Many patients who die of cancer receive no or delayed prescriptions for strong opioid medications, according to a study published in the journal Pain.
Most patients with advanced cancer experience pain, often severe, but inadequate treatment of cancer pain continues to be a major public health problem. Efforts to improve treatment of cancer pain may be hindered by concern over the ongoing opioid epidemic, especially among patients with non-cancer pain.
Lucy Ziegler, PhD, University of Leeds, Leeds, United Kingdom, and colleagues used UK Cancer Registry Data to study about 4,600 cancer patients who died between 2005 and 2012 and who received at least 1 prescription for an analgesic.
The analysis focused on the extent and duration of treatment with strong opioids, such as morphine. The authors cite UK statistics showing overall opioid prescribing increased by 466% between 2000 and 2010, but only by 16% increase for patients with cancer.
Overall, 48% of patients received at least 1 prescription for strong opioids in the year before they died. Another 25% of patients were prescribed weak opioids, such as codeine; the rest received only non-opioid pain medications.
Certain groups of patients were more or less likely to be treated with strong opioids. Patients who died in a hospital were 60% less likely to have a prescription for strong opioids during the last year of life, compared with those who died in hospice. Patients who received chemotherapy in the last year of life were 30% more likely to receive a strong opioid.
For patients receiving strong opioids, the median time between receiving a strong opioid and death was 9 weeks. By 6 weeks before death, just 30% of patients had been prescribed a strong opioid.
“This doesn’t match up with previous studies reporting that severe pain can occur much earlier in the cancer trajectory,” the authors wrote.
Older patients were more likely to have late opioid prescribing (defined as later than 9 weeks before death). After other factors were taken into account, patients aged 60 years or older were about 2 to 4 times more likely to be in the late-prescribing group, compared with those aged 50 years or younger.
Late opioid prescribing was more likely for patients who died in a hospital, at home, or in a care home (compared with hospice setting), and less likely for those who received chemotherapy or radiation therapy.
“Our data supports the hypothesis of potential undertreatment of cancer pain and suggests that many more patients with advanced cancer and pain may benefit from a strong opioid analgesic,” the authors wrote.
The lower rate of early opioid treatment for patients who die in a hospital may reflect poor pain control as the reason for hospital admission, the authors suggest. They also call for further studies to find out why opioid treatment is more likely to be delayed in older patients.
The authors acknowledge some important limitations of their study, especially the lack of data on pain severity.
“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 concluded. “One mechanism to achieve this is through earlier integration of palliative care to improve pain control and begin to address the inequalities evidenced here.”
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