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CME / ABIM MOC / CE

Should We Be Controlling Opioid Use in Individuals With Cancer?

  • Authors: MDEdge News Author: M. Alexander Otto, MMS, PA; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 10/20/2020
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 10/20/2021
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Target Audience and Goal Statement

This article is intended for hematologists/oncologists, geriatricians, internists, psychiatrists, nurses, pharmacists and other members of the health care team who treat and manage patients with cancer pain for whom opioids may be indicated.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  • Assess temporal patterns in opioid prescribing for Medicare beneficiaries among oncologists and nononcologists, based on an analysis using the Centers for Medicare and Medicaid Services Part D prescriber dataset
  • Evaluate the clinical implications of temporal patterns in opioid prescribing for Medicare beneficiaries among oncologists and nononcologists, based on an analysis using the Centers for Medicare and Medicaid Services Part D prescriber dataset
  • Outline implications for the healthcare team


Disclosures

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Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


MDEdge News Author

  • M. Alexander Otto, MMS, PA

    Disclosures

    Disclosure: M. Alexander Otto, MMS, PA, has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer, Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Editor/Nurse Planner

  • Hazel Dennison, DNP, RN, FNP-BC, CHCP, CPHQ, CNE

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Hazel Dennison, DNP, RN, FNP-BC, CHCP, CPHQ, CNE, has disclosed no relevant financial relationships.

CME Reviewer

  • Esther Nyarko, PharmD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Disclosure: Esther Nyarko, PharmD, has disclosed no relevant financial relationships.

Medscape, LLC staff have disclosed that they have no relevant financial relationships. 


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CME / ABIM MOC / CE

Should We Be Controlling Opioid Use in Individuals With Cancer?

Authors: MDEdge News Author: M. Alexander Otto, MMS, PA; CME Author: Laurie Barclay, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME / ABIM MOC / CE Released: 10/20/2020

Valid for credit through: 10/20/2021

processing....

Clinical Context

The US opioid epidemic has appropriately engendered strategies to curb opioid prescribing, which is associated with long-term opioid use. These strategies include the creation of prescription drug monitoring programs, state-based opioid prescription limits, and national prescribing guidelines.

However, patients with cancer often need opioids for symptom management, and it was previously undetermined whether these efforts have affected prescribing by oncologists. The goal of this analysis using the Centers for Medicare and Medicaid Services Part D prescriber dataset was to examine temporal patterns in opioid prescribing for Medicare beneficiaries among both oncologists and nononcologists.

Study Synopsis and Perspective

Regulations to curb opioid abuse might be blocking legitimate access by patients with cancer who need opioids for pain, according to a review of Medicare prescription claims data.

Researchers found that from 2013 to 2017, opioid prescribing in the United States dropped by 20.7% among oncologists (from 68.5 to 54.3 opioids per 100 beneficiaries; P<.001) and 22.8% among nononcologist physicians (from 49.5 to 38.2 opioids per 100 beneficiaries; P<.001).

"Given similar declines in opioid prescribing among oncologists and non-oncologists, there is concern that opioid prescribing guidelines intended for the non-cancer population are being applied inappropriately to patients with cancer and survivors," say the investigators, led by Vikram Jairam, MD, a therapeutic radiology resident at Yale University School of Medicine, New Haven, Connecticut.

"While caution against opioid misuse in cancer survivors is certainly warranted, appropriate pain management is equally as critical to ensure the best quality of life for these patients," they comment.

The review was published online on August 12 in the Journal of the National Cancer Institute.[1]

"An important unanswered question" in this study "is whether the reductions in opioid prescribing observed were appropriate or inappropriate," say medical oncologists Andrea Enzinger, MD, and Alexi Wright, MD, from the Dana-Farber Cancer Institute, Boston, Massachusetts, in an accompanying editorial.[2]

To answer this, it is essential to determine whether reductions occur "in patients on active treatment, cancer survivors