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Racial stigma regarding opioid use disorder (OUD) and opioid misuse affect access to cancer pain management for patients in the United States.

Black Americans’ excess burdens of cancer pain and opioid overdose are major public health and clinical challenges, and providers can take steps to decrease these disparities in cancer pain care management, according to a commentary in the Journal of Clinical Oncology.

“The United States requires a critical examination of opioid-prescribing policies and practices in the context of cancer to avoid further perpetuating disparities among patients with comorbid cancer pain, OUD [opioid use disorder, opioid use that causes significant problems in daily life], and opioid misuse [opioid use in ways other than prescribed that may lead to opioid-related harms],” Katie Fitzgerald-Jones, PhD, APN, CARN-AP and her colleagues wrote.

Racial Disparities Affect Cancer Pain Management

Race-based attitudes toward OUD and opioid misuse make it difficult for Black Americans to have equitable access to cancer pain medications, according to the authors.

Buprenorphine and methadone are considered “gold-standard” OUD treatments and can be used to treat cancer pain, but strict federal regulations create barriers to methadone access for comorbid cancer pain and OUD. Methadone for OUD is typically prescribed to patients who are considered high-risk and require greater clinical oversight. Black Americans are more likely to receive methadone than buprenorphine, and they may need to travel long distances and undergo frequent in-person dosing, counseling, and urine drug testing.

“Patients have reported methadone for OUD akin to liquid handcuffs,” the authors wrote.

By contrast, although buprenorphine for OUD can be accessed in the provider’s office without additional licensure requirements under the Consolidated Appropriations Act (2023), it is rarely included in cancer pain guidelines or readily prescribed in cancer care. Buprenorphine is more likely used by White patients and patients who are college-educated, employed, or likely to use prescription opioids rather than obtain them outside the medical system.

Screening Tools Reinforce Disparities

Cancer guidelines recommend screening for opioid misuse risk. However, the screening tools are not very accurate in predicting OUD or opioid-related harms and they can reinforce racism. For example, the Screener for Opioid Assessment for Patients with Pain (SOAPP) and the revised SOAPP-R questionnaires ask about the patient’s history of legal problems or arrests.

“Given that definitions of criminality are rooted in structural racism with disparities in policing and justice system involvement, racialized groups who experience greater criminalization and respond affirmatively to this question may be flagged as more at risk of opioid misuse,” the authors noted.

Once an opioid-misuse screening tool labels a person at risk for misuse, cancer-specific guidelines suggest closer follow-up. Compared with White patients, Black patients receive closer monitoring, less frequent opioid doses, and fewer long-acting opioids. Black patients are also more likely to undergo urine drug testing and have their opioids tapered.

Practical Steps Can Improve Equity

Dr. Fitzgerald-Jones and her colleagues suggested several actions oncologists and other providers can take to improve equity in access to opioids for cancer pain, including the following:

• Improve access to methadone. Develop strategies to improve methadone access for people with OUD and cancer through community pharmacies, medical offices, and telehealth. Consider continuing methadone for OUD outside of methadone clinics and prescribing buprenorphine for OUD and some opioid misuse behaviors, in keeping with recent expert consensus-based guidance on opioid decision making for patients with advanced cancer and opioid misuse or OUD.
• Build team-based care. In primary care settings, nurses and pharmacists should be involved in providing buprenorphine and facilitating home-based initiation.
• Reevaluate Screening Practices. National cancer guidelines should reconsider the utility of opioid misuse screening tools to dictate opioid care. Clinicians can, instead, improve equity by regularly assessing opioid risks and benefits, and exploring differential diagnoses for opioid misuse, including pain self-management and opioid education, naloxone prescribing, care coordination, and gradual opioid tapering.
• Educate Clinicians. With only 45.5% of US cancer centers offering substance use services, educate and train oncology clinicians to more effectively manage pain, prescribe opioids, reduce harm, and treat substance use.
• Conduct research. Investigate ways to integrate the needs for pain management, OUD treatment, and equitable opioid access.