Underprescription of Opioids in Cancer Patients During End of Life – Christina T. Loguidice – January 05, 2017
Researchers have provided the first detailed analysis of the relatively late onset and short duration of strong opioid treatment in cancer patients before death, lending support to the hypothesis that — despite opioid prescribing increasing exponentially for other types of pain, raising concerns of an international opioid prescribing epidemic — cancer-related pain is being undertreated.
“For patients with cancer, opioid prescribing has not increased to the same extent and still represents only 16.1% of all opioid prescriptions issued in the United Kingdom,” wrote Lucy Ziegler, PhD, from the University of Leeds, UK and colleagues, citing National Health Service data.2 “Our [study] data suggest that many more patients with advanced cancer and pain may benefit from a strong opioid analgesic.”
This is true of many pain patients because there is NO DIFFERENCE between cancer and non-cancer pain.
Patients in the cohort were stratified into 3 analgesic groups:
- those who received no analgesics;
- those who received at least 1 prescription for nonopioids/weak opioids, but no strong opioids; and
- those who received at least 1 prescription for a strong opioid.
The group that received a strong opioid was further divided into
- early receivers (given ≥10 weeks before death) and
- late receivers (given ≤9 weeks before death)
to determine factors affecting prescription timing.
Among the cohort, 1470 patients had received no analgesics and the remaining 4610 cumulatively received 96 810 analgesic prescriptions, with
- 31.5% being for nonopioids,
- 25.2% being for weak opioids, and
- 43.3% being for strong opioids.
The number of opioids prescribed is usually an indicator of how much pain the patient is suffering, yet this is never mentioned as the underlying reason for prescribing opioids.
Different cancers cause very different amounts and types of pain (superficial melanoma versus bone cancer), so the cancer type, severity. and the resulting amount of pain should determine the need for opioids, not prescribing statistics.
- 48% of patients received at least 1 prescription for a strong opioid, but only
- 30% received a strong opioid at 6 weeks before death.
When examining opioid prescriptions, the investigators found
- 36.7% were for morphine,
- 15.9% for diamorphine (This is heroin)
- 11.2% for oxycodone,
- 10.4% for fentanyl,
- 3.7% for buprenorphine, and
- 0.3% for other agents.
Patients who died in the hospital versus in a hospice setting were 60% less likely to receive a strong opioid in the community in the last year of life whereas patients who received chemotherapy in the last year of life were 30% more likely to receive a strong opioid than those who did not receive chemotherapy
Summary & Clinical Applicability
“The clinical implications of this study are clear; within the advanced cancer population, there is a need to develop mechanisms to improve pain assessment and initiate a more proactive approach to prescribing, particularly for older patients,” the authors wrote.
“One mechanism to achieve this is through earlier integration of palliative care to improve pain control and begin to address the inequalities evidenced here,” they concluded.
This is true for all those suffering from constant pain, whether they have cancer or not.