Factors Associated With Opioid Use in Long-term Cancer Survivors

Association between trajectories of prescription opioid use and risk of opioid use disorder and overdose among US nonmetastatic breast cancer survivors

PURPOSE

To examine the association between prescription opioid use trajectories and risk of opioid use disorder (OUD) or overdose among nonmetastatic breast cancer survivors by treatment type.

METHODS

This retrospective cohort study included female nonmetastatic breast cancer survivors with at least 1 opioid prescription fill in 2010-2019 Surveillance, Epidemiology and End Results linked Medicare data. Opioid mean daily morphine milligram equivalents (MME) calculated within 1.5 years after initiating active breast cancer therapy. Group-based trajectory models identified distinct opioid use trajectory patterns. Risk of time to first OUD/overdose event within 1 year after the trajectory period was calculated for distinct trajectory groups using Cox proportional hazards models. Analyses were stratified by treatment type.

RESULTS

Four opioid use trajectories were identified for each treatment group. For 38,030 survivors with systemic endocrine therapy, 3 trajectories were associated with increased OUD/overdose risk compared with early discontinuation: minimal dose (< 5 MME; adjusted hazard ratio [aHR] = 1.73 [95% CI  1.43-2.09]), very low dose (5-25 MME; 2.67 [2.05-3.48]), and moderate dose (51-90 MME; 6.20 [4.69-8.19]). For 9477 survivors with adjuvant chemotherapy, low-dose opioid use was associated with higher OUD/overdose risk (aHR = 7.33 [95% CI 2.52-21.31]) compared with early discontinuation. For 3513 survivors with neoadjuvant chemotherapy, the differences in OUD/OD risks across the 4 trajectories were not significant.

CONCLUSIONS

Among Medicare nonmetastatic breast cancer survivors receiving systemic endocrine therapy or adjuvant chemotherapy, compared with early discontinuation, low-dose or moderate-dose opioid use were associated with six- to sevenfold higher OUD/overdose risk. Breast cancer survivors at high-risk of OUD/overdose may benefit from targeted interventions (e.g., pain clinic referral).

"It Is So Easy For Them to Dismiss": A Phenomenological Study of Cancer Survivors With Chronic Cancer-Related Pain

Background: For many cancer survivors post-cure, chronic pain is a devastating complication of cancer treatment. The prevalence of chronic pain among cancer survivors is double that of the general population. However, little is known about the pain experience of cancer survivors who may have a different perspective than people with advanced cancer or people with noncancer pain. Objective: To understand the lived experience of chronic cancer-related pain in cancer survivors. Methods: We used a qualitative design with a descriptive phenomenological method to conduct in-depth interviews of 13 cancer survivors residing in the United States who completed curative cancer therapy, were at least three months from treatment, and experienced pain attributable to cancer. Data collection was focused on the lived experience and management of chronic cancer-related pain and a deep understanding of how the experience of chronic cancer-related pain shapes pain management choices. Results: The participants had a variety of primary cancer types and cancer pain syndromes. Three essential themes epitomized the experience of living with chronic cancer-related pain: invisible suffering at the cost of survival, an opioid paradox, and a lack of answers on what to expect and what might help. Conclusion and Implications: The results highlight an opportunity for pain self-management, education, and psychosocial interventions to optimize pain in cancer. Participants' experiences identify several opportunities to improve chronic cancer-related pain. Future efforts should prioritize access to multimodal pain treatments, high-quality communication, and expand clinicians' knowledge and skills to manage chronic pain.

Factors Associated With Guideline-Concordant Pharmacological Treatment for Neuropathic Pain Among Breast Cancer Survivors

PURPOSE

To identify factors associated with receiving guideline-concordant treatment among breast cancer survivors with neuropathic pain.

MATERIALS AND METHODS

A retrospective case-control study was conducted using the SEER-Medicare linked database. We included female breast cancer survivors diagnosed with non-metastatic breast cancer (stages 0-III) between 2007 and 2015 who developed treatment-related neuropathic pain during their survivorship period. Guideline-concordant treatment was defined based on NCCN guidelines. Factors associated with receiving guideline-concordant treatment were assessed using multivariable logistic regression and backward selection was used to identify potential associated factors.

RESULTS

Around 16.7% of breast cancer survivors in the study developed a neuropathic pain condition. The mean time to develop neuropathic pain was 1.4 years after beginning adjuvant treatment. On average, patients who developed neuropathic pain and received guideline-concordant treatment did so at 2.4 months after their neuropathic pain diagnosis. We found that survivors that are black and of other races were less likely to receive guideline-concordant treatment for breast cancer treatment-related neuropathic pain. Whereas survivors with diabetes, mental health disorders, hemiplegia, prior continuous opioid use, benzodiazepine use, nonbenzodiazepine CNS depressant use, or antipsychotic medication use were less likely to receive guideline-concordant treatment.

