Cancer Patients Face Difficulties in Getting Opioids

Alicia Ault

June 26, 2018

WASHINGTON — Cancer patients have found it more difficult to receive opioids since the opioid epidemic has been in the news and since new policies to stem abuse have been introduced.

During the past year and a half (from late 2016 to May 2018), cancer patients and survivors have experienced increasing barriers to getting opioid prescriptions, a new survey has found.

The nationwide survey was conducted for the American Cancer Society Cancer Action Network (ACS CAN) and the Patient Quality of Life Coalition (PQLC). The survey focused on patients who take or have taken opioid medications. It included 300 cancer patients and survivors, as well as 150 patients with other serious illnesses and 155 patients with chronic pain.

"This research tells an important story about how changes that have been implemented over the past two years related to prescription opioid medications are impacting patient access," the ACS stated.

The survey found that 43% of cancer patients take opioids, which is the same amount reported 2 years ago. However, fewer cancer survivors are now taking opioids — the figure is now 10%, compared to 24% in 2016.

Barriers to access included difficulties in obtaining opioid medications.

Forty-one percent of cancer patients and survivors said they could not get an opioid because the pharmacy did not have the drug in stock, compared to just 16% who reported that problem in 2016. A little more than a third reported being questioned by a pharmacist about why they needed an opioid, and 27% said the pharmacist would not fill the prescription, even if the medication was in stock, a 15% increase from 2 years ago.

Similarly, a third of respondents said their insurer would not cover their opioid prescription, a 19% rise. A quarter to a third said they faced other barriers, including being limited to a single pharmacy for opioid prescriptions (an 18% increase), having the number of refills reduced (up 15% from 2016), and having the number of pills in each prescription reduced.

ACS CAN released the data as Congress is poised to take action on a number of opioid-related bills. The patient advocacy group said the survey shows that some policies already in place may be having an adverse effect on those who need the medications.

"Policy solutions must be balanced in a way that doesn't lead to the unintended consequence of creating barriers to legitimate pain care for those with serious or chronic conditions including cancer," said Keysha Brooks-Coley, vice president of federal advocacy for ACS CAN and chair of the PQLC coalition, in a statement.

Frederick Schnell, MD, FACP, medical director of the Community Oncology Alliance (COA), said he remembers when clinicians fought to increase access to better and stronger analgesics for patients with cancer. "There was an underprescribing problem that took a long time to fix," Schnell told Medscape Medical News.

But the pendulum is swinging in the other direction, said Schnell, who is also medical director of the Georgia Center for Research and Oncology Education, in Atlanta. "I think it may have swung a little bit too far as we try to get access to care for patients," he said.

The survey found that almost half of cancer patients and survivors said their physician told them that pain treatment options were limited by laws, guidelines, or insurance coverage; 35% of patients said their physician had refused to give them an opioid prescription. A quarter said the pharmacist would only dispense part of the prescription, advising them to come back again if they needed more.

Judith Paice, PhD, RN, director of the Cancer Pain Program at Northwestern University Feinberg School of Medicine, Chicago, Illinois, said what the survey shows is not surprising. "It certainly reinforces what I've been hearing from my patients and what I've been seeing," Paice told Medscape Medical News.

In a recent opinion piece in Cancer, Paice warned of a perfect storm of continued undertreatment of cancer pain, physician reluctance to prescribe opioids, and the fact that some cancer patients are likely at much higher risk for substance use disorders — an issue that will grow with the increasing number of cancer survivors.

Limitations at the pharmacy may come because some retailers have made a concerted effort to stock minimal amounts of the medications, said Paice, who is also a member of the American Society of Clinical Oncology's (ASCO's) chronic pain guideline panel.

It's not always the pharmacy that's the barrier, she said. Patients "don't understand that the decision was made by the insurance company," Paice said.

Some states have passed laws that limit opioid prescriptions. New research from the consulting firm Avalere found that in states where limits have been set, declines in opioid sales have been steeper than the national average. Overall, opioid sales declined 11% across the nation in 2017. In states that had limitations, opioid sales decreased 13% to 25%, according to Avalere.

Policy Fixes?

Congress has developed dozens of legislative proposals to address the opioid crisis, some of which may soon come to fruition.

ACS CAN singled out one as deserving of support, the Palliative Care Hospice Education and Training Act (PCHETA), which would increase federal funding for research efforts to improve pain treatments, foster the development of nonopioid treatments for pain, and establish education and training programs in pain management for healthcare providers.

Paice said, "I'm primarily dismayed by many of the bills that have been introduced."

The ACS CAN survey asked patients and survivors to rate their support for 20 policies currently under consideration. The top five were as follows:

  • Expanding prescription drug monitoring programs (PDMPs) so physicians and pharmacists can check whether a patient has filled opioid prescriptions in other states

  • Requiring all physicians and pharmacists to check their state's PDMP every time they write or fill a prescription for opioids to ensure their patient does not already have an opioid prescription from another physician or pharmacist in their state

  • Requiring patients who have received multiple opioid prescriptions from multiple physicians to have only one designated physicians prescribe their opioid medications

  • Increasing US Food and Drug Administration (FDA) efforts to approve new nonopioid treatments

  • Requiring health insurance plans to cover alternative ways to treat pain, such as physical therapy and other nonmedication treatments, in order to make these alternatives as affordable for patients as opioids

ACS CAN said that physicians who participated in focus groups related to the survey supported those policies. They were also in favor of increasing federal funding of pain treatment research, organizing and implementing prescription drug take-back or drug disposal programs, and increasing the quality and availability of training for physicians and other healthcare professionals in pain management.

Schnell said the COA was in favor of increasing the use of PDMPs. But he said increasing FDA approval of nonopioid treatments was somewhat of a red herring, inasmuch as it's up to pharmaceutical companies to develop such therapies.

Paice said, "I'm primarily dismayed by many of the bills that have been introduced."

She noted that both the ACS and ASCO have opposed policies that lock patients into receiving opioids from a single physician. "The way these particular policies are being advanced, it will delay patients from getting their medications," she said. For instance, on occasions in which a physician is not available, a colleague would not be able to write prescriptions for that physican's patients. "It will mean that you can never take a vacation," she said, adding, "If the patient needs the medication, then they won't get it."

The bottom line, said Paice, is that in 2018, patients are "definitely going to see more barriers" to getting access to opioids.

Dr Schnell and Dr Paice have disclosed no relevant financial relationships.

ACS CAN. Opioid Access Research Project summary. Full text

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