Study finds signs of worsening pain management for patients with terminal cancer

In a sign that pain management for patients dying of cancer is worsening, a new study by Dana-Farber Cancer Institute investigators has found a sharp decline in opioid access among these patients over a recent 10-year period, even as many more of them turned to hospital emergency rooms for pain treatment.

The findings, in a paper published online today by the Journal of Clinical Oncology, suggest that efforts to counter the ongoing epidemic of opioid abuse may have had the unintended effect of reducing terminally ill cancer patients’ access to these critically needed pain medications.

The study drew on data for 270,632 Medicare patients with poor prognosis cancers who died between 2007 and 2017. Investigators analyzed the data for trends in opioid prescriptions written within 30 days of patients’ death or enrollment in hospice care.

Over the study period the researchers found a 34% reduction in the number of opioid prescriptions filled per patient and a 38% reduction in the total dose of opioids filled per patient near the end of their lives. The researchers found a particularly steep decline in use of long-acting opioids, which provide more predictable, steady pain relief and are important for managing severe cancer pain. Between 2007-2017, the number of long-acting opioid prescriptions filled per patient fell by 50%.

At the same time that patients dying of cancer were filling fewer opioid prescriptions, the proportion of these patients who visited hospital emergency departments for pain rose 50.8%. These findings suggest that many patients may be forced to seek care in emergency departments because they lack access to necessary opioid pain medications at home, the study authors say.

“The opioid crisis in the United States prompted regulators, healthcare providers, and insurers to enact a variety of measures to curb the inappropriate prescribing of these medications,” says Andrea Enzinger, MD, a medical oncologist specializing in gastrointestinal cancers and a member of the Population Sciences Department at Dana-Farber Cancer Institute, the first author of the new study. “While 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.

“Opioids are the cornerstone of managing moderate to severe cancer pain,” she continues. “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.”

“Policies have focused largely on reducing inappropriate prescribing, which is useful, but they are a blunt instrument. New regulations have made it very cumbersome and time-consuming to prescribe opioids, even for patients with cancer. Pharmacies and insurance companies have also added further barriers that make it difficult for patients to fill these prescriptions,” Enzinger remarks. “The safety aspect is important, but these additional barriers interfere with patients’ ability to access critical pain medication.”

Cultural biases and preconceptions also may be deterring patients with end-stage cancers from requesting and using opioids. “Many patients dying of cancer are living with high levels of pain that interfere with their ability to spend valuable time with their family because they’re afraid of becoming addicted. Some patients worry that using pain medications means they’re weak, are doing something immoral or wrong, or are disappointing their families – instead of simply getting adequate pain relief,” says the study’s senior author, Alexi Wright, MD, MPH, a medical oncologist and Director of Gynecologic Oncology Outcomes Research at Dana-Farber.

The irony is that restrictions designed to prevent opioid addiction are having a harmful effect on patients who, because they are within weeks or months of the end of life, need not be concerned about addiction. “Patients with end-stage cancer were not the intended targets of these restrictions,” Wright remarks. “This is a population of patients who everyone would agree should have access to opioids for pain relief.”

Although patients with end-stage cancer are exempt from many of the restrictions on opioid prescriptions, the challenges of obtaining and filling a prescription remain an obstacle for those whom the exemptions are intended to protect, she adds.

The findings point to the need for research into the causes of declines in opioid use documented in the study, investigators say, and whether certain populations, such as racial minorities, are disproportionately affected. Studies are also needed to determine whether opioid prescribing has changed during earlier phases of cancer care and if differences exist between patients with private health insurance and those covered by Medicaid.

“Solutions are needed at the policy level and within the insurance industry to reduce the burden of opioid regulations on patients with terminal cancer and to ensure they can obtain the pain relief they need,” Enzinger says.

The co-authors of the study are: Kaushik Ghosh, PhD, of the New England Bureau of Economic Research; Mary Beth Landrum, PhD, of Harvard Medical School; David M. Cutler, PhD, of the New England Bureau of Economic Research, Harvard Medical School, Harvard T.H. Chan School of Public Health, and the Department of Economics at Harvard University; and Nancy L. Keating, MD, MPH, of Harvard Medical School and Brigham and Women’s Hospital.

The study was funded by a grant from the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality.

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