CONCLUSION

This study suggests that minority races, prior medication use, and comorbid conditions are associated with guideline-concordant treatment among breast cancer survivors with neuropathic pain. These findings warrant attention towards minority races to prescribe them guideline-concordant treatment as well as caution when prescribing concurrent pain medications to survivors with comorbidities and prior medication use.

New persistent opioid use among adolescents and young adults with sarcoma

BACKGROUND

Adolescents and young adults (AYA) with sarcoma experience both acute and chronic pain related to their disease and treatment. Studies in older adults have reported a high risk of persistent opioid use after cancer therapy among previously opioid-naive patients; however, few studies have evaluated posttreatment opioid use among AYAs. This article describes patterns of new persistent opioid use among AYAs in the year after treatment for sarcoma.

METHODS

Opioid-naive patients who were 10 to 26 years old and diagnosed with sarcoma (2008-2016) were identified with the IBM Marketscan Database. Included subjects had an International Classification of Diseases code for sarcoma (ninth or tenth revision), received anticancer therapy (chemotherapy, surgery, and/or radiation) within 30 days of the first diagnosis code, and had continuous insurance coverage (commercial or Medicaid) for more than 12 months both before the diagnosis and after the last therapy. The primary outcome was new persistent opioid use, which was defined as at least 2 opioid prescriptions in the 12 months following treatment completion. Covariates included age, sex, insurance, tumor type, surgical procedure, mental health (MH) or substance use diagnoses before or during therapy, and concomitant lorazepam use.

RESULTS

In total, 938 patients met the inclusion criteria; 521 (56%) were male, and 578 (62%) were younger than 18 years. In total, 727 (78%) had commercial insurance, and 273 (29%) had an MH diagnosis either before or during the treatment period. Of the total group, 464 (49%) used opioids during treatment only. Of those who used opioids during treatment, 135 (23%) received at least 2 prescriptions in the year after therapy. In a multivariable analysis, Medicaid versus commercial insurance (odds ratio [OR], 1.74; 95% confidence interval [CI], 1.15-2.64) and non-soft tissue sarcoma (OR for Ewing sarcoma, 3.23; 95% CI, 1.81-5.78; OR for osteosarcoma, 2.05; 95% CI, 1.36-3.09) conferred a higher likelihood of new persistent use.

CONCLUSIONS

In this cohort of AYAs treated for sarcoma, 64% of the patients received opioid prescriptions during treatment, and 23% of these patients became new persistent users. Because of the risks associated with persistent opioid use, studies of novel pain management strategies along with age-appropriate education and anticipatory guidance are urgently needed.

LAY SUMMARY

Using an insurance claims database, we conducted a study to determine the rate of new persistent opioid use among adolescents and young adults treated for sarcoma. We found that 64% of adolescents and young adults treated for sarcoma received opioid prescriptions during treatment, and 23% of these patients met the criteria for new persistent opioid use. These findings support the need for age-appropriate education and novel pain management strategies in this vulnerable population.

Patterns and Trends in Receipt of Opioids Among Patients Receiving Treatment for Cancer in a Large Health System

BACKGROUND

Given limited evidence on opioid prescribing among patients receiving treatment for cancer during the ongoing opioid epidemic, our objective was to assess predictors of and trends in opioid receipt during cancer treatment, including how patterns differ by type of cancer.

METHODS

Using cancer registry data, we identified patients with a first lifetime primary diagnosis of breast, colorectal, or lung cancer from 2013 to 2017 who underwent treatment within a large cancer center network. Cancer registry data were linked to electronic health record information on opioid prescriptions. We examined predictors of and trends in receipt of any opioid prescription within 12 months of cancer diagnosis.

RESULTS

The percentage of patients receiving opioids varied by cancer type: breast cancer, 35% (1,996/5,649); colorectal, 37% (776/2,083); lung, 47% (1,259/2,654). In multivariable analysis, opioid use in the year before cancer diagnosis was the factor most strongly associated with receipt of opioids after cancer diagnosis, with 4.90 (95% CI, 4.10-5.86), 5.09 (95% CI, 3.88-6.69), and 3.31 (95% CI, 2.68-4.10) higher odds for breast, colorectal, and lung cancers, respectively. We did not observe a consistent decline in opioid prescribing over time, and trends differed by cancer type.

