Racial, Ethnic, and Socioeconomic Discrepancies in Opioid Prescriptions Among Older Patients With Cancer

Household Income Is Associated with Chronic Pain and High-Impact Chronic Pain among Cancer Survivors: A Cross-Sectional Study Using NHIS Data

Pain is a prevalent issue among cancer patients, yet its link with socioeconomic status has not been thoroughly examined. This study investigated chronic pain (lasting ≥3 months) and high-impact pain (chronic pain limiting activities) among cancer survivors based on household income relative to the federal poverty level (FPL), using data from the National Health Interview Survey (2019-2020). Of the 4585 participants with a history of solid cancers, 1649 (36.3%) reported chronic pain and 554 (12.6%) reported high-impact chronic pain. After adjustment, participants with incomes < 200% FPL had significantly higher odds of chronic pain (adjusted odds ratio [aOR]: 1.60, 95% CI: 1.25-2.05) and high-impact chronic pain (aOR: 1.73, 95% CI: 1.09-2.74) compared to those with incomes ≥ 400% FPL. Opioid use for chronic pain was most prevalent among those with incomes < 200% FPL (28.3%) compared to those with 200-399% (21.3%) and ≥400% (19.0%). Higher-income participants reported greater use of alternative pain management methods such as yoga (50.5%), chiropractic care (44.8%), and physical therapy (44.3%). This study highlights the association between household income and chronic pain outcomes among cancer survivors, emphasizing the necessity for targeted interventions to mitigate healthcare access disparities and improve pain management for all individuals affected by cancer.

Effects of socioeconomic burden on opioid use following total shoulder arthroplasty

BACKGROUND

Preoperative opioid users experience worse outcomes and higher complication rates compared to opioid-naïve patients following shoulder arthroplasty. This study evaluates the effects of socioeconomic status, as measured by the Distressed Communities Index (DCI), on pre- and postoperative opioid use and its influence on clinical outcomes such as readmission and revision surgery.

METHODS

A retrospective review of patients who underwent primary shoulder arthroplasty (Current Procedural Terminology code 23472) from 2014 to 2022 at a single academic institution was performed. Exclusion criteria included arthroplasty for fracture, active malignancy, and revision arthroplasty. Demographics, Charlson Comorbidity Index, DCI, and clinical outcomes including 90-day readmission and revision surgery were collected. Patients were classified according to the DCI score of their zip code. Using the Prescription Drug Monitoring Program database, patient pre- and postoperative opioid use in morphine milligram equivalents was gathered.

RESULTS

Individuals from distressed communities used more opioids within 90 days preoperatively compared to patients from prosperous, comfortable, mid-tier, and at-risk populations, respectively. Patients from distressed communities also used significantly more opioids within 90 days postoperatively compared with prosperous, comfortable, and mid-tier, respectively. Of patients from distressed communities, 35.1% developed prolonged opioid use (filling prescriptions >30 days after surgery), significantly more than all other cohorts. Among all patients, 3.5% were readmitted within 90 days and were more likely to be prolonged opioid users (38.9 vs. 21.3%, P < .001). Similarly, 1.5% of patients underwent revision surgery. Those who underwent revision were significantly more likely to be prolonged opioid users (38.2 vs. 21.7%, P = .002).

CONCLUSIONS

Shoulder arthroplasty patients from distressed communities use more opioids within 90 days before and after their surgery and are more likely to become prolonged opioid users, placing them at risk for readmission and revision surgery. Identifying patients at an increased risk for excess opioid use is essential to employ appropriate strategies that minimize the detrimental effects of prolonged use following surgery.

Identifying provider, patient and practice factors that shape long-term opioid prescribing for cancer pain: a qualitative study of American and Australian providers

INTRODUCTION

Prescribing long-term opioid therapy is a nuanced clinical decision requiring careful consideration of risks versus benefits. Our goal is to understand patient, provider and context factors that impact the decision to prescribe opioids in patients with cancer.

METHODS

We conducted a secondary analysis of the raw semistructured interview data gathered from 42 prescribers who participated in one of two aligned concurrent qualitative studies in the USA and Australia. We conducted a two-part analysis of the interview: first identifying all factors influencing long-term prescribing and second open coding-related content for themes.

RESULTS

Factors that influence long-term opioid prescribing for cancer-related pain clustered under three key domains (patient-related, provider-related and practice-related factors) each with several themes. Domain 1: Patient factors related to provider-patient continuity, patient personality, the patient's social context and patient characteristics including racial/ethnic identity, housing and socioeconomic status. Domain 2: Provider-related factors centred around provider 'personal experience and expertise', training and time availability. Domain 3: Practice-related factors included healthcare interventions to promote safer opioid practices and accessibility of quality alternative pain therapies.

