A Different Kind of Opioid Crisis in Cancer Patients

Nick Mulcahy

September 21, 2016

Terminal cancer patients in the United Kingdom are not getting strong pain treatment in a timely manner, say researchers.

The median time between the first prescription of a "strong" opioid and death was only 9 weeks, according to a study of a representative population sample of advanced cancer patients in the United Kingdom. The study was published online September 15 in Pain.

That's a problem, say the authors, because epidemiologic data indicate that the onset of pain typically occurs much earlier in such patients.

"We have identified...the relatively late onset and short duration of strong opioid treatment in cancer patients prior to death," said lead study author Lucy Ziegler, PhD, a senior research fellow in palliative care in the Leeds Institute of Health Sciences, in a press statement.

"Pain can be experienced at many stages throughout the illness of cancer; in fact, pain is the most common presenting symptom at diagnosis," Dr Ziegler told Medscape Medical News in an email.

The undertreatment of cancer pain is also a problem in the United States, said Judith A. Paice, PhD, RN, research professor in medicine-hematology/oncology at Northwestern University in Chicago, Illinois. Dr Paice is an expert who was not involved in the current study.

"The problem in the United States may be worsening through the unintentional consequences associated with measures to limit the opioid abuse epidemic," Dr Paice told Medscape Medical News.

The problem in the United States may be worsening Dr Judith Paice/span>

The new study is the first to determine the median interval between the first prescription of a strong opioid and death in a large population.

The researchers used UK Cancer Registry data to study a sample of 6080 patients who died of cancer between 2005 and 2012.

Overall, fewer than half of all study patients (48%) received a strong opioid, and in that group, an average of only four prescriptions were issued during the median duration of 9 weeks before death.

Strong opioids include morphine, oxycodone, fenantyl, buprenorphine, and diamorphine and are distinguished from "weak" opioids.

The study authors point out that their newly found opioid prescription rate of 48% is consistent with another recent UK study that reported that 43.6% of patients with cancer received an opioid in the last months of life (J Clin Oncol. 2012;10:4373-9). Also, within the past 10 years or so, a Dutch study (Pharmacoepidemiol Drug Saf. 2009;18:16-23) and a Danish study (J Pain Symptom Manage. 2005;29:336-43) found that 51% and 54% of cancer patients, respectively, were prescribed an opioid in the last 12 months of life.

The authors of the new study say that in advanced cancer, the prevalence of pain is estimated to be roughly 60% to 90% of all patients. Therefore, these data collectively suggest that cancer pain is undertreated in various major European countries.

The social context of the new study is also important, suggest the researchers.

Echoing the comment from Northwestern University's Dr Paice, they explain that there is now a fear of an epidemic of opioid overuse in the United States and throughout Europe and that that may be inadvertently affecting cancer patients.

In England, the growing use of buprenorphine, oxycodone hydrochloride, and morphine sulphate increased annual costs for these three drugs by more than £10 million (US$12.98 million) between 2002 and 2013. Also, dispensing data reported by the UK National Health and Social Care Information Center show a 466% increase in opioid prescribing between 2000 and 2010.

However, in cancer patients, opioid prescribing has not increased as dramatically and represents only 16.1% of all opioid prescriptions issued in the United Kingdom, the authors say.

For cancer patients, there are evidently barriers to accessing these drugs, which need to be identified and overcome, the authors declare.

Dr Paice has advice for clinicians working with people who have cancer: "The lesson is to be aware of the potential for pain, conduct a thorough pain assessment and physical examination, while considering pharmacologic and nonpharmacologic therapies that may be safe and effective."

Other Findings

Reviewing a centralized UK prescriptions database, the authors extracted all prescriptions for analgesics issued to each patient in the cohort during the 12 months before death.

The team found that 96,810 analgesic prescriptions were issued to 4610 patients in the study; 31.5% of all prescriptions were for nonopioids, 25.2% for weak opioids, and 43.3% for strong opioids.

The team also analyzed the extent and duration of strong-opioid treatment with respect to clinical and patient characteristics.

Strong-opioid prescribing was not influenced by cancer type, duration of illness, or sex but was adversely influenced by older age, they report.

Patients aged 60 years or older were between 1.7 and 4.3 times more likely to receive a late prescription of a strong opioid in comparison with patients younger than 50 years.

Compared with patients who died in a hospice, those who died in a hospital were 60% less likely to receive a strong opioid in primary care before admission (relative risk ratio, 0.4; 95% confidence interval, 0.3 - 0.5; P < .01).

The authors took into consideration the fact that the overall finding of belated pain treatment may be a result of late cancer diagnoses by UK oncologists. But they investigated that possibility and rejected it as an explanation.

"Median survival for our sample from diagnosis was 60 weeks, suggesting that most opioid prescribing in fact occurred late in the trajectory between diagnosis and death, regardless of cancer duration," summarized coauthor Mike Bennett, St. Gemma's Professor of Palliative Medicine, University of Leeds, in a press statement.

Dr Ziegler also pointed out that more than 90% of all patients in the cohort had received some form of cancer treatment. "Therefore, it was not the absence of a cancer diagnosis or poor engagement with cancer services that hindered timely access to an opioid," she said.

Dr Ziegler argued that "effective pain control is fundamental to good quality of life.

"For patients who are approaching the end of their lives, it is crucially important we strive to get this right and that we help them achieve the best quality of life possible," she said.

The study was funded by the National Institute for Health Research. The authors have disclosed no relevant financial relaitonships.

Pain. Published online September 15. Abstract

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