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Mudumbai SC, He H, Chen JQ, Kapoor A, Regala S, Mariano ER, Stafford RS, Abnet CC, Pfeiffer RM, Freedman ND, Etemadi A. Opioid use in cancer patients compared with noncancer pain patients in a veteran population. JNCI Cancer Spectr 2024; 8:pkae012. [PMID: 38457606 PMCID: PMC11009465 DOI: 10.1093/jncics/pkae012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 02/05/2024] [Accepted: 02/13/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Opioid safety initiatives may secondarily impact opioid prescribing and pain outcomes for cancer care. METHODS We reviewed electronic health record data at a tertiary Veterans Affairs system (VA Palo Alto) for all patients from 2015 to 2021. We collected outpatient Schedule II opioid prescriptions data and calculated morphine milligram equivalents (MMEs) using Centers for Disease Control and Prevention conversion formulas. To determine the clinical impact of changes in opioid prescription, we used the highest level of pain reported by each patient on the 0-to-10 Numeric Rating Scale in each year, categorized into mild (0-3), moderate (4-6), and severe (7 and above). RESULTS Among 89 569 patients, 9073 had a cancer diagnosis. Cancer patients were almost twice as likely to have an opioid prescription compared with noncancer patients (69.0% vs 36.7%, respectively). The proportion of patients who received an opioid prescription decreased from 27.1% to 18.1% (trend P < .01) in cancer patients and from 17.0% to 10.2% in noncancer patients (trend P < .01). Cancer and noncancer patients had similar declines of MMEs per year between 2015 and 2019, but the decline was more rapid for cancer patients (1462.5 to 946.4, 35.3%) compared with noncancer patients (1315.6 to 927.7, 29.5%) from 2019 to 2021. During the study period, the proportion of noncancer patients who experienced severe pain was almost unchanged, whereas it increased among cancer patients, reaching a significantly higher rate than among noncancer patients in 2021 (31.9% vs 27.4%, P < .01). CONCLUSIONS Our findings suggest potential unintended consequences for cancer care because of efforts to manage opioid-related risks.
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Affiliation(s)
- Seshadri C Mudumbai
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Han He
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ji-Qing Chen
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Aditi Kapoor
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Samantha Regala
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Edward R Mariano
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Randall S Stafford
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Christian C Abnet
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Ruth M Pfeiffer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Neal D Freedman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Arash Etemadi
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
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Meghani SH, Quinn R, Robinson A, Chittams J, Vapiwala N, Naylor M, Cheatle M, Knafl GJ. Trajectories and predictors of high-occurrence pain flares in ambulatory cancer patients on opioids. JNCI Cancer Spectr 2024; 8:pkae003. [PMID: 38268502 PMCID: PMC10880071 DOI: 10.1093/jncics/pkae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/11/2024] [Accepted: 01/17/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Pain flares have a substantive impact on the quality of life and well-being of patients with cancer. We identified longitudinal trajectories (clusters) of cancer pain flares in ambulatory patients and sociodemographic and clinical predictors of these trajectories. METHODS In a prospective cohort study using ecological momentary assessment (mEMA), we collected patient-reported daily pain flare ratings data over 5 months and identified predictors and correlates using validated measures. RESULTS The mean age of the sample (N = 270) was 60.9 years (SD = 11.2), 64.8% were female, and 32.6% self-identified as African American. Four pain flare clusters were identified. The "high-occurrence" cluster (23% of patients) experienced 5.5 (SD = 5.47) daily flares, whereas low-moderate clusters (77%) reported 2.4 (SD = 2.74) daily flares (P < .000). Those in the high-occurrence cluster reported higher pain scores (P = .000), increased pain-related interference (P = .000), depressive symptoms (P = .023), lower quality of life (P = .001), and reduced pain self-efficacy (P = .006). Notably, 67.2% of those prescribed opioids as needed (PRN only) were in the high-occurrence pain flare cluster, compared with 27.9% with PRN and around-the-clock opioid prescriptions (P = .024). Individual predictors of high-occurrence pain flares were income below $30 000, unemployment, being African American, lower education level, Medicaid insurance, current opioid misuse (COMM), baseline inpatient hospital stay duration, and PRN-only opioid regimen. In the multiple predictor model, lower education level, unemployment, COMM score, extended inpatient duration, and PRN-only opioid regimen remained significant. CONCLUSION In ambulatory patients with cancer, high occurrence of pain flares may be mitigated by attention to opioid prescription factors and addressing social determinants of health needs of underserved patients.