CONCLUSION

Despite the differences in the contexts of the two countries, providers consider similar patient, provider and practice-related factors when long-term prescribing opioids for patients with cancer. Some of these factors may be categorised as cognitive biases that may intersect in an already disadvantaged patient and exacerbate disparities in the treatment of their pain. A more systematic understanding of these factors and how they impact the quality of care can inform appropriate interventions.

Understanding predictors of mental health and substance use treatment utilization among US adults: A repeated cross-sectional study

Background

Understanding discrepancies in mental health and substance use treatment utilization can help identify inequities in access to health services. We investigate mental health and substance use treatment utilization as function of demographic and social determinants, as well as pre-existing mental health and substance use disorders.

Methods

In this repeated cross-sectional study, we used the 2017-2019 National Survey on Drug Use and Health data on US adults above age 18. Two logistic regression models were conducted, using predictors of age, gender, race/Hispanicity, sexual identity, education, insurance, family income, and past year mental health and substance use disorders, with outcomes of mental health or substance use treatment utilization. Weighted estimates of substance use disorders and insurance types and Pearson's correlation tests of vulnerability among age, gender, and treatment type were reported.

Findings

Racial minorities, uninsured populations, sexual minorities, and females had lower odds of receiving mental health treatment, while older populations, lower income groups, and dual eligible enrollees had higher odds. Individuals with substance use disorders but no mental illness had higher odds of receiving mental health treatment. Those utilizing mental health treatment were mostly of high income, privately insured, and using cannabis, cocaine, and opioids. Older populations, men, and Medicaid only enrollees had higher odds of receiving substance use disorder treatment, whereas racial minorities had lower odds. Distribution of income, insurance type, and substance use were more widespread than mental health treatment.

Interpretation

Mental health treatment can be used as an avenue for substance use treatment, particularly opioid use disorders. It is important to target vulnerable populations, like racial minorities and uninsured populations to improve access to mental health and substance use treatment.

Association of Race/Ethnicity, Persistent Poverty, and Opioid Access Among Patients with Gastrointestinal Cancer Near the End of Life

BACKGROUND

Social determinants of health (SDoH) can impact access to healthcare. We sought to assess the association between persistent poverty (PP), race/ethnicity, and opioid access among patients with gastrointestinal cancer near the end-of-life (EOL).

METHODS

SEER-Medicare patients with gastric, liver, pancreatic, biliary, colon, and rectal cancer were identified between 2008 and 2016 near EOL, defined as 30 days before death or hospice enrolment. Data were linked with county-level poverty from the American Community Survey and the US Department of Agriculture (2000-2015). Counties were categorized as never high-poverty (NHP), intermittent high-poverty (IHP) and persistent poverty (PP). Trends in opioid prescription fills and daily dosages (morphine milligram equivalents per day) were examined.

RESULTS

Among 48,631 Medicare beneficiaries (liver: n = 6551, 13.5%; pancreas: n = 13,559, 27.9%; gastric: n = 5486, 1.3%; colorectal: n = 23,035, 47.4%), there was a steady decrease in opioid prescriptions near EOL. Black, Asian, Hispanic, and other racial groups had markedly decreased odds of filling an opioid prescription near EOL (Black: OR 0.84, 95% CI 0.79-0.90; Asian: OR 0.86, 95% CI 0.79-0.94; Hispanic: OR 0.90, 95% CI 0.84-0.95; Other: OR 0.83, 95% CI 0.74-0.93; all p < 0.05). Even after filling an opioid prescription, this subset of patients received lower daily doses versus White patients (Black: -16.5 percentage points, 95% CI -21.2 to -11.6; Asian: -11.9 percentage points, 95% CI -18.5 to -4.9; Hispanic: -19.1 percentage points, 95%CI -23.5 to -14.6; all p < 0.05). The disparity in opioid access and average daily doses among was attenuated in IHP/PP areas for Asian, Hispanic, and other racial groups, yet exacerbated among Black patients.

CONCLUSIONS

Race/ethnicity-based disparities in EOL pain management persist with SDoH-based variations in EOL opioid use. In particular, PP impacted EOL opioid access and utilization.

Race, Ethnicity, and Sustained Opioid Use After Major Abdominal Surgery for Cancer

Purpose

Sustained opioid use is a well-known complication after surgery. Our objective was to determine whether there is any association between a patient's race or ethnicity and the sustained use of opioids in the year following surgery. Opioid use over the initial 3, 6, and 12 postoperative months was categorized as "sustained early", persistent, and chronic, respectively.

