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

Authors: Lindsay M. Sabik PhD1, Kirsten Y. Eom MPH1, Zhaojun Sun PhD1, Jessica S. Merlin MD, PhD, MBA2,3, Hailey W. Bulls PhD, MA2,3, Patience Moyo PhD4, Jennifer A. Pruskowski PharmD5, G.J. van Londen MD, MS6,7, Margaret Rosenzweig PhD, CRNP-C, AOCNP8, and Yael Schenker MD, MAS, FAAHPM2,3
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  • 1 Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania;
  • | 2 Palliative Research Center (PaRC), and
  • | 3 Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania;
  • | 4 Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island;
  • | 5 Division of Geriatric Medicine,
  • | 6 Division of Hematology-Oncology, and
  • | 7 Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
  • | 8 Department of Acute & Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania.

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.

Submitted May 4, 2021; final revision received September 1, 2021; accepted for publication October 18, 2021. Published online March 1, 2022.

Author contributions: Study concept and design: Sabik, Schenker. Data acquisition and analysis: Sabik, Sun, Eom. Data interpretation: All authors. Writing – original draft: Sabik. Critical revision: All authors.

Disclosures: Dr. Merlin has disclosed receiving grant/research support from the Cambia Health Foundation. The remaining authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Funding: Research reported in this publication was supported by the University of Pittsburgh Medical Center Hillman Cancer Center Developmental Funding Program through the NCI of the NIH under award number P30CA047904 (Y. Schenker) and the Palliative Research Center at the University of Pittsburgh. It was also supported by the National Center for Advancing Translational Sciences of the NIH under award number KL2TR001856 (H.W. Bulls). Data were provided by University of Pittsburgh Medical Center Registry Services and the University of Pittsburgh’s Health Record Research Request (R3) service supported by the NIH through grant UL1 TR001857.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Correspondence: Lindsay M. Sabik, PhD, Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, A613 Public Health, 130 De Soto Street, Pittsburgh, PA 15261. Email: lsabik@pitt.edu

Supplementary Materials

    • Supplemental Materials (PDF 468 KB)
  • 1.

    te Boveldt N, Vernooij-Dassen M, Burger N, et al. Pain and its interference with daily activities in medical oncology outpatients. Pain Physician 2013;16:379389.

  • 2.

    Rodriguez C, Ji M, Wang HL, et al. Cancer pain and quality of life. J Hosp Palliat Nurs 2019;21:116123.

  • 3.

    Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA 2009;302:741749.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4.

    Efficace F, Bottomley A, Smit EF, et al. Is a patient’s self-reported health-related quality of life a prognostic factor for survival in non-small-cell lung cancer patients? A multivariate analysis of prognostic factors of EORTC study 08975. Ann Oncol 2006;17:16981704.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    O’Connor M, Weir J, Butcher I, et al. Pain in patients attending a specialist cancer service: prevalence and association with emotional distress. J Pain Symptom Manage 2012;43:2938.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    van den Beuken-van Everdingen MH, Hochstenbach LM, Joosten EA, et al. Update on prevalence of pain in patients with cancer: systematic review and meta-analysis. J Pain Symptom Manage 2016;51:10701090.e9.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    McGuire DB. Occurrence of cancer pain. J Natl Cancer Inst Monogr 2004;2004:5156.

  • 8.

    Portenoy RK. Treatment of cancer pain. Lancet 2011;377:22362247.

  • 9.

    Glare PA, Davies PS, Finlay E, et al. Pain in cancer survivors. J Clin Oncol 2014;32:17391747.

  • 10.

    World Health Organization. Cancer Pain Relief: With a Guide to Opioid Availability, 2nd ed. Geneva, Switzerland: World Health Organization; 1996.

    • Search Google Scholar
    • Export Citation
  • 11.

    American Society of Clinical Oncology. Important cancer exemption in proposal to reduce prescription drug misuse in Medicaid. Accessed May 1, 2021. Available at: https://www.asco.org/practice-policy/policy-issues-statements/asco-in-action/important-cancer-exemption-proposal-reduce?cid=DM5750&bid=53516042

    • Search Google Scholar
    • Export Citation
  • 12.

    Meara E, Horwitz JR, Powell W, et al. State legal restrictions and prescription-opioid use among disabled adults. N Engl J Med 2016;375:4453.

  • 13.

    Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA 2016;315:16241645.

  • 14.

    Paice JA. Under pressure: the tension between access and abuse of opioids in cancer pain management. J Oncol Pract 2017;13:595596.

  • 15.