CONCLUSIONS

Our findings suggest that prescription of opioids to patients with cancer varies by cancer type and other factors. In particular, patients are more likely to receive opioids after cancer diagnosis if they were previously exposed before diagnosis, suggesting that pain among patients with cancer may commonly include non-cancer-related pain. Heterogeneity and complexity among patients with cancer must be accounted for in developing policies and guidelines aimed at addressing pain management while minimizing the risk of opioid misuse.

Approaches to opioid prescribing in cancer survivors: Lessons learned from the general literature

LAY SUMMARY

Guidance on how to approach opioid decisions for people beyond active cancer treatment is lacking. This editorial discusses strategies from the general literature that can be thoughtfully tailored to cancer survivors to provide patient-centered pain and opioid care.

Safety of opioid prescribing among older cancer survivors

BACKGROUND

Cancer survivors receive more long-term opioid therapy (LTOT) than people without cancer, but the safety of LTOT prescribing is unknown.

METHODS

Opioid-naive adults aged ≥66 years who had been diagnosed in 2008-2015 with breast, lung, head and neck, or colorectal cancer were identified with data from Surveillance, Epidemiology, and End Results cancer registries linked with Medicare claims. Survivors with 1 or more LTOT episodes (≥90 consecutive days) occurring ≥1 year after their cancer diagnosis and before censoring at hospice entry, another cancer diagnosis, 6 months before death, or December 2016 were included. The safety of prescribing during the first 90 days of the first LTOT episode was measured during follow-up. As a positive safety indicator, the proportion of survivors with concurrent nonopioid pain management was measured. Indicators of less safe prescribing were the proportion of survivors with a high average daily opioid dose (≥90 morphine milligram equivalents) and the proportion of survivors with concurrent benzodiazepine dispensing. Multivariable logistic regression analyses were conducted to identify clinical predictors of each safety outcome.

RESULTS

In all, 3628 cancer survivors received LTOT during follow-up (median duration, 4.9 months; interquartile range, 3.5-8.0 months). Seventy-two percent of the survivors received multimodal pain management concurrently with LTOT. Eight percent of the survivors had high-dose opioid prescriptions; 25% of the survivors received benzodiazepines during LTOT. Multivariable analyses identified variations in safety measures by multiple clinical factors, although none were consistently significant across outcomes.

CONCLUSIONS

To improve safe LTOT prescribing for survivors, efforts should focus on increasing multimodal pain management and reducing inappropriate benzodiazepine prescribing. Different clinical predictors of each outcome suggest different drivers of safe prescribing.

Opioid use and misuse in children, adolescents, and young adults with cancer: a systematic review of the literature

Adolescents and young adults (AYAs) are at increased risk for negative opioid-related outcomes, including misuse and overdose. High-quality cancer care requires adequate pain management and often includes opioids for tumor- and/or treatment-related pain. Little is known about opioid use and misuse in children and AYAs with cancer, and we therefore conducted a systematic review of the literature using PRISMA guidelines to identify all relevant studies that evaluated opioid use and/or misuse among this population. Eleven studies were identified that met our inclusion criteria. The range of opioid use among the studies was 12-97%, and among the five studies that reported opioid misuse or aberrant behaviors, 7-90% of patients met criteria. Few studies reported factors associated with opioid misuse but included prior mental health and/or substance use disorders, and prior opioid use. In summary, opioid use is highly variable among children and AYAs with cancer; however, the range of use varies widely depending on the study population, such as survivors or end-of-life cancer patients. Few studies have examined opioid misuse and/or aberrant behaviors, and future research is needed to better understand opioid use and misuse among children and AYAs with cancer, specifically those who will be cured of their cancer and may subsequently experience adverse opioid-related outcomes.

Chronic Opioid Therapy in Cancer Survivors at a Specialty Oncology Pain Clinic: Opioid Dosing, Efficacy, and Safety During Five Years of Pain Management

There are limited data regarding long-term safety and efficacy in cancer survivors receiving chronic opioid therapy. With conflicting recommendations on opioid-prescribing practices and lack of available outcome data, this study aimed to provide a longitudinal perspective on opioid prescribing in cancer survivors. A retrospective chart review at a comprehensive cancer care center pain clinic used data from pain clinic provider notes from 2013 to 2018. Inclusion criteria were patients in clinical remission not receiving active chemotherapy or immunotherapy and receiving opioids during the study period. Opioid dosing changes and outcomes between zero and five years were evaluated by standard statistical analysis. Thirty-two patients met inclusion criteria. Solid malignancies were more common than hematologic malignancies (72% vs. 28%). Common pain complaints were related to postsurgical changes (43%), postradiation (32%), and chemotherapy-induced pain syndromes (25%). There were no serious adverse events. One patient exhibited possible aberrant behavior. At the initial visit, the median morphine milligram equivalent per day (MME/day) was 130. Median MME/day at Year 0 (study start) and Year 5 was 135 and 159, respectively (P = 0.475). Functional status was satisfactory in 58% at Year 0 and increased to 91% of patients meeting their functional goals at Year 5. In a carefully monitored group of cancer survivors with persistent pain, chronic opioid therapy was safely managed during extended periods without significant opioid escalation or evidence of serious adverse events including aberrant behaviors. This population benefited when opioid therapy was managed with a focus on function rather than reduction of pain intensity scores.