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Affiliation(s)
- Salimah H Meghani
- Department of Biobehavioral Health Sciences; NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, PA, USA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan Quinn
- Department of Biobehavioral Health Sciences; NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew Robinson
- Department of Biobehavioral Health Sciences; NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, PA, USA
| | - Jesse Chittams
- Department of Biobehavioral Health Sciences; NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, PA, USA
| | - Neha Vapiwala
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Mary Naylor
- Department of Biobehavioral Health Sciences; NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Martin Cheatle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - George J Knafl
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Menahem S, Freud T, Batat E, Shvartzman P. Opioid consumption by cancer patients in an Israeli Health Maintenance Organization from 2007-2018. Support Care Cancer 2023; 31:560. [PMID: 37668801 DOI: 10.1007/s00520-023-08027-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 08/28/2023] [Indexed: 09/06/2023]
Abstract
PURPOSE Opioids are the cornerstone of therapy for cancer patients with moderate to severe pain. The objective was to characterize opioid purchases by cancer patients in Clalit Health Services (CHS), the largest Health Maintenance Organization in Israel, over the years 2007-2018. METHODS Data for all CHS cancer patients aged 18 years old and above who purchased an opioid at least once during the 12-year study period were obtained from computerized databases. The amount of opioids was converted into oral morphine equivalents (OME). RESULTS 108,543 cancer patients who purchased opioids at least once were enrolled. They comprised 30.5% of the CHS purchasers of opioids in the study period. The total number of cancer patients who purchased an opioid at least once increased gradually from 13,057 in 2007 to 20,675 (58% increase) in 2018, while the annual number of CHS cancer patients increased by only 39%. The annual OME per capita increased from 753 mg in 2007 to 1,432 mg in 2018 (91% increase). In 2007 8.1% of the cancer patients purchased opioids and 9.2% in 2018. Two thirds of all cancer patients purchased opioids for three months or less, 11.9% continued for more than one year, and 5.8% for more than two years. CONCLUSIONS There is a clinically non-significant increase in the rate of cancer patients purchasing opioids. About two thirds of the cancer patients purchased opioids for only three months, and 94% for up to two years. Under-treatment of cancer pain should still be of concern. While patients are prescribed higher doses, under-prescription may still be a problem..
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Affiliation(s)
- Sasson Menahem
- Pain and Palliative Care Unit, Kappy and Eric Flanders National Palliative Care Resource Center, The Haim Doron Division of Community Health,Faculty of Health Sciences, Ben-Gurion University of the Negev, PO BOX 653, Beer-Sheva, Israel
- Siaal Research Center for Family Medicine and Primary Care, Department of Family Medicine, The Haim Doron Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Community Division, Clalit Health Services, Southern District, Beer-Sheva, Israel
| | - Tamar Freud
- Siaal Research Center for Family Medicine and Primary Care, Department of Family Medicine, The Haim Doron Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Erez Batat
- Health Planning and Policy Wing, Clalit Health Services, Community Division, Tel-Aviv, Israel
| | - Pesach Shvartzman
- Pain and Palliative Care Unit, Kappy and Eric Flanders National Palliative Care Resource Center, The Haim Doron Division of Community Health,Faculty of Health Sciences, Ben-Gurion University of the Negev, PO BOX 653, Beer-Sheva, Israel.
- Siaal Research Center for Family Medicine and Primary Care, Department of Family Medicine, The Haim Doron Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
- Community Division, Clalit Health Services, Southern District, Beer-Sheva, Israel.
- Pain and Palliative Care Unit, Soroka University Medical Center, Beer-Sheva, Israel.
