Risk for Opioid-Related Death Very Low in Cancer Patients

Roxanne Nelson, BSN, RN

October 03, 2018

Opioid use by cancer patients is associated with a much lower risk for opioid-related death in comparison with the general population, according to new findings.

In the first study to comprehensively explore the risks associated with opioid use in this population, researchers found that cancer patients are 10 less likely to die as a result of opioid use, as compared to those without cancer.

During the 10-year period from 2006 to 2016, opioid deaths jumped from 5.33 to 8.97 per 100,000 people in the general population, but among cancer patients, opioid deaths rose from 0.52 to 0.66 per 100,000.

Overall, opioids accounted for the death of 895 cancer patients during that period, compared to 193,500 in the general population.

The findings were presented at the American Society of Clinical Oncology (ASCO) Quality Care Symposium (QCS).

The results of our study were truly surprising. Dr Fumiko Chino

"The results of our study were truly surprising," said lead author Fumiko Chino, MD, a radiation oncologist at the Duke Cancer Institute in Durham, North Carolina. "There were some limited data from prior to the opioid epidemic that cancer patients may be at lower risk for overdose, but there was no evidence what the current risk for opioid overdose was in our patient population — or if that risk had been rising at the rapid rate seen in the general population."

She told Medscape Medical News that the "differences in overdose rates were truly striking."

Patients with cancer are a vulnerable population, and some have posited that they may be at higher risk for overdose, owing to comorbidities such as depression and anxiety. In addition, smoking or alcohol use that may be associated with risk for substance abuse disorder. "Our study shows that the vast majority of cancer patients are not at risk for opioid overdose and are likely using their medications as prescribed for appropriate control of cancer related pain," Chino said.

Chino noted that because this is a retrospective study and data are limited, the investigators were unable to assess rates of opioid addition or opioid use disorder in the cancer patient population. But the low overall rates of overdose do suggest that this is not a population with rapidly increasing rates of addiction.

"Based on my own anecdotal data, however, I will state that the vast majority of my patients do not want to be on these medications and rapidly decrease or terminate the use of opioids when they are no longer required to manage symptoms," she emphasized. "One of the most impressive aspects of our study is the low rates of opioid overdose in cancer patients, despite what I know is much higher exposure to opioid medications than the general population."

In a discussion of the paper, David Hui, MD, University of Texas MD Anderson Cancer Center, Houston, explained that there is a potentially higher risk for opioid misuse in cancer patients because of greater exposure to opioids, as well as the presence of risk factors and psychological distress.

One caveat of this study is that the data used are dependent on the accuracy of death certificates, and opioid overdose and cancer may not be both recorded, he explained. "Cancer patients may be more likely to be coded as dying of cancer, so opioid-related, so it may be underreported."

Differences Between Populations

Chino and her colleagues used the National Center for Health Statistics to identify opioid deaths in cancer patients from 2006 to 2016. Aside from the much smaller number of deaths, cancer patients who died from opioid use differed in several ways from those in the general population who died because of opioids.

Cancer patients were more highly educated (12.7% vs 6.9% with at least a college degree), more likely to be female (38.5 vs 29.2%), less likely to be white (82.3 vs 84.2%), and more likely to be non-Hispanic (94.5 vs 91.3%), and fewer were single (24.2 vs 48.1%) (for all except race, P < .001; for race, P = .027). In addition, cancer patients were older (median age, 57 years; interquartile range [IQR], 50 - 65 years, vs median age, 42 years; IQR, 31 - 51 years).

Deaths from opioid use were higher for patients with certain types of cancer, including lung (22%), gastrointestinal (21%), head and neck (12%), hematologic (11%), and genitourinary (10%) cancers.

Reassurances for Providers and Policy Makers

Meeting discussant Hui surmised that there are a number of potential reasons for the significantly lower rates among cancer patients. "They tend to be older, which puts them at a lower risk; they have an evidence-based indication; and they are regularly monitored by physicians," he said. "They also have greater access to psychological support and palliative care and a competing risk for mortality for those with advanced disease."

He also pointed out that these results provide reassurance for clinicians treating cancer pain and provide data for public policy makers. "Nowadays, there is a tremendous amount of discussion in the government as well as other institutions to limit the opioid dose for patients with nonmalignant pain, and some of this debate is slipping into the oncology world as well," Hui said. "So any more data to support that cancer patients are at a lower risk are very much welcome."

Chino agreed that her study provides some reassurance to both providers and patients that opioid medications can be used safely and effectively for cancer-related pain. "Opioid-related deaths in the cancer patient are not rising at the rate of the general population," she emphasized. "I absolutely believe that restrictive prescribing patterns should not affect access to opioids for patients with cancer, given their much lower risk for overdose."

Dr Chino has disclosed no relevant financial relationships. Dr Hui's has received institutional research funding from Helsinn Therapeutics, Insys Therapeutics, and Teva.

American Society of Clinical Oncology (ASCO) Quality Care Symposium (QCS). Abstract 230, presented September 28, 2018.

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