Opioid use by cancer status and time since diagnosis among older adults enrolled in the Prostate, Lung, Colorectal, and Ovarian screening trial in the United States

BACKGROUND

Dosing limits in opioid clinical practice guidelines in the United States are likely misapplied to cancer patients, however, opioid use may be difficult to ascertain as they are largely excluded from opioid use studies.

METHODS

The primary objective was to determine whether cancer patients were more likely to be chronic opioid users after diagnosis. We described prescription opioid use among U.S. older adult cancer patients during two time periods, within 2 years of diagnosis (short-term) and at least 2 years beyond diagnosis (long-term), compared to those without cancer (controls). Among participants in the Prostate, Lung, Colorectal, and Ovarian (PLCO) screening trial with linkages to Medicare Part D data during 2011-2015, we used multivariable logistic regression to estimate the association between cancer diagnosis and opioid use outcomes controlling for demographics. The primary outcome of opioid use was measured with the following metrics: Any opioid use, chronic use (90 consecutive days supply of opioid use while allowing for a 7-day gap between refills), high use (average daily morphine equivalent (MME) ≥120 mg for any 90-day period), and total MME dose above 2,000 mg (MME₂₀₀₀ ).

RESULTS

The short-term cohort included 1,491 cancer patients and 24,930 controls. Any use in the 2-year post-diagnosis period was higher among cancer patients OR 3.3 (95% CI: 3.0-3.7). Chronic use rates were similar by cancer status (4.6% vs. 3.8% for cases and controls, respectively). The long-term cohort included 4,377 cancer patients and 27,545 controls. Rates of any use were similar among cancer patients and controls (63% vs. 59%).

CONCLUSIONS

Any opioid use was similar among long-term cancer survivors compared to controls, but differed among short-term survivors for any opioid use and marginally for chronic opioid use.

Variations in Long-term Opioid Therapy Definitions: A Systematic Review of Observational Studies Using Routinely Collected Data (2000-2019)

Routinely collected data have been increasingly used to assess long-term opioid therapy (LTOT) patterns, with very little guidance on how to measure LTOT from these data sources. We conducted a systematic review of studies published between January 2000 and July 2019 to catalogue LTOT definitions, the rationale for definitions and LTOT rates in observational research using routinely collected data in nonsurgical settings. We screened 4056 abstracts, 210 full-text manuscripts and included 128 studies, mostly from the United States (81%) and published between 2015 and 2019 (69%). We identified 78 definitions of LTOT, commonly operationalised as 90 days of use within a year (23%). Studies often used multiple criteria to derive definitions (60%), mostly based on measures of duration, such as supply days/days of use (66%), episode length (21%) or prescription fills within specified time periods (12%). Definitions were based on previous publications (63%), clinical judgment (16%) or empirical data (3%); 10% of studies applied more than one definition. LTOT definition was not provided with enough details for replication in 14 studies and 38 studies did not specify the opioids evaluated. Rates of LTOT within study populations ranged from 0.2% to 57% according to study design and definition used. We observed a substantial rise in the last 5 years in studies evaluating LTOT with large variability in the definitions used and poor reporting of the rationale and implementation of definitions. This variation impacts on research reproducibility, comparability of findings and the development of strategies aiming to curb therapy that is not guideline-recommended.

Exploring Factors Associated With Long-Term Opioid Therapy in Cancer Survivors: An Integrative Review

CONTEXT

The prevalence of chronic pain in cancer survivors is double that of the general U.S.

POPULATION

Opioids have been the foundation of cancer pain management for decades; however, there is a paucity of literature on long-term opioid therapy (LTOT) in cancer survivors. An understanding of factors related to LTOT use in cancer survivors is needed to address chronic pain and balance opioid harms in the expanding population of cancer survivors.

OBJECTIVES

To analyze the research of LTOT utilization and factors associated with persistent opioid use in cancer survivors.

METHODS

A five-stage integrative review process was adapted from Whittemore and Knafl. Data sources searched included Web of Science, PubMed, Embase, Cochrane, and Google Scholar. Quantitative research studies from 2010 to present related to cancer survivors managed on LTOT were included. Editorials, reviews, or abstracts were excluded.

