Opioid-related hospitalizations among patients with cancer appear to be rare but are increasing slowly over time. Clinicians should screen for risk factors of opioid abuse prior to prescribing opioids for cancer-related pain.


 

Opioids are routinely prescribed for cancer-related pain, but little is known about the prevalence of opioid-related hospitalizations among patients with cancer. “This is an important topic because oncologists and palliative care clinicians must often balance providing patients legitimate access to opioids while protecting them from risks associated with these medications,” explains Isaac S. Chua, MD. Few studies have explored opioid-related harm in patients with cancer. Some estimates have shown that the rate of opioid addiction in people with cancer is as high as 7.7%, but these data are based on small, preliminary studies.

For a research letter published in JAMA Oncology, Dr. Chua and colleagues examined trends and risk factors of opioid-related hospitalizations among patients with cancer between 2006 and 2014 using the United States National Inpatient Sample of the Healthcare Cost and Utilization Project. “We wanted to understand national trends and risk factors of opioid-related harm for patients with cancer by examining the prevalence of opioid-related hospitalizations in this patient population,” says Dr. Chua. Opioid-related hospitalizations were identified using ICD-9 codes for heroin poisoning, opioid poisoning, and opioid dependence or abuse in the primary diagnosis field.

 

Important New Data

According to the study, just over 14,000 (0.06%) of the more than 25 million overall hospitalizations for patients with cancer were opioid related. A linear regression model approximated an increasing trend in the overall number of opioid-related hospitalizations from 2006 to 2014 with an average increase of 78.9 admissions per year. After adjusting for all-cause hospitalizations, the linear time trend of opioid-related hospitalizations increased on average by 0.003% per year.

“In general, opioid-related hospitalizations were rare among patients with cancer, but they appear to be gradually increasing over time,” says Dr. Chua. When the study team stratified their findings by diagnosis type, they found that non-heroin opioid poisoning accounted for 88.0% of all opioid-related hospitalizations (Figure). Several factors were associated with opioid-related hospitalizations for patients with cancer, including:

  • Drug abuse (odds ratio [OR], 7.92; 95% confidence interval [CI], 95-9.02)
  • Depression (OR, 2.34; 95% CI 13-2.58)
  • Psychotic disorders (OR, 4.13; CI 66-4.65)

White race, younger age, and year of hospitalization were also linked to higher rates of opioid-related hospitalizations for these patients. Alcohol abuse was associated with opioid-related hospitalizations, but the association was not significant (OR, 1.15; 95% CI 0.99-1.35).

 

Assessing the Implications

The characteristics linked to opioid-related hospitalizations among patients with cancer in the study were consistent with established risk factors for opioid abuse in those without cancer. “Prescribing opioids is not without risk, especially for certain patients with cancer,” Dr. Chua says. “Prior to prescribing opioids to these patients, routinely screening for risk factors of opioid abuse may identify people at greatest risk of an opioid-related hospitalization. Understanding this risk may better inform clinical decision making around opioid prescribing and monitoring.”

Dr. Chua notes that identifying risk factors may be particularly helpful when managing high-risk patients. “These individuals may require more frequent follow-up visits, random urine drug testing, or early referrals to addiction medicine or psychiatry,” he says. “Identifying these risk factors early will allow clinicians to develop patient care plans that provide adequate pain control while minimizing risks of opioid-related harm.”

Currently, clinicians have little guidance on pain management in patients with both cancer and aberrant opioid use behavior. Further complicating matters is that there is no “usual” dose of opioid prescribed to patients because each individual will have different needs when it comes to treating pain. Although there is no validated screening tool for cancer patients, several screening tools have been validated in the non-cancer patient population and are free, including the Opioid Risk Tool (available at http://www.drugabuse.gov). This brief, self-report screening tool is designed for use in adult patients to assess risk for opioid abuse among those prescribed these drugs for treating chronic pain. “Screening patients for these risk factors using a standardized tool, such as the Opioid Risk Tool, may optimize efforts for safe prescribing practices, especially among high-risk patients,” Dr. Chua says.

References

Chua IS, Leiter RE, Brizzi KT, et al. US national trends in opioid-related hospitalizations among patients with cancer. JAMA Oncol. 2019;5(5):734-735. Available at: https://jamanetwork.com/journals/jamaoncology/fullarticle/2729062.

Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6(6):432-442.

Childers JW, King LA, Arnold RM. Chronic pain and risk factors for opioid misuse in a palliative care clinic. Am J Hosp Palliat Care. 2015;32(6):654-659.

Song Z. Mortality quadrupled among opioid-driven hospitalizations, notably within lower-income and disabled white populations. Health Aff (Millwood). 2017;36(12):2054-2061.