    American Society of Clinical Oncology. ASCO policy statement on opioid therapy: protecting access to treatment of cancer-related pain. Accessed May 19, 2020. Available at: https://www.asco.org/sites/new-www.asco.org/files/content-files/advocacy-and-policy/documents/2016-ASCO-Policy-Statement-Opioid-Therapy.pdf

    • Search Google Scholar
    • Export Citation
  • 16.

    Graetz I, Yarbrough CR, Hu X, et al. Association of mandatory-access prescription drug monitoring programs with opioid prescriptions among Medicare patients treated by a medical or hematologic oncologist. JAMA Oncol 2020;6:11021103.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17.

    Agarwal A, Dayal A, Kircher SM, et al. Analysis of price transparency via National Cancer Institute-designated cancer centers’ chargemasters for prostate cancer radiation therapy. JAMA Oncol 2020;6:409412.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Haider A, Zhukovsky DS, Meng YC, et al. Opioid prescription trends among patients with cancer referred to outpatient palliative care over a 6-year period. J Oncol Pract 2017;13:e972981.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 19.

    Azizoddin DR, Knoerl R, Adam R, et al. Cancer pain self-management in the context of a national opioid epidemic: experiences of patients with advanced cancer using opioids. Cancer 2021;127:32393245.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Schenker Y, Hamm M, Bulls HW, et al. This is a different patient population: opioid prescribing challenges for patients with cancer-related pain. JCO Oncol Pract 2021;17:e10301037.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Chino FL, Kamal A, Chino JP. Opioid-associated deaths in patients with cancer: a population study of the opioid epidemic over the past 10 years [abstract]. J Clin Oncol 2018;36(Suppl):Abstract 230.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22.

    Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA 2011;305:13151321.

  • 23.

    Carmichael AN, Morgan L, Del Fabbro E. Identifying and assessing the risk of opioid abuse in patients with cancer: an integrative review. Subst Abuse Rehabil 2016;7:7179.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Sutradhar R, Lokku A, Barbera L. Cancer survivorship and opioid prescribing rates: a population-based matched cohort study among individuals with and without a history of cancer. Cancer 2017;123:42864293.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Anghelescu DL, Ehrentraut JH, Faughnan LG. Opioid misuse and abuse: risk assessment and management in patients with cancer pain. J Natl Compr Canc Netw 2013;11:10231031.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Childers JW, King LA, Arnold RM. Chronic pain and risk factors for opioid misuse in a palliative care clinic. Am J Hosp Palliat Care 2015;32: 654659.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 27.

    Merlin JS, Childers J, Arnold RM. Chronic pain in the outpatient palliative care clinic. Am J Hosp Palliat Care 2013;30:197203.

  • 28.

    Moyo P, Gellad WF, Sabik LM, et al. Opioid prescribing safety measures in Medicaid enrollees with and without cancer. Am J Prev Med 2019;57:540544.

  • 29.

    National Institute on Drug Abuse. Opioid summaries by state. Accessed May 18, 2020. Available at: https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state

    • Search Google Scholar
    • Export Citation
  • 30.

    UPMC facts and stats. Accessed April 24, 2020. Available at: https://www.upmc.com/about/facts

  • 31.

    UPMC Cancer Center. About UPMC. Accessed April 24, 2020. Available at: https://hillman.upmc.com/difference/about

  • 32.

    Center for Rural Pennsylvania. Rural urban definitions. Accessed June 5, 2020. Available at: https://www.rural.palegislature.us/demographics_rural_urban.html

    • Search Google Scholar
    • Export Citation
  • 33.

    National Center for Injury Prevention and Control, CDC. Drug overdose deaths. Accessed June 5, 2020. Available at: https://www.cdc.gov/drugoverdose/deaths/index.html

    • Search Google Scholar
    • Export Citation
  • 34.

    Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin 2020;70:730.

  • 35.

    Tuminello S, Schwartz RM, Liu B, et al. Opioid use after open resection or video-assisted thoracoscopic surgery for early-stage lung cancer. JAMA Oncol 2018;4:16111613.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 36.

    Cuthbert CA, Xu Y, Kong S, et al. Patient-level factors associated with chronic opioid use in cancer: a population-based cohort study. Support Care Cancer 2020;28:42014209.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37.

    Lee JS, Hu HM, Edelman AL, et al. New persistent opioid use among patients with cancer after curative-intent surgery. J Clin Oncol 2017;35:40424049.

  • 38.

    Vitzthum LK, Riviere P, Sheridan P, et al. Predicting persistent opioid use, abuse, and toxicity among cancer survivors. J Natl Cancer Inst 2020;112:720727.