RESULTS

After reviewing 315 articles, 21 articles were included. We found that there were several definitions of LTOT in the reviewed studies, but the duration of opioid use (i.e., more than three months after completion of curative treatment) was the most common. The reviewed literature describes a relationship between LTOT and important biopsychosocial factors (cancer type, socioeconomic factors, and comorbidities).

CONCLUSION

The studies in this review shed light on the factors associated with LTOT in cancer survivors. LTOT was common in certain populations of cancer survivors and those with a collection of patient-specific characteristics. This review suggests that there is a critical need for specialized research on chronic cancer pain and opioid safety in cancer survivors.

Postoperative penile prosthesis pain: is it worse in diabetic patients?

Inflatable penile prosthesis (IPP) surgery is an effective, safe and satisfactory treatment option for medication-refractory erectile dysfunction. Postoperative complications include infection, mechanical failure, erosion, and pain. Current literature suggests the need for a better approach to postoperative pain management after IPP surgery. Clinical studies have demonstrated that postoperative pain is different in diabetic patients. We sought to determine if there is a difference in pain after IPP placement in diabetics. This is a single-institution retrospective review. The main outcome measure was the number of 30-day postoperative visits for pain. The secondary outcome included differences in how pain was managed. The top HbA1c quartile was compared with the other HbA1c quartiles. Diabetes was present in 92 (54.4%) patients and 96% of these had HbA1c > 8. Significant postoperative pain was more common in patients with HbA1c > 8 (41% vs 13%, p = 0.047) and resulted in more unplanned visits (27% vs 11%, p = 0.042). Patients with HbA1c > 8 with significant postoperative pain were more likely to be managed with opioids and gabapentin (30% vs 14%, p = 0.05). There were no statistical differences in age between diabetics and non-diabetics (mean 59 vs 61, p = 0.193). Hispanic and African-American patients represented 87% of the poorly controlled diabetics compared with only 13% of white patients (p < 0.001). Poorly controlled diabetics had more medical comorbidities (p < 0.001). On logistic regression, a HbA1c > 8 was predictive of an unplanned visit for pain with an OR of 2.83 (p = 0.04). Significant pain after IPP surgery was higher in diabetics with HbA1c > 8, which resulted in more unplanned 30-day postoperative visits. Patients with significant postoperative pain were managed with a combination of opioids and gabapentin. Future studies are required to optimize pain management in diabetics following IPP placement.

Opioid Misuse Risk: Implementing Screening Protocols in an Ambulatory Oncology Clinic

With morbidity and mortality related to opioid use continuing to increase, clinicians need to better understand the risk for opioid misuse in patient populations. Screening for opioid misuse risk has not been routinely adopted as a standard practice in clinical settings. A pilot study was performed to determine the feasibility of screening for future opioid misuse risk using the Opioid Risk Tool (ORT) in an ambulatory oncology clinic. Twelve patients in this sample scored in the moderate- to high-risk range for aberrant behavior, and 8 patients reported a personal history of substance abuse, indicating a need for opioid misuse risk screening in populations of patients with cancer. Because it is easy and quick to use, the ORT may be a feasible tool to incorporate into standard practice.

Changes in use of opioid therapy after colon cancer diagnosis: a population-based study

PURPOSE

To describe patterns of opioid use in cancer survivors.

METHODS

In a cohort study of colon cancer patients diagnosed during 1995-2014 and enrolled at two Kaiser Permanente regions, we constructed quarterly measures of opioid use from 1 year before cancer diagnosis through 5 years after diagnosis to examine changes in use. Measures included any use, incident use, regular use (use ≥ 45 days in a 91-day quarter), and average daily dose (converted to morphine milligram equivalent, MME). We also assessed temporal trends of opioid use.

RESULTS

Of 2,039 colon cancer patients, 11-15% received opioids in the four pre-diagnosis quarters, 68% in the first quarter after diagnosis, and 15-17% in each subsequent 19 quarters. Regular opioid use increased from 3 to 5% pre-diagnosis to 5-7% post diagnosis. Average dose increased from 15 to 17 MME/day pre-diagnosis to 14-22 MME/day post diagnosis (excluding the quarter in which cancer was diagnosed). Among post-diagnosis opioid users, 73-95% were on a low dose (< 20 MME/day). Over years, regular use of opioids increased in survivorship with no change in dosage.

CONCLUSION

Opioid use slightly increased following a colon cancer diagnosis, but high-dose use was rare. Research is needed to differentiate under- versus over-treatment of cancer pain.