Patients and Methods

Single-institution retrospective study of adults (≥18 years) who had undergone open abdominal surgery for cancer. Multivariable logistic regression was used to evaluate the association between race/ethnicity and opioid use.

Results

Of the 3523 patients included in the study, 2543 (72.2%) were non-Hispanic (NH) White, 476 (13.5%) were Hispanic or Latino, 262 (7.4%) were NH-Black, 186 (5.3%) were Asian, and 56 (1.6%) belonged to other racial or ethnic groups. The overall rates of sustained early, persistent, and chronic opioid use were 15.9%, 7.1%, and 2.6%, respectively. In the multivariable analysis, patient race/ethnicity was associated with sustained early postoperative opioid use (p-value=0.037), with Hispanics/Latinos having significantly higher odds than NH-Whites (OR = 1.382 [95% CI: 1.057-1.808]; p = 0.018). However, neither persistent nor chronic opioid use was associated with race/ethnicity (p = 0.697 and p = 0.443, respectively).

Conclusion

In this retrospective study of adults who had undergone open abdominal surgery, patient race/ethnicity was not consistently associated with the development of sustained opioid use over the first 12 postoperative months.

Opioid Monitoring Using Urine Toxicology Screens in Outpatient Oncology Palliative Medicine

PURPOSE

There is a paucity of real-world data on opioid screening and urine toxicology testing in outpatient oncology palliative medicine.

METHODS

This was a retrospective analysis of adult patients with cancer completing ≥ one outpatient palliative medicine visit and the Edmonton Symptom Assessment Scale (ESAS). Patient demographics, the Screener and Opioid Assessment for Patients with Pain-Short Form (SOAPP-SF), ESAS, medications, and urine toxicology screens (UTSs) were collected at baseline and follow-up visits. The primary end point was the frequency and type(s) of noncompliant UTSs (ie, presence of a nonprescribed substance or absence of a prescribed substance). Secondarily, risk factors for noncompliant UTSs were evaluated using univariate and multivariable logistic regression.

RESULTS

Of 189 evaluable patients (632 clinic visits), 113 underwent ≥one UTSs, 125 SOAPP-SF, and 75 had both. The median age was 56 (range, 26-80) years, 56% were female, 58% were White, 40% were Black, 48% had stage IV disease, the median baseline pain score was 7, and the median SOAPP-SF was 3. Oxycodone was the most prescribed drug (n = 125). Of 113 patients who underwent UTSs, 54% (n = 61) had ≥one noncompliant result. Thirty-nine percent (n = 44) had a total of 128 noncompliant results for the presence of a nonprescribed substance; 29% (n = 33) had a total of 53 noncompliant results for the absence of a prescribed substance. SOAPP-SF Q4 (use of illegal drugs) (odds ratio [OR], 3.61; 95% CI, 1.81 to 7.19; P < .001) and prescription with nonopioid adjuvant medications (OR, 2.83; 95% CI, 1.12 to 7.19; P = .029) were associated with increased odds of a noncompliant UTS.

CONCLUSION

More than half of the tested population had noncompliant UTS. Screening and evaluating risk factors for nonmedical opioid use is critical in oncology palliative medicine.

Racial and Ethnic Disparities in Opioid Access and Urine Drug Screening Among Older Patients With Poor-Prognosis Cancer Near the End of Life

PURPOSE

To characterize racial and ethnic disparities and trends in opioid access and urine drug screening (UDS) among patients dying of cancer, and to explore potential mechanisms.

METHODS

Among 318,549 non-Hispanic White (White), Black, and Hispanic Medicare decedents older than 65 years with poor-prognosis cancers, we examined 2007-2019 trends in opioid prescription fills and potency (morphine milligram equivalents [MMEs] per day [MMEDs]) near the end of life (EOL), defined as 30 days before death or hospice enrollment. We estimated the effects of race and ethnicity on opioid access, controlling for demographic and clinical factors. Models were further adjusted for socioeconomic factors including dual-eligibility status, community-level deprivation, and rurality. We similarly explored disparities in UDS.

