Advertisement

Has Declining Opioid Dispensing to Cancer Patients Been Tailored to Risk of Opioid Harms?

      Abstract

      Context

      Opioid prescribing to cancer patients is declining, but it is unknown whether reductions have been tailored to those at highest risk of opioid-related harms.

      Objectives

      Examine whether declines in opioid dispensing to patients receiving active cancer treatment are sharper in patients with substance use disorder (SUD) or mental health diagnoses.

      Methods

      We used 2008–2018 national, commercial healthcare claims data to examine adjusted and unadjusted trends in opioid dispensing (receipt of ≥1 fill; average daily dosage; receipt of high-dose opioids; receipt of concurrent opioids and benzodiazepines) to patients ages ≥18 receiving treatment for one of four cancer types (breast; colorectal; head and neck; sarcoma; N = 324,789 patients). To compare declines across subgroups with varying risk of opioid-related harms, we stratified by SUD and mental health diagnosis. To address potential confounding, we estimated subgroup-specific trends using generalized estimating equations, adjusting for covariates.

      Results

      Across groups, rate of ≥1 opioid fill per quarter fell 32.5% (95% CI: 31.8%–33.2%) from 2008 to 2018; daily dose among those receiving opioids fell 37.6% (95% CI: 36.7%–38.6%). In most cases, these declines were not sharper in subgroups at greater risk of opioid-related harms. For example, patients with opioid use disorder experienced the smallest declines in dispensing frequency, and there was no evidence that declines were sharper in patients with mental health diagnoses.

      Conclusion

      Sharp declines in opioid prescribing during the drug overdose crisis have affected a wide range of patients undergoing cancer treatment and may not have been sufficiently tailored to patient characteristics. Research on implications for opioid-related harms and pain management is needed.

      Key Words

      SUD (substance use disorder)
      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

        • Mauri AI
        • Townsend TN
        • Haffajee RL.
        The association of state opioid misuse prevention policies with patient- and provider-related outcomes: a scoping review.
        Milbank Q. 2020; 98 (1468-0009.12436): 57-105
        • Dowell D
        • Zhang K
        • Noonan RK
        • Hockenberry JM.
        Mandatory provider review and pain clinic laws reduce the amounts of opioids prescribed and overdose death rates.
        Health Affairs. 2016; 35: 1876-1883
        • Davis CS
        • Lieberman AJ.
        Laws limiting prescribing and dispensing of opioids in the United States, 1989-2019.
        Addiction. 2020; : 15359
        • Chidgey BA
        • McGinigle KL
        • McNaull PP
        When a vital sign leads a country astray—the opioid epidemic.
        JAMA Surg. 2019; 154: 987
        • Guy GP
        • Zhang K
        • Bohm MK
        • et al.
        Vital signs: changes in opioid prescribing in the United States, 2006–2015.
        MMWR Morb Mortal Wkly Rep. 66. 2017: 697-704
        • Page R
        • Blanchard E.
        Opioids and cancer pain: patient needs and access challenges.
        JOP. 2019; (225–225)
        • Agarwal A
        • Roberts A
        • Dusetzina SB
        • Royce TJ.
        Changes in opioid prescribing patterns among generalists and oncologists for Medicare part D beneficiaries from 2013 to 2017.
        JAMA Oncol. 2020; 6: 1271
      1. Chou R, Wagner J, Ahmed AY, Blazina I, Brodt E, Buckley DI, et al. Treatments for acute pain: A systematic review [Internet]. Agency for Healthcare Research and Quality (AHRQ); 2020 Dec [Accessed January 26, 2021]. Available from: https://effectivehealthcare.ahrq.gov/products/treatments-acute-pain/research

        • Dowell D
        • Haegerich TM
        • Chou R.
        CDC guideline for prescribing opioids for chronic pain—United States, 2016.
        JAMA. 2016; 315: 1624
        • Greco MT
        • Roberto A
        • Corli O
        • et al.
        Quality of cancer pain management: An update of a systematic review of undertreatment of patients with cancer.
        J Clin Oncol. 2014; 32: 4149-4154
        • Enzinger AC
        • Ghosh K
        • Keating NL
        • et al.
        • 2021 Sep 10;39(26):2948-2958.
        US trends in opioid access among patients with poor prognosis cancer near the end-of-life.
        J Clin Oncol. 2021; 39: 2948-2958
        • Schatz AA
        • Oliver TK
        • Swarm RA
        • et al.
        Bridging the gap among clinical practice guidelines for pain management in cancer and sickle cell disease.
        J Natl Compr Cancer Netw. 2020; 18: 392-399
        • Paice JA
        • Portenoy R
        • Lacchetti C
        • et al.
        Management of chronic pain in survivors of adult cancers.
        Am Soc Clin Oncol Clin Practice Guideline. 2016; 34: 3325-3345
        • Yusufov M
        • Braun IM
        • Pirl WF.
        A systematic review of substance use and substance use disorders in patients with cancer.
        Gen Hosp Psychiatry. 2019; 60: 128-136
        • Dev R
        • Haider A.
        Alcohol, tobacco, and substance use and association with opioid use disorder in patients with non-malignant and cancer pain: a review.
        Curr Anesthesiol Rep. 2020; 10: 388-395
        • Bohnert ASB
        • Valenstein M
        • Bair MJ
        Association between opioid prescribing patterns and opioid overdose-related deaths.
        JAMA. 2011; 305: 7
        • van den Beuken-van Everdingen MHJ
        • Hochstenbach LMJ
        • Joosten EAJ
        • Tjan-Heijnen VCG
        • Janssen DJA.
        Update on prevalence of pain in patients with cancer: systematic review and Meta-Analysis.
        J Pain Symptom Manage. 2016; 51 (e9): 1070-1090
      2. University of Michigan Institute for Healthcare Policy and Innovation. OptumInsight data seminar. 2016.

