Prescriptions for opioids declined in states with mandatory-access Rx monitoring programs

Cancer patients who were prescribed opioids for pain control were much less likely to die from overdose compared with the general population, a longitudinal study from the United States found.

From 2006 through 2016, death from opioid overdose was 10 times less likely to be listed as the primary cause of death in individuals who had cancer compared with individuals who did not have cancer, Fumiko Chino, MD, Memorial Sloan Kettering Cancer Center in New York, and colleagues reported in a research letter published in JAMA Oncology.

“Opioid-related deaths in the cancer population are much rarer than in the general population,” the authors observed. “Continued care should be taken when treating cancer-related pain.”

Death certificate data were obtained from the National Center for Health Statistics between the years 2006 through to 2016. “All deaths owing to opioids were included,” the authors noted. “[I]f present, cancer was noted as a contributing cause.”

Over the decade reviewed, 193,500 deaths due to opioid overdose were documented in the general population. This compared to only 895 deaths in the population who had cancer, the researchers observed.

Over the same time interval, the number of opioid-related deaths in the general population increased from 5.33 per 100,000 to 8.97 per 100,000, they wrote. In contrast, the number of opioid-related deaths in individuals with cancer increased from 0.52 per 100,000 to 0.66 per 100,000 (P<0.001).

The authors pointed out that some types of cancer seem to be associated with a higher risk of opioid overdose. This includes head and neck cancer, which represented 12% of opioid-related deaths in this study despite the fact that head and neck cancer represents under 4% of new cancer diagnoses.

On the other hand, “one-third of patients experience cancer-related pain after curative treatment,” the authors emphasized.

This is an important observation, as prescribing restrictions to reduce the risk of opioid abuse have reduced access to needed pain control in patients on active cancer treatment and for long-term survivors who continue to experience pain. For example, one study of patients referred to palliative care found that opioid doses had dropped by almost half from 2010-2015.

Another study found that the number of patients with cancer, as well as the number of long-term survivors who required an opioid for pain control, also dropped by more than half from 2016-2019.

Over 40,000 people in the U.S. died in 2016 from opioid overdose.

PDMPs and Opioids

In a separate research letter also published in JAMA Oncology, investigators found that the number of oncology patients registered with Medicare who filled a prescription for opioids declined in states where mandatory-access prescription drug monitoring programs (PDMPs) had been enacted.

As Ilana Graetz, PhD, Rollins Emory University in Atlanta, Georgia and colleagues pointed out, over 30 states have now enacted laws mandating use of PDMPs to reduce inappropriate opioid prescribing.

Physicians practicing in those states must check the PDMP database before issuing a prescription for an opioid, although in some states, patients with cancer are exempted from this mandate.

For their data, researchers used the Medicare Part D prescriber files for the years 2013 through to 2017, restricting their sample to practitioners who specialized in medical or hematologic oncology.

“By 2017, 21 states had implemented mandatory-access PDMPs, including 5 states that explicitly exempted the reviewing requirement for patients with cancer,” Graetz and colleagues explained.

Compared with practitioners in states with no mandated PDMP, the proportion of oncologists’ patients who filled an opioid prescription declined by 4.8% between 2013 and 2017 in states where mandatory PDMP orders had been enacted.

In states where mandatory PDMPs had been implemented but which exempted cancer patients, the number of patients who filled an opioid prescription over the same time interval declined by 2.8% compared to states where PDMPs had not been mandated.

“There is growing concern that some physicians—burdened by the task of consulting a PDMP and added scrutiny over their prescribing — have reduced their opioid prescribing even for patients with legitimate pain management needs,” Graetz and colleagues observed.

“From our early results, we find that exemptions for patients with a cancer diagnosis did not shield Medicare patients treated by a medical or hematologic oncologist from the unintended spillovers of mandated PDMP requirements,” they stated, adding that as more states consider policies to curtail the opioid crisis, “it is critical to understand how [these policies] affect both problematic and legitimate opioid use.”

Commenting on findings from both studies, James Murphy, MD, University of California, in San Diego and colleagues pointed out that as noted by Chino, et al themselves, physicians may have been far less likely to consider opioid overdose as a cause of death among patients with cancer than in the general population.

“This misattribution bias could lead to underreporting of opioid-related mortality among patients in this population,” they suggested.

Nevertheless, the editorialists felt that the data provided by Chino, et al should reassure health care providers that death from opioid abuse is rare among cancer patients and that rates have not increased very much over time.

They also pointed out that the study by Graetz et al evaluated prescription practices only among oncology providers and not from other providers who could also prescribe opioids, including primary care providers, those in palliative care, or other specialties.

That said, Murphy et al felt that the study demonstrated that prescription practices in states where PDMPs had been mandated had reduced opioid prescriptions only modestly— “[suggesting] that oncologists continue to prioritize pain management,” they underscored.

The editorialists acknowledge that the opioid epidemic continues to be a “critical public health concern” and one deserving of public policy attention.

Nevertheless, considerable concern has been expressed that overly conservative policies may be undermining the need for good pain management and leave much of cancer-related pain undertreated.

“The available research…underscores the fact that the needs and risks of patients with cancer diverge from the general noncancer population,” they stated.

“[W]e need to make sure we protect individuals with cancer,” Murphy and colleagues emphasize.

  1. Cancer patients prescribed an opioid for pain control were 10 times less likely to die of overdose than the general population over a study interval of 10 years.

  2. Prescriptions for opioids have declined in states where prescription drug monitoring programs (PDMPs) have been mandated compared with states where PDMPs have not been enacted.

Pam Harrison, Contributing Writer, BreakingMED™

No funding sources were stated for either study.

Chino reported receiving grants from Varian and the Chanel Endowment for Survivorship Research.

Neither Graetz nor her coauthors had any conflicts of interest to declare.

Murphy reported receiving personal fees from the Boston Consulting Group.

Cat ID: 393

Topic ID: 392,393,393,570,730,935,192,922