  • 39.

    Barbera L, Sutradhar R, Howell D, et al. Factors associated with opioid use in long-term cancer survivors. J Pain Symptom Manage 2019;58:100107.e2.

  • 40.

    Meghani SH, Byun E, Gallagher RM. Time to take stock: a meta-analysis and systematic review of analgesic treatment disparities for pain in the United States. Pain Med 2012;13:150174.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41.

    Young JL, Roffers SD, Gloeckler Ries LA, et al., eds. SEER Summary Staging Manual - 2000: Codes and Coding Instructions, NIH Pub. No. 01-4969. Bethesda, MD: National Cancer Institute; 2001.

    • Search Google Scholar
    • Export Citation
  • 42.

    Chen L, Chubak J, Yu O, et al. Changes in use of opioid therapy after colon cancer diagnosis: a population-based study. Cancer Causes Control 2019;30:13411350.

  • 43.

    Marcusa DP, Mann RA, Cron DC, et al. Prescription opioid use among opioid-naive women undergoing immediate breast reconstruction. Plast Reconstr Surg 2017;140:10811090.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44.

    Roberts AW, Fergestrom N, Neuner JM, et al. New-onset persistent opioid use following breast cancer treatment in older adult women. Cancer 2020;126:814822.

  • 45.

    Brescia AA, Harrington CA, Mazurek AA, et al. Factors associated with new persistent opioid usage after lung resection. Ann Thorac Surg 2019;107:363368.

  • 46.

    Salz T, Lavery JA, Lipitz-Snyderman AN, et al. Trends in opioid use among older survivors of colorectal, lung, and breast cancers. J Clin Oncol 2019;37:10011011.

  • 47.

    Schieber LZ, Guy GP Jr, Seth P, et al. Trends and patterns of geographic variation in opioid prescribing practices by state, United States, 2006-2017. JAMA Netw Open 2019;2:e190665.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48.

    Murthy VH. Letter from United States Surgeon General Vivek H. Murthy, MD, MBA. Accessed May 19, 2020. Available at: http://i2.cdn.turner.com/cnn/2016/images/08/25/sg.opioid.letter.pdf

    • Search Google Scholar
    • Export Citation
  • 49.

    Winstanley EL, Zhang Y, Mashni R, et al. Mandatory review of a prescription drug monitoring program and impact on opioid and benzodiazepine dispensing. Drug Alcohol Depend 2018;188:169174.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 50.

    Centers for Medicare and Medicaid Services. CMS roadmap: strategy to fight the opioid crisis. Accessed May 19, 2020. Available at: https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Opioid-epidemic-roadmap.pdf

    • Search Google Scholar
    • Export Citation
  • 51.

    Fisch MJ, Chang VT. Striving for safe, effective, affordable care for cancer survivors with chronic pain: another kind of moonshot. JAMA Oncol 2016;2:862864.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 52.

    Bruera E. Parenteral opioid shortage—treating pain during the opioid-overdose epidemic. N Engl J Med 2018;379:601603.

  • 53.

    Paice JA. Navigating cancer pain management in the midst of the opioid epidemic. Oncology (Williston Park) 2018;32:386390., 403.

  • 54.

    Paice JA. Cancer pain management and the opioid crisis in America: how to preserve hard-earned gains in improving the quality of cancer pain management. Cancer 2018;124:24912497.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 55.

    American Cancer Society Cancer Action Network. Key findings summary: Opioid Access Research Project. Accessed May 19, 2020. Available at: https://www.fightcancer.org/sites/default/files/ACS%20CAN%20PQLC%20Opioid%20Research%20Project%20Key%20Findings%20Summary%20Memo%20FINAL.pdf

    • Search Google Scholar
    • Export Citation
  • 56.

    Mills SEE, Nicolson KP, Smith BH. Chronic pain: a review of its epidemiology and associated factors in population-based studies. Br J Anaesth 2019;123:e273283.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 57.

    van Hecke O, Torrance N, Smith BH. Chronic pain epidemiology – where do lifestyle factors fit in? Br J Pain 2013;7:209217.

  • 58.

    Whiteman DC, Wilson LF. The fractions of cancer attributable to modifiable factors: a global review. Cancer Epidemiol 2016;44:203221.

  • 59.

    Gegechkori N, Haines L, Lin JJ. Long-term and latent side effects of specific cancer types. Med Clin North Am 2017;101:10531073.

  • 60.

    Moryl N, Coyle N, Essandoh S, et al. Chronic pain management in cancer survivors. J Natl Compr Canc Netw 2010;8:11041110.

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