        • Jeffery MM
        • Hooten WM
        • Henk HJ
        • et al.
        Trends in opioid use in commercially insured and Medicare advantage populations in 2007-16: retrospective cohort study.
        BMJ. 2018; 362: k2833
      3. NYU Langone Health. Getting started with the institutional review board submission process. 2020. Available at: https://med.nyu.edu/research/office-science-research/clinical-research/resources-researchers-study-teams/institutional-review-board-operations/getting-started-the-irb-submission-process#determine-if-your-project-is-human-subjects-research. Accessed November 29, 2020.

      4. National Cancer Institute Surveillance, Epidemiology, and end results program. Cancer Stat Facts [Internet]. 2020 [Accessed December 29, 2020]. Available from: https://seer.cancer.gov/statfacts/

      5. American Cancer Society. Cancer facts & figures 2020. Atlanta; 2020 p. 76.

      6. National Comprehensive Cancer Network. NCCN guidelines [Internet]. 2020 [Accessed August 31, 2020]. Available from: https://www.nccn.org/professionals/physician_gls/default.aspx#site

        • Nordstrom BL
        • Whyte JL
        • Stolar M
        • Mercaldi C
        • Kallich JD.
        Identification of metastatic cancer in claims data.
        Pharmacoepidemiol Drug Saf. 2012; 21: 21-28
        • Elixhauser A
        • Steiner C
        • Harris DR
        • Coffey RM.
        Comorbidity measures for use with administrative data.
        Med Care. 1998; 36: 8-27
        • Larochelle MR
        • Zhang F
        • Ross-Degnan D
        • Wharam JF.
        Rates of opioid dispensing and overdose after introduction of abuse-deterrent extended-release oxycodone and withdrawal of propoxyphene.
        JAMA Intern Med. 2015; 175: 978
        • Substance Abuse and Mental Health Services Administration
        Managing chronic pain in adults with or in recovery from substance use disorders [Internet].
        Substance Abuse and Mental Health Services Administration, Rockville, MD2011: 128 (Treatment Improvement Protocol (TIP) Series 54. HHS Publication No. (SMA) 12-4671). Available from:
        • Voon P
        • Karamouzian M
        • Kerr T.
        Chronic pain and opioid misuse: a review of reviews.
        Subst Abuse Treat Prev Policy. 2017; 12: 36
        • Goesling J
        • Lin LA
        • Clauw DJ.
        Psychiatry and pain management: at the intersection of chronic pain and mental health.
        Curr Psychiatry Rep. 2018; 20: 12
        • Brown JH
        • Torres HP
        • Maddi RD
        • et al.
        Cancer patients’ perceived difficulties filling opioid prescriptions after receiving outpatient supportive care.
        J Pain Symptom Manage. 2020; 60: 915-922
        • Fowler JF
        • Lindstrom MJ.
        Loss of local control with prolongation in radiotherapy.
        Int J Radiat Oncol Biol Phys. 1992; 23: 457-467
        • Petereit DG
        • Sarkaria JN
        • Chappell R
        • et al.
        The adverse effect of treatment prolongation in cervical carcinoma.
        Int J Radiat Oncol Biol Phys. 1995; 32: 7
        • Chino F
        • Kamal A
        • Chino J.
        Incidence of opioid-associated deaths in cancer survivors in the United States, 2006-2016: a population study of the opioid epidemic.
        JAMA Oncol [Internet]. 2020; ([Accessed May 8, 2020]; Available from:)
        • Agnoli A
        • Xing G
        • Tancredi DJ
        • Magnan E
        • Jerant A
        • Fenton JJ.
        Association of dose tapering with overdose or mental health crisis among patients prescribed long-term opioids.
        JAMA. 2021; 326: 411
        • Martins SS
        • Ponicki W
        • Smith N
        • et al.
        Prescription drug monitoring programs operational characteristics and fatal heroin poisoning.
        Int J Drug Policy. 2019; 74: 174-180
      7. Alpert A, Powell D, Pacula RL. Supply-side drug policy in the presence of substitutes: Evidence from the Introduction of Abuse-Deterrent Opiods.:60.

        • Evans WN
        • Lieber EMJ
        • Power P.
        How the reformulation of OxyContin ignited the heroin epidemic.
        Rev Econ Stat. 2019; 101: 1-15
        • Ali MM
        • Dowd WN
        • Classen T
        • Mutter R
        • Novak SP.
        Prescription drug monitoring programs, nonmedical use of prescription drugs, and heroin use: Evidence from the National Survey of Drug Use and Health.
        Addict Behav. 2017; 69: 65-77
        • Beheshti D.
        Adverse health effects of abuse-deterrent opioids: Evidence from the reformulation of OxyContin.
        Health Econ. 2019; 28: 1449-1461
        • Ciccarone D.
        The triple wave epidemic: Supply and demand drivers of the US opioid overdose crisis.
        Int J Drug Policy. 2019; 71: 183-188
        • Chua IS
        • Leiter RE
        • Brizzi KT
        • et al.
        US national trends in opioid-related hospitalizations among patients with cancer.
        JAMA Oncol. 2019; 5: 734