Are Cancer Patients Getting the Opioids They Need to Control Pain?
, by NCI Staff
Oncologists and other doctors have been prescribing fewer opioid drugs for their older patients, a new study has found. From 2013 to 2017, the national opioid prescribing rate for Medicare beneficiaries declined by approximately 21% among oncologists and by 23% among all other doctors.
More research is needed to learn the precise reasons for these declines, but efforts to contain the opioid epidemic may have played a role, according to findings published in the Journal of the National Cancer Institute on August 12.
In response to the opioid epidemic, the study authors suggested, measures to make opioids harder to obtain may have prevented some patients from receiving appropriate prescriptions for opioids to manage cancer pain.
In the study, the declines were driven mainly by fewer prescriptions for hydrocodone-acetaminophen and long-acting opioids, including oxycodone (OxyContin). During the 5-year study period, oncologists and other doctors wrote more prescriptions for gabapentin, an alternative nonopioid medication. At the same time, there was a rise in the number of opioid prescriptions written by palliative care doctors, who are experts in managing pain.
“The findings raise concerns about whether opioid prescribing legislation and guidelines intended for the noncancer population are being applied inappropriately to patients with cancer and survivors,” Henry Park, M.D., of the Yale University School of Medicine and his colleagues wrote.
For more than a decade, various legislative and policy measures have been used to address the epidemic of opioid addiction in the United States, including guidelines from medical groups on opioid prescribing and the promotion of nonopioid pain medicines. But researchers have not known whether these approaches may have affected the ability of people with cancer to obtain opioid drugs.
“It appears that oncologists are not prescribing opioids as much as they did previously,” said Dr. Park, who co-led the study. “Future research needs to focus on whether opioid prescribing guidelines intended for patients without cancer are being applied inappropriately to patients who have had cancer.”
Strategies to Address an Epidemic
The researchers used Medicare claims data from the Centers for Medicare and Medicaid Services to compare pain medicine prescribing trends for older patients in the United States among oncologists and all other doctors. The data represented 21,041 oncologists and 723,861 non-oncologists (including 4,115 palliative care providers).
Among other findings, the investigators reported a 30% decrease in the prescribing of hydrocodone-acetaminophen by oncologists over the 5-year study period (2013 through 2017). Oxycodone prescribing declined by 33% among oncologists.
During this period, the rates of prescribing gabapentin increased by 5.9% among oncologists and 23.1% among other doctors. “Gabapentinoids are often seen as safe and effective alternatives to opioids, although evidence regarding their efficacy in treating cancer-related pain has been mixed,” the study team wrote.
Among palliative care providers, the opioid prescribing rate increased by about 15%.
The Medicare data do not reveal the precise reasons for the prescribing trends, but “a reasonable assumption is that it is related to the seismic shifts in prescribing regulations and attitudes toward opioids,” noted Andrea Enzinger, M.D., and Alexi Wright, M.D., of the Dana-Farber Cancer Institute in an editorial accompanying the study.
“Although a cancer diagnosis permits exceptions from some of these regulations, onerous amounts of additional work are often required of providers,” they wrote.
The extra work, Drs. Enzinger and Wright explained, creates a burden that may “disincentivize” oncologists from prescribing opioids and could lead to a shifting of this responsibility to palliative care.
State Laws and Opioid Prescribing Trends
The Yale researchers also analyzed the data according to state. During the study period, 43 states showed a decrease in opioid prescribing by oncologists. In five states (Oklahoma, Texas, Idaho, Utah, and California), opioid prescribing actually decreased more among oncologists than among other doctors, the researchers noted.
In general, opioid prescribing is regulated by state medical licenses and state laws, explained Lori Minasian, M.D., deputy director of NCI’s Division of Cancer Prevention, who was not involved in the research. For example, Dr. Minasian explained, in some states prescriptions for opioids can provide only enough medication to last a few days.
“Future studies,” she continued, “could dig deeper and try looking at the disparities in state laws for prescribing opioids and see whether these disparities may provide insights into the prescribing patterns we see among oncologists and other physicians.”
Dr. Minasian also pointed out that there currently are not enough palliative care physicians in the United States to address the needs of patients with cancer who may not be able to obtain prescriptions for opioid drugs from an oncologist.
The new findings are consistent with another recent study that also used Medicare data to assess patterns of opioid prescriptions. In that study, researchers also found large declines in opioid prescription rates for Medicare beneficiaries by physicians in general and by oncologists.
“Opioid policy and advocacy appear to have been effective in reducing the extent of opioid prescribing in the Medicare population,” the investigators wrote in JAMA Oncology. “Similar declines between generalists and oncologists raise concern that access to cancer pain management may have been inadvertently restricted.”
The Yale researchers pointed to a 2018 survey of people with cancer and survivors that found that 35% of respondents reported that their physicians would not give them an opioid prescription. Almost half of those surveyed said that their physicians explained that their options for treating pain were limited by laws, guidelines, or insurance coverage.
“While caution against opioid misuse in cancer survivors is certainly warranted, appropriate pain management is equally as critical to ensure the best quality of life for these patients,” Dr. Park and his colleagues wrote.
In their editorial, Drs. Enzinger and Wright wrote that future research is needed to better understand how patients with cancer at various phases of the disease are affected by evolving access to opioids—and “whether there are disparities in access among vulnerable patient groups (e.g., racial/ethnic minorities, or those residing in rural areas).”
This research, they added, could ultimately help answer the question of whether reductions in opioid prescribing by oncologists “represent progress made, or gains lost in the fight against cancer pain.”