RESULTS

Between 2007 and 2019, White, Black, and Hispanic decedents experienced steady declines in EOL opioid access and rapid expansion of UDS. Compared with White patients, Black and Hispanic patients were less likely to receive any opioid (Black, -4.3 percentage points, 95% CI, -4.8 to -3.6; Hispanic, -3.6 percentage points, 95% CI, -4.4 to -2.9) and long-acting opioids (Black, -3.1 percentage points, 95% CI, -3.6 to -2.8; Hispanic, -2.2 percentage points, 95% CI, -2.7 to -1.7). They also received lower daily doses (Black, -10.5 MMED, 95% CI, -12.8 to -8.2; Hispanic, -9.1 MMED, 95% CI, -12.1 to -6.1) and lower total doses (Black, -210 MMEs, 95% CI, -293 to -207; Hispanic, -179 MMEs, 95% CI, -217 to -142); Black patients were also more likely to undergo UDS (0.5 percentage points; 95% CI, 0.3 to 0.8). Disparities in EOL opioid access and UDS disproportionately affected Black men. Adjustment for socioeconomic factors did not attenuate the EOL opioid access disparities.

CONCLUSION

There are substantial and persistent racial and ethnic inequities in opioid access among older patients dying of cancer, which are not mediated by socioeconomic variables.

Racial disparities in opioid prescription and pain management among breast cancer survivors

BACKGROUND

We examined whether there are racial disparities in pain management, opioid medicine prescriptions, symptom severity, and quality of life constructs in breast cancer survivors.

METHODS

We conducted a secondary analysis of longitudinal data from the Women's Hormonal Therapy Initiation and Persistence (WHIP) study (n = 595), a longitudinal study of hormonal receptor-positive breast cancer survivors. Upon study enrollment, patients completed a survey assessing an array of psychological, behavioral, and treatment outcomes, including adjuvant endocrine therapy (AET)-induced symptoms, and provided a saliva biospecimen. Opioid prescription records were extracted from the health maintenance organizations (HMOs) pharmacy database. The final analytic sample included women with complete HMO pharmacy records for 1 year.

RESULTS

There were 251 eligible patients, of which 169 (67.3%) were White. The average age was 61.09 years old (SD = 11.07). One hundred seventy-two patients (68.5%) had received at least one opioid medication and 37.1% were prescribed opioids longer than 90 days (n = 93). Sixty-four Black patients (78%) had a record of being prescribed with opioids compared to 64% of White patients (n = 108, p = 0.03). Black patients reported worse vasomotor, neuropsychological, and gastrointestinal symptoms, as well as lower quality of life and greater healthcare discrimination than White patients (p's < 0.05). Black patients were more likely to be prescribed opioids for 90 days or longer compared to White patients, when controlling for age, marital status, income, body mass index (BMI), cancer stage, and chemotherapy status (adjusted Odds Ratio = 2.72, p = 0.014).

CONCLUSION

Findings indicate that there are racial differences in opioid prescriptions supplied for pain management and symptomatic outcomes. Future research is needed to understand the causes of disparities in cancer pain management and symptomatic outcomes.

Sociodemographic Differences in Patient-Reported Pain and Pain Management of Patients With Head and Neck Cancer in a Community Oncology Setting

PURPOSE

While pain is prevalent among survivors of head and neck cancer (HNC), there is a lack of data on pain management in the community oncology setting. We described sociodemographic correlates and disparities associated with patient-reported pain among patients with HNC.

METHODS

We used the 2017-2021 nationwide community oncology data set from Navigating Cancer, which included electronic patient-reported outcomes. We identified a retrospective cohort of patients diagnosed with HNC (N = 25,572), with ≥ 1 patient-reported pain event. We adjusted for demographic (sex, age, smoking history, marital status) and clinical (cancer site) factors associated with pain reporting and pain resolution by new pain prescription on the basis of race (White v non-White patients), using multivariate logistic regression models.

RESULTS

Our analytic cohort included 2,331 patients, 90.58% White, 58.62% married, with an average age of 66.47 years. Of these, 857 patients (36.76%) reported ≥ 1 pain event during study period. Mean resolution time (in minutes) for pain incidents was significantly longer for White patients than non-White patients (99.6 ± 3.2 v 74.9 ± 7.2, P < .05). After adjusting for covariates, smoking was associated with a 25% increased odds of reporting pain incidents (adjusted odds ratio [aOR], 1.25; 95% CI, 1.03 to 1.52). There was no statistically significant difference in odds of pain reporting between White versus non-White patients (aOR, 0.97; 95% CI, 0.73 to 1.30). However, White patients were significantly more likely to receive new prescription for pain than non-White patients (aOR, 2.52; 95% CI, 1.09 to 5.86).

CONCLUSION

We found racial differences in patient-reported pain management, with White patients significantly more likely to receive new pain prescriptions. As pain management is a mainstay in cancer care, equity in pain management is critical to optimize quality of life for patients with HNC.

Use of Opioids for Adults With Pain From Cancer or Cancer Treatment: ASCO Guideline

PURPOSE

To provide guidance on the use of opioids to manage pain from cancer or cancer treatment in adults.

METHODS

A systematic review of the literature identified systematic reviews and randomized controlled trials of the efficacy and safety of opioid analgesics in people with cancer, approaches to opioid initiation and titration, and the prevention and management of opioid adverse events. PubMed and the Cochrane Library were searched from January 1, 2010, to February 17, 2022. American Society of Clinical Oncology convened an Expert Panel to review the evidence and formulate recommendations.

RESULTS

The evidence base consisted of 31 systematic reviews and 16 randomized controlled trials. Opioids have primarily been evaluated in patients with moderate-to-severe cancer pain, and they effectively reduce pain in this population, with well-characterized adverse effects. Evidence was limited for several of the questions of interest, and the Expert Panel relied on consensus for these recommendations or noted that no recommendation could be made at this time.

RECOMMENDATIONS

Opioids should be offered to patients with moderate-to-severe pain related to cancer or active cancer treatment unless contraindicated. Opioids should be initiated PRN (as needed) at the lowest possible dose to achieve acceptable analgesia and patient goals, with early assessment and frequent titration. For patients with a substance use disorder, clinicians should collaborate with a palliative care, pain, and/or substance use disorder specialist to determine the optimal approach to pain management. Opioid adverse effects should be monitored, and strategies are provided for prevention and management.Additional information is available at www.asco.org/supportive-care-guidelines.

Physical and mental health quality of life among underserved African American and Latino older adults

OBJECTIVES

There is an increasing amount of research on Health-Related Quality of Life (HRQoL) among older adults in the U.S. However, under-resourced and underserved African American and Latino older adults remain underrepresented in research and interventional studies, resulting in limited data on their quality of life and health promotion practices. This study examined the association between HRQoL and several layers of independent variables, including health conditions, level of pain, sleep disorders, and lifestyle factors, among African American and Latino older adults.

DESIGN

Nine hundred and five African Americans and Latinos aged 55 years and older from an underserved urban community participated in this face-to-face structured study. Multiple linear regression was performed.

RESULTS

This study documented that HRQoL among African American and Latino participants was substantially lower compared with their White counterparts reported by other studies. Adjusting for other relevant variables, this study documented an association between: (1) physical HRQoL and financial strain, perceived health, the severity of pain, number of major chronic conditions, smoking, and binge drinking; and (2) mental HRQoL and financial strain, perceived health status, the severity of pain, and sleep disorders.

CONCLUSION

Significantly lower levels of HRQoL among underserved African American and Latino older adults, compared with their White counterparts, point to another important racial/ethnic disparity in the U.S. geriatric population. The devastating consequences of financial strain, excessive chronic conditions, undiagnosed and untreated pain, and sleep disorders are all experienced by underserved African American and Latino older adults, and these factors directly contribute to a lower quality of life among this segment of our population. Longitudinal multi-faceted, multi-disciplinary, culturally sensitive, both clinic- and community-based participatory interventions are needed to address these factors, particularly pain and sleep disorders, in order to enhance the quality of life among these underserved communities.

Music Therapy for Pain in Black and White Cancer Patients: A Retrospective Study

CONTEXT

Racial pain disparities present challenges to cancer symptom management. Music therapy has demonstrated benefits for pain and is a promising treatment option for diverse populations due to music's multicultural presence. However, Black cancer patients are under-represented in music therapy trials.

OBJECTIVES

This study compared pain severity, treatment approaches, and responses to music therapy between Black and white cancer patients. The findings will be used to generate hypotheses for future music therapy research to address racial disparities in pain management.

METHODS

We conducted a retrospective program evaluation of Black and white patients who received music therapy at an NCI-Designated Comprehensive Cancer Center. We used the Edmonton Symptom Assessment Scale (ESAS) to assess pain. We abstracted opioid use, music therapy referral reasons, and treatment approaches from the electronic health record.

RESULTS

Among 358 patients, 18% were Black, 42% reported moderate-to-severe pain, and 47% received opioids. Black patients reported higher baseline pain than white patients, but similar proportions of Black and white patients received opioids. Greater proportions of Black patients received music therapy referrals for pain (73% vs. 56%, P = 0.04) and engaged in active techniques (92% vs. 82%, P = 0.04). Black and white patients reported clinically meaningful pain reduction of similar magnitude after music therapy. Black patients discussed spirituality more commonly during music therapy, whereas white patients focused on family bonds.

CONCLUSION

Black and white patients reported clinically meaningful pain reduction through varying music therapy approaches. Our findings may help inform cultural adaptations of music therapy to address racial pain disparities in oncology.