Opioid Epidemic or Pain Crisis?

Using the Virginia All Payer Claims Database to Describe Opioid Medication Prescribing Patterns and Potential Harms for Patients With Cancer

Virginia T. LeBaron, PhD; Fabian Camacho, MS; Rajesh Balkrishnan, PhD; Nengliang (Aaron) Yao, PhD; Aaron M. Gilson, PhD


J Oncol Pract. 2019;15(12):e997-e1009. 

In This Article

Abstract and Introduction


Purpose: A key challenge regarding the current opioid epidemic is understanding how concerns regarding opioid-related harms affect access to pain management, an essential element of cancer care. In certain regions of the United States where disproportionately high cancer mortality and opioid fatality rates coexist (such as southwest Virginia in central Appalachia), this dilemma is particularly pronounced.

Methods: This longitudinal, exploratory, secondary analysis used the Commonwealth of Virginia All Payer Claims Database to describe prescription opioid medication (POM) prescribing patterns and potential harms for adult patients with cancer living in rural southwest Virginia between 2011 and 2015. Descriptive and inferential statistical analyses were conducted at the patient, prescriber, and prescription levels to identify patterns and predictors of POM prescribing and potential harms. To explore geographic patterns, choropleth and heat maps were created.

Results: Of the total sample of patients with cancer (n = 4,324), less than 25% were prescribed a Controlled Substance Schedule II POM at least three times in any study year. More than 60% of patients never received a Controlled Substance Schedule II POM prescription. Six hundred fifty-two patients (15.1%) experienced 1,599 hospitalizations for any reason; 10 or fewer patients were admitted for 11 opioid use disorder–related hospitalizations. The main findings suggest potential undertreatment of cancer-related pain; no difference in risk for opioid-related hospitalization on the basis of frequency of POM prescriptions; and geographic disparities where opioid overdoses are occurring versus where POM prescription use is highest.

Conclusion: These findings have significant opioid policy and practice implications related to the need for cancer-specific prescribing guidelines, how to optimally allocate health delivery services, and the urgent need to improve data interoperability and access related to POMs.


The United States is coping with two opioid-related epidemics. In one epidemic, patients with legitimate medical need continue to suffer and die in avoidable pain;[1,2] it is estimated that anywhere from 60% to 90% of patients with cancer, even those with metastatic disease, experience untreated or undertreated pain.[3,4] In the other epidemic, a mainstay class of medications used to treat serious cancer pain (prescription opioid medications [POMs]) are implicated in a concerning number of fatalities.[5–8] A key challenge is understanding how concerns regarding POM-related harms affect access to pain management, an essential element of cancer care.

For a variety of complex social, economic, and cultural reasons, these dual epidemics present particular challenges in certain regions of the United States, such as southwest Virginia.[9–13] Southwest Virginia is a rural and medically underserved area in central Appalachia struggling with the confluence of disproportionately high rates of cancer[14] and high rates of opioid-related fatalities.[7] For example, within the rural central Appalachian counties of Virginia, West Virginia, and Kentucky, cancer death rates were 15% to 36% higher than those in non-Appalachian urban areas.[14] Concurrently, some of the highest mortality rates for POM overdoses in the United States occur within the same region; an example is Buchanan County in rural southwest Virginia with a POM fatal overdose rate in 2018 of 23.4 to 46.5 per 100,000.[7] Little is known about the intersection of these epidemics and how to most effectively and safely manage pain in a region where there exists both a high cancer burden and significant misuse of POMs.[15]