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Bulls HW, Hamm M, Wasilko R, de Abril Cameron F, Belin S, Goodin BR, Liebschutz JM, Wozniak A, Sabik LM, Merlin JS, Schenker Y. Manifestations of Opioid Stigma in Patients With Advanced Cancer: Perspectives From Patients and Their Support Providers. JCO Oncol Pract 2022; 18:e1594-e1602. [PMID: 35878073 PMCID: PMC9835931 DOI: 10.1200/op.22.00251] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/02/2022] [Accepted: 06/13/2022] [Indexed: 01/16/2023] Open
Abstract
PURPOSE Stigma surrounding prescription opioids, or opioid stigma, is increasingly recognized as a barrier to effective and guideline-concordant cancer pain management. Patients with advanced cancer report high rates of pain and prescription opioid exposure, yet little is known about how opioid stigma may manifest in this population. METHODS We conducted in-depth qualitative interviews with 20 patients with advanced cancer and 11 support providers between March 2020, and May 2021. We took a rigorous inductive, qualitative descriptive approach to characterize how opioid stigma manifests in the lives of patients with advanced cancer. RESULTS Patients and their support providers described three primary manifestations of opioid stigma: (1) direct experiences with opioid stigma and discrimination in health care settings (eg, negative, stigmatizing interactions in pharmacies or a pain clinic); (2) concerns about opioid stigma affecting patient care in the future, or anticipated stigma; and (3) opioid-restricting attitudes and behaviors that may reflect internalized stigma and fear of addiction (eg, feelings of guilt). CONCLUSION This qualitative study advances our understanding of opioid stigma manifestations in patients with advanced cancer, as well as coping strategies that patients may use to alleviate their unease (eg, minimizing prescription opioid use, changing clinicians, and distancing from perceptions of addiction). In recognition of the costs of undermanaged cancer pain, it is important to consider innovative treatment strategies to address opioid stigma and improve pain management for patients with advanced cancer. Future research should examine opportunities to build an effective, multilevel opioid stigma intervention targeting patients, clinicians, and health care systems.
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Affiliation(s)
- Hailey W. Bulls
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
- Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA
- Challenges in Managing and Preventing Pain Clinical Research Center (CHAMPP), University of Pittsburgh, Pittsburgh, PA
| | - Megan Hamm
- Qualitative, Evaluation, and Stakeholder Engagement Services (QualEASE), Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA
| | - Rachel Wasilko
- Qualitative, Evaluation, and Stakeholder Engagement Services (QualEASE), Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA
| | - Flor de Abril Cameron
- Qualitative, Evaluation, and Stakeholder Engagement Services (QualEASE), Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA
| | - Shane Belin
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
- Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA
| | - Burel R. Goodin
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL
| | - Jane M. Liebschutz
- Division of General Internal Medicine, Center for Research on Health Care, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Antoinette Wozniak
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Lindsay M. Sabik
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Jessica S. Merlin
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
- Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA
- Challenges in Managing and Preventing Pain Clinical Research Center (CHAMPP), University of Pittsburgh, Pittsburgh, PA
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
- Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA
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Jones KF, Abdulhay LB, Orris SR, Merlin JS, Schenker Y, Bulls HW. The Relevance of State Laws Regulating Opioid Prescribing for People Living With Serious Illness. J Pain Symptom Manage 2022; 64:89-99. [PMID: 35561937 DOI: 10.1016/j.jpainsymman.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/29/2022] [Accepted: 05/02/2022] [Indexed: 10/18/2022]
Abstract
CONTEXT Opioids are commonly used to relieve symptoms such as pain and dyspnea in people living with serious illness. In recent years, 36 states enacted limitations for opioid prescriptions to mitigate the impact of the opioid overdose crisis. Palliative care clinicians have been vocal about the unintended consequences of opioid policies, yet little is known about how state policies apply to opioid prescribing in non-cancer-related serious illness. OBJECTIVE To summarize current state-level limitations to opioid prescribing and exemptions relevant to people living with non-cancer-related serious illness. METHODS Investigators searched publicly available laws ("[state] + opioid legislation") to extract information on opioid prescribing and exemptions. Laws were examined for application to palliative care, hospice, non-cancer-related serious illness, and language about specific symptoms was documented when applicable (e.g., pain, dyspnea). RESULTS Most state laws focused on acute pain and/or initial opioid prescriptions. Thirty-three of the thirty-six states with opioid-limiting legislation exempt situations applicable to people living with non-cancer-related serious illness. Three states did not have any exemptions relevant to people living with non-cancer-related serious illness. DISCUSSION The results indicate that while most states recognize the importance of timely opioid access for palliation of pain, clinically relevant exemptions for people living with non-cancer-related serious illness may be lacking. When present, language describing palliative care, hospice, and terminal illness exemptions is often broad and may generate confusion between primary and specialty palliative care.
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Affiliation(s)
- Katie Fitzgerald Jones
- William F. Connell School of Nursing (K.F.J.), Boston College, Chestnut Hill, Massachusetts, USA.
| | - Lindsay Bell Abdulhay
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steve R Orris
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jessica S Merlin
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hailey W Bulls
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Luo C, Chen K, Doshi R, Rickles N, Chen Y, Schwartz H, Aseltine RH. The association of prescription opioid use with suicide attempts: An analysis of statewide medical claims data. PLoS One 2022; 17:e0269809. [PMID: 35771866 PMCID: PMC9246186 DOI: 10.1371/journal.pone.0269809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/30/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Suicides and opioid overdose deaths are among the most pressing public health concerns in the US. However direct evidence for the association between opioid use and suicidal behavior is limited. The objective of this article is to examine the association between frequency and dose of prescription opioid use and subsequent suicide attempts.
Methods and findings
This retrospective cohort study analyzed 4 years of statewide medical claims data from the Connecticut All-Payer Claims Database. Commercially insured adult patients in Connecticut (n = 842,773) who had any medical claims beginning in January 2012 were followed through December 2015. The primary outcome was suicide attempt identified using International Classification of Diseases (ICD 9) diagnosis codes. Primary predictor variables included frequency of opioid use, which was defined as the number of months with claims for prescription opioids per year, and strength of opioid dose, which was standardized using morphine milligram equivalent (MME) units. We also controlled for psychiatric and medical comorbidities using ICD 9 codes. We used Cox proportional hazards regression to examine the association between frequency, dose, and suicide attempts, adjusting for medical and psychiatric comorbid conditions. Interactions among measures of opioid use and comorbid conditions were analyzed.
In this cohort study with follow-up time up to 4 years (range = 2–48 months, median = 46 months), the hazard ratios (HR) from the time-to-event analysis indicated that patients prescribed opioid medications for at least 6 months during the past year and at 20–50 MME levels or higher had 4.44 (95% CI: [3.71, 5.32]) to 7.23 (95% CI: [6.22, 8.41]) times the risk of attempted suicide compared to those not prescribed opioids. Risk of suicide attempt was sharply elevated among patients with psychiatric conditions other than anxiety who were prescribed more frequent and higher opioid doses. In contrast, more frequent and higher doses of prescription opioids were associated with lower risk of suicide attempts among patients with medical conditions necessitating pain management.
This study is limited by its exclusive focus on commercially insured patients and does not include patients covered by public insurance. It is also limited to patients’ receipt of prescription opioids and does not take into account opioids obtained through other means, nor does it include measures of actual patient opioid use.
Conclusions
This analysis provides evidence of a complex relationship among prescription opioids, mental health, pain and other medical comorbidities, and suicide risk. Findings indicate the need for proactive suicide surveillance among individuals diagnosed with affective or psychotic disorders who are receiving frequent and high doses of opioids. However, appropriate opioid treatment may have significant value in reducing suicide risk for those without psychiatric comorbidities.
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Affiliation(s)
- Chongliang Luo
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- Division of Public Health Sciences, Washington University School of Medicine in St. Louis, St Louis, MO, United States of America
| | - Kun Chen
- Department of Statistics, University of Connecticut, Storrs, CT, United States of America
- Center for Population Health, Uconn Health, Farmington, CT, United States of America
| | - Riddhi Doshi
- Center for Population Health, Uconn Health, Farmington, CT, United States of America
- Beacon Health Options, Rocky Hill, CT, United States of America
| | - Nathaniel Rickles
- Center for Population Health, Uconn Health, Farmington, CT, United States of America
- Department of Pharmacy Practice, School of Pharmacy, University of Connecticut, Storrs, CT, United States of America
| | - Yong Chen
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Harold Schwartz
- Institute of Living, Hartford Healthcare, Hartford, CT, United States of America
- Department of Psychiatry, University of Connecticut Health Center, Farmington, CT, United States of America
| | - Robert H. Aseltine
- Center for Population Health, Uconn Health, Farmington, CT, United States of America
- Division of Behavioral Sciences and Community Health, Uconn Health, Farmington, CT, United States of America
- * E-mail:
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Bulls HW, Chu E, Goodin BR, Liebschutz JM, Wozniak A, Schenker Y, Merlin JS. Framework for opioid stigma in cancer pain. Pain 2022; 163:e182-e189. [PMID: 34010940 PMCID: PMC8589872 DOI: 10.1097/j.pain.0000000000002343] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/11/2021] [Indexed: 02/03/2023]
Abstract
ABSTRACT Millions of patients with cancer pain are treated with prescription opioids each year. However, efforts to mitigate the ongoing opioid crisis result in unintended consequences with opioid pain management, including opioid stigma. Emerging research indicates that opioid stigma is problematic in patients with cancer, but few studies have examined contributors to and impacts of opioid stigma in this population. To guide future research in this area, we propose a conceptual framework-the opioid stigma framework (OSF)-with which to understand and improve opioid stigma in patients with cancer pain. Development of the OSF was guided by a literature review of stigma in health-related conditions, adaptation of the existing Health Stigma and Discrimination Framework, a topical review of challenges related to opioid cancer pain management, and author expertise in cancer, pain, and opioid prescribing. The proposed OSF highlights 5 domains: (1) contributors to opioid stigma, or factors that increase the likelihood that a patient will experience opioid stigma; (2) intersecting stigmas, or the convergence of multiple stigmatized identities within a patient; (3) stigma manifestations, or the ways opioid stigma is manifested in patients, clinicians, and the community; (4) proximal outcomes, or the immediate consequences of opioid stigma in patients; and (5) long-term impacts in patients. The OSF provides 2 main avenues to facilitate future research: (1) providing a framework to explore the mechanisms that underlie opioid stigma and its impact on cancer pain management and (2) supporting the development of targeted, tailored interventions to eliminate opioid stigma.
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Affiliation(s)
- Hailey W. Bulls
- Section of Palliative Care and Medical Ethics and
Palliative Research Center (PaRC), Division of General Internal Medicine, Department
of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Edward Chu
- Department of Medicine & Molecular Pharmacology, Albert
Einsten Cancer Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Burel R. Goodin
- Department of Psychology, University of Alabama at
Birmingham, Birmingham, AL, USA
| | - Jane M. Liebschutz
- Division of General Internal Medicine, Center for Research
on Health Care, Department of Medicine, University of Pittsburgh, Pittsburgh, PA,
USA
| | - Antoinette Wozniak
- Division of Hematology/Oncology, Department of Medicine,
University of Pittsburgh, Pittsburgh, PA, USA
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics and
Palliative Research Center (PaRC), Division of General Internal Medicine, Department
of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jessica S. Merlin
- Section of Palliative Care and Medical Ethics and
Palliative Research Center (PaRC), Division of General Internal Medicine, Department
of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Singh SA, Moreland RA, Fang W, Shaikh P, Perez JM, Morris AM, Dahshan B, Krc RF, Chandran D, Holbein M. Compassion Inequities and Opioid Use Disorder: A Matched Case-Control Analysis Examining Inpatient Management of Cancer-Related Pain for Patients With Opioid Use Disorder. J Pain Symptom Manage 2021; 62:e156-e163. [PMID: 33984461 PMCID: PMC8416788 DOI: 10.1016/j.jpainsymman.2021.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/02/2021] [Accepted: 05/03/2021] [Indexed: 11/24/2022]
Abstract
CONTEXT The opioid epidemic spurred guidelines intended to reduce inappropriate prescribing. Although acute cancer-related pain was excluded from these recommendations, studies demonstrate reduced opioid prescribing for patients hospitalized with advanced cancer. OBJECTIVES We performed a matched case-control analysis to determine how a history of opioid use disorder (OUD) affects inpatient management of cancer pain. METHODS Charts of patients with OUD admitted for cancer pain from 2015-2020 were retrospectively reviewed. Hospitalizations were matched 1:1 by patient age and sex. Home milligram-morphine equivalent per day (MME/day) was calculated from the home medication list. Admission MME/day was the average MME/day administered during hospitalization. RESULTS A total of 80 hospitalizations (40:40) were matched for 25 patients with a history of OUD and 31 patients with no history of OUD. Cancer was metastatic/relapsed for 70% of admissions. The median overall survival was 2.3 months (95% CI 0-5.21, P = 0.13). Patients with OUD had a significantly lower change from Home to Admission MME/day (-3 vs. 37, P < 0.01) and were less likely to have any increase in Admission MME/day (OR 0.1, 95% CI 0.02-0.43, P < 0.01). When considering opioids administered after pain specialty consultation, there was no difference between groups. CONCLUSION Our results suggest that patients with OUD receive lower quality inpatient management of cancer-related pain. Provider education and early involvement of pain specialists are crucial in delivering equitable and compassionate end-of-life care for patients with OUD.
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Affiliation(s)
- Sarah A Singh
- Department of Radiation Oncology, West Virginia University, Morgantown, West Virginia, USA.
| | - Rachel A Moreland
- Department of Psychiatry, West Virginia University, Morgantown, West Virginia, USA
| | - Wei Fang
- Department of Biostatistics, Clinical and Translational Science Institute, West Virginia University Health Sciences Center Erma Byrd Biomedical Research Center, Morgantown, West Virginia, USA
| | - Parvez Shaikh
- Department of Radiation Oncology, West Virginia University, Morgantown, West Virginia, USA
| | - John Michael Perez
- Department of Psychiatry, West Virginia University, Morgantown, West Virginia, USA
| | - Ann M Morris
- Department of Radiation Oncology, West Virginia University, Morgantown, West Virginia, USA
| | - Basem Dahshan
- Department of Radiation Oncology, West Virginia University, Morgantown, West Virginia, USA
| | - Rebecca F Krc
- Department of Radiation Oncology, West Virginia University, Morgantown, West Virginia, USA
| | - Dilip Chandran
- Department of Psychiatry, West Virginia University, Morgantown, West Virginia, USA
| | - Monika Holbein
- Department of Hematology and Oncology, West Virginia University, Morgantown, West Virginia, USA
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Enzinger AC, Ghosh K, Keating NL, Cutler DM, Landrum MB, Wright AA. US Trends in Opioid Access Among Patients With Poor Prognosis Cancer Near the End-of-Life. J Clin Oncol 2021; 39:2948-2958. [PMID: 34292766 DOI: 10.1200/jco.21.00476] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Heightened regulations have decreased opioid prescribing across the United States, yet little is known about trends in opioid access among patients dying of cancer. METHODS Among 270,632 Medicare fee-for-service decedents with poor prognosis cancers, we used part D data to examine trends from 2007 to 2017 in opioid prescription fills and opioid potency (morphine milligram equivalents per day [MMED]) near the end-of-life (EOL), defined as the 30 days before death or hospice enrollment. We used administrative claims to evaluate trends in pain-related emergency department (ED) visits near EOL. RESULTS Between 2007 and 2017, the proportion of decedents with poor prognosis cancers receiving ≥ 1 opioid prescription near EOL declined 15.5% (relative percent difference [RPD]), from 42.0% (95% CI, 41.4 to 42.7) to 35.5% (95% CI, 34.9 to 36.0) and the proportion receiving ≥ 1 long-acting opioid prescription declined 36.5% (RPD), from 18.1% (95% CI, 17.6 to 18.6) to 11.5% (95% CI, 11.1 to 11.9). Among decedents receiving opioids near EOL, the mean daily dose fell 24.5%, from 85.6 MMED (95% CI, 82.9 to 88.3) to 64.6 (95% CI, 62.7 to 66.6) MMED. Overall, the total amount of opioids prescribed per decedent near EOL (averaged across those who did and did not receive an opioid) fell 38.0%, from 1,075 morphine milligram equivalents per decedent (95% CI, 1,042 to 1,109) to 666 morphine milligram equivalents per decedent (95% CI, 646 to 686). Simultaneously, the proportion of patients with pain-related ED visits increased 50.8% (RPD), from 13.2% (95% CI, 12.7 to 13.6) to 19.9% (95% CI, 19.4 to 20.4). Sensitivity analyses demonstrated similar declines in opioid utilization in the 60 and 90 days before death or hospice, and suggested that trends in opioid access were not confounded by secular trends in hospice utilization. CONCLUSION Opioid use among patients dying of cancer has declined substantially from 2007 to 2017. Rising pain-related ED visits suggests that EOL cancer pain management may be worsening.
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Affiliation(s)
- Andrea C Enzinger
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Kaushik Ghosh
- New England Bureau of Economic Research, Cambridge, MA
| | - Nancy L Keating
- Department of Healthcare Policy, Harvard Medical School, Boston, MA.,Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - David M Cutler
- New England Bureau of Economic Research, Cambridge, MA.,Department of Healthcare Policy, Harvard Medical School, Boston, MA.,Department of Economics, Harvard University, Cambridge, MA.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
| | | | - Alexi A Wright
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
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