opioids for patients at end-of-life.

      Objective

      We assessed trends in opioid prescribing among patients on discharge from the hospital to hospice care.

      Methods

      This was a retrospective cohort study among adult (age ≥18 years) patients discharged from a 544-576 bed, academic medical center to hospice care between January 1, 2010 to December 31, 2018. Study data were collected from a repository of patients’ electronic health record data. Our primary outcome was the frequency of opioid prescribing on discharge to hospice care. Our primary exposure was the calendar year of discharge. We also investigated non-opioid analgesic prescribing and stratified opioid prescribing trends by patient characteristics (e.g., demographics, cancer diagnosis, and location of hospice care).

      Results

      Among 2,648 discharges to hospice care, mean (standard deviation) age was 65.8 (16.0) years, 46.3% were female, and 58.7% had a cancer diagnosis. Opioid prescribing on discharge to hospice care decreased significantly from 91.2% (95% confidence interval (CI) = 87.1%–94.1%) in 2010 to 79.3% (95% CI = 74.3%–83.5%) in 2018 adjusting for age, sex, cancer diagnosis, and location of hospice care. Prescribing of non-opioid analgesic medications increased over the same time period.

      Conclusions

      We observed a statistically significant decreasing trend in opioid prescribing on discharge to hospice care. Further research should aim to confirm these findings and to identify opportunities to ensure optimal pain management among patients transitioning to hospice care.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Pain and Symptom Management
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Groninger H
        • Vijayan J.
        Pharmacologic management of pain at the end of life.
        Am Fam Physician. 2014; 90: 26-32
        • Smith AK
        • Cenzer IS
        • Knight SJ
        • et al.
        The epidemiology of pain during the last 2 years of life.
        Ann Intern Med. 2010; 153: 563-569
        • Costantini M
        • Ripamonti C
        • Beccaro M
        • et al.
        Prevalence, distress, management, and relief of pain during the last 3 months of cancer patients' life. Results of an Italian mortality follow-back survey.
        Ann Oncol. 2009; 20: 729-735
        • Black B
        • Herr K
        • Fine P
        • et al.
        The relationships among pain, nonpain symptoms, and quality of life measures in older adults with cancer receiving hospice care.
        Pain Med. 2011; 12: 880-889
        • Katz N.
        The impact of pain management on quality of life.
        J Pain Symptom Manage. 2002; 24: S38-S47
        • Sera L
        • McPherson ML
        • Holmes HM.
        Commonly prescribed medications in a population of hospice patients.
        Am J Hospice Palliat Care. 2014; 31: 126-131
        • van den Beuken-van Everdingen MH
        • Hochstenbach LM
        • Joosten EA
        • Tjan-Heijnen VC
        • Janssen DJ.
        Update on prevalence of pain in patients with cancer: systematic review and meta-analysis.
        J Pain Symptom Manage. 2016; 51: 1070-90 e9
        • Weiss SC
        • Emanuel LL
        • Fairclough DL
        • Emanuel EJ.
        Understanding the experience of pain in terminally ill patients.
        Lancet. 2001; 357: 1311-1315
        • Lau DT
        • Kasper JD
        • Hauser JM
        • et al.
        Family caregiver skills in medication management for hospice patients: a qualitative study to define a construct.
        J Gerontol. 2009; 64: 799-807
        • Letizia M
        • Creech S
        • Norton E
        • Shanahan M
        • Hedges L.
        Barriers to caregiver administration of pain medication in hospice care.
        J Pain Symptom Manage. 2004; 27: 114-124
        • Tjia J
        • Ellington L
        • Clayton MF
        • Lemay C
        • Reblin M.
        Managing medications during home hospice cancer care: the needs of family caregivers.
        J Pain Symptom Manage. 2015; 50: 630-641
        • Florence CS
        • Zhou C
        • Luo F
        • Xu L.
        The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013.
        Med Care. 2016; 54: 901-906
        • Hedegaard H
        • Miniño AM
        • Warner M.
        Drug overdose deaths in the United States, 1999–2017.
        National Center for Health Statistics, NCHS Data Brief, no 329 Hyattsville, MD2018 (Available from:)
        • Merlin JS
        • Young SR
        • Arnold R
        • et al.
        Managing opioids, including misuse and addiction, in patients with serious illness in ambulatory palliative care: a qualitative study.
        Am J Hosp Palliat Care. 2020; 37: 507-513
        • Merlin JD, A.
        • Tulsky J.
        Health affairs.
        2019 ([cited 2021]. Available from:)
        • National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Board on Health Care Services
        Pain management for people with serious illness in the context of the opioid use disorder epidemic: proceedings of a workshop. National Academies Press, Washington, DC2019 (Available from:)
        • Dowell D
        • Haegerich T
        • Chou R.
        No shortcuts to safer opioid prescribing.
        N Engl J Med. 2019; 380: 2285-2287
        • Haegerich TM
        • Jones CM
        • Cote PO
        • Robinson A
        • Ross L.
        Evidence for state, community and systems-level prevention strategies to address the opioid crisis.
        Drug Alcohol Depend. 2019; 204107563
        • Furuno JP
        • Noble BN
        • Horne KN
        • et al.
        Frequency of outpatient antibiotic prescription on discharge to hospice care.
        Antimicrob Agents Chemother. 2014; 58: 5473-5477
        • Kadoyama KL
        • Noble BN
        • Izumi S
        • et al.
        Frequency and documentation of medication decisions on discharge from the hospital to hospice care.
        J Am Geriatr Soc. 2019; 67: 1258-1262
        • Kowalewska CA
        • Noble BN
        • Fromme EK
        • McPherson ML
        • Grace KN
        • Furuno JP.
        Prevalence and clinical intentions of antithrombotic therapy on discharge to hospice care.
        J Palliat Med. 2017; 20: 1225-1230
        • Centers for Disease Control and Prevention
        CDC guideline for prescribing opioids for chronic pain.
        2019 (Available from:)
        • Kral L
        • Ku J
        • Kematick BS
        • Fudin J.
        Pearls for opioid use in seriously ill patients.
        J Pain Palliat Care Pharmacother. 2019; 33: 54-58
        • Wickham H.
        ggplot2: elegant graphics for data analysis.
        Springer-Verlag, New York2016
        • Kassambra A.
        ggpubr: 'ggplot2′ based publication ready plots.
        2020 (Available from:)
        • R Core Team
        R: A language and environment for statistical Computing Vienna, Austria.
        2020 (Available from:)
        https://www.R-project.org/
        Date accessed: May 10, 2021
      1. Word Health Organization. WHO's cancer pain ladder for adults. Available from: https://www.who.int/cancer/palliative/painladder/en/. Accessed 1 August 2020.

        • Caraceni A
        • Hanks G
        • Kaasa S
        • et al.
        Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC.
        Lancet Oncol. 2012; 13: e58-e68
        • McNicol E
        • Strassels SA
        • Goudas L
        • Lau J
        • Carr DB.
        NSAIDS or paracetamol, alone or combined with opioids, for cancer pain.
        Cochrane Database Syst Rev. 2005; CD005180
        • McNicol ED
        • Midbari A
        • Eisenberg E.
        Opioids for neuropathic pain.
        Cochrane Database Syst Rev. 2013; CD006146
        • Wiffen PJ
        • Wee B
        • Derry S
        • Bell RF
        • Moore RA.
        Opioids for cancer pain - an overview of Cochrane reviews.
        Cochrane Database Syst Rev. 2017; 7CD012592
        • Maltoni M
        • Scarpi E
        • Modonesi C
        • et al.
        A validation study of the WHO analgesic ladder: a two-step vs three-step strategy.
        Support Care Cancer. 2005; 13: 888-894
        • Izumi S
        • Noble BN
        • Candrian CB
        • et al.
        Health care worker perceptions of gaps and opportunities to improve hospital-to-hospice transitions.
        J Palliat Med. 2019;
        • Centers for Medicare & Medicaid Services
        Hospice quality reporting program-current measures.
        2019 (Available from:)
        • Blackhall LJ
        • Alfson ED
        • Barclay JS.
        Screening for substance abuse and diversion in Virginia hospices.
        J Palliat Med. 2013; 16: 237-242
        • Kneuss TG
        • Protus BM
        • Lovell AG
        • Kullgren JG.
        State legislation to prevent diversion of opioids in hospice programs: a deeper look into ohio law.
        J Hosp Palliat Nurs. 2019; 21: 365-372
        • Sacco P
        • Cagle JG
        • Moreland ML
        • Camlin EAS.
        Screening and assessment of substance use in hospice care: examining content from a national sample of psychosocial assessments.
        J Palliat Med. 2017; 20: 850-856
      2. Substance use-disorder prevention that promotes opioid recovery and treatment for patients and communities act, 115th congress.
        2018
      3. Oregon Health Authority. Opioid overdose and misuse. prescribing and overdose data for oregon. Available from: https://www.oregon.gov/oha/ph/preventionwellness/substanceuse/opioids/pages/data.aspx. Accessed 1 November 2019.

      4. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. U.S. opioid dispensing rate. maps. Available from: https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html. Accessed 1 August 2020.

        • National Hospice and Palliative Care Organization
        Facts and figures.
        2020 ([cited 2020 2/1/2021]. Available from:)
        • Furuno JPN
        • Noble B.N.
        • McPherson M.L.
        • et al.
        Variation in hospice patient and admission characteristics by referral location.
        Med Care. 2020; 58: 1069-1074