Study Finds Disparities in Access to Opioids for Cancer Pain at End of Life

Older Black and Hispanic patients with advanced cancer are less likely than White patients to receive opioid medications for pain relief in the last weeks of life, according to the results of a recent study published in the Journal of Clinical Oncology.1

The study comes at a time when tightened restrictions on prescription opioids, prompted by the national epidemic of opioid abuse, have significantly decreased availability to these medications. Although the restrictions are not specifically aimed at patients with cancer, researchers have documented a decline in patient access to opioid medications, even at the end of life (EOL).

“Most previous studies of inequities in cancer pain management were conducted before the full scope of the opioid crisis was recognized and regulations to curb opioid prescribing were put in place,” the study’s lead investigator Andrea C. Enzinger, MD, Assistant Professor, Medical Oncology, Dana-Farber Cancer Institute, and Assistant Professor, Medicine, Harvard Medical School, Boston, MA, said in a news release.2

Andrea C. Enzinger, MD

“Over the past decade, there has been a seismic shift in prescribing practices and sharp declines in access to these medications for patients with cancer. But we know very little about the current state of disparities in access in this environment of increased regulation, and about the magnitude of disparities among patients with terminal cancer,” she added.

Study Details

Dr Enzinger and colleagues examined racial and ethnic disparities and trends in opioid prescription orders between 2007 and 2019 among 318,549 Medicare recipients who had poor-prognosis cancers and were nearing the EOL. They also assessed disparities in urine drug screening among these patients.

A total of 272,358 recipients were White, 29,555 were Black, and 16,636 were Hispanic. The mean patient age was 77.6 years; 18.2% of the cohort were aged ≥85 years. Lung cancer was the most common malignancy in all 3 racial groups.

Compared with White patients, Black and Hispanic patients had a lower likelihood of receiving any opioid (Black patients, –4.3 percentage points; 95% confidence interval [CI], –4.8 to –3.6; Hispanic patients, –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).

Black patients received lower daily doses of opioids (10.5 morphine milligram equivalents [MME]/day; 95% CI, –12.8 to –8.2), followed by Hispanic patients (9.1 MME/day; 95% CI, –12.1 to –6.1), compared with White patients. Black patients also received lower total doses (210 MME/day; 95% CI, –293.1 to –181.3) near the EOL, followed by Hispanic patients (179.7 MME/day; 95% CI, –217.1 to –142.3), compared with White patients.

In addition, Black patients were required to submit to urine drug screenings more frequently than White or Hispanic patients throughout the study period. From 2007 to 2019, the proportion of patients undergoing such screenings in the 180 days before death or entry to hospice care increased from 0.5% to 6.6% for White patients compared with 1.0% to 7.9% for Black patients. Urine testing increased from 0.5% to 6.8% for Hispanic patients.

The investigators reported that these disparities in treatment were found to exist even after correcting for measures of poverty, community-level deprivation, or rurality.

Limitations of the study included the assessment of opioid prescription fills and not unfulfilled prescriptions, lack of examination of opioid prescriptions in hospice, and that the findings only represent Medicare beneficiaries and are likely conservative estimates of prescribing disparities, the researchers noted.

“In summary, from 2007 to 2019, we observed dramatic declines and substantial racial and ethnic inequities in prescription opioid access among Medicare beneficiaries with poor-prognosis cancers near EOL,” Dr Enzinger and colleagues concluded, adding that they will follow up on their findings with research to identify the main causes of these inequities, and ultimately to target those causes with novel interventions.

References

  1. Enzinger AC, Ghosh K, Keating NL, et al. Racial and ethnic disparities in opioid access and urine drug screening among older patients with poor-prognosis cancer near the end of life. J Clin Oncol. 2023 Jan 10. Epub ahead of print.
  2. Dana-Farber Cancer Institute. Study finds racial inequities in access to opioids among older patients with cancer near end of life. January 10, 2023. www.dana-farber.org/newsroom/news-releases/2023/study-finds-racial-inequities-in-access-to-opioids-among-older-patients-with-cancer-near-end-of-life/. Accessed February 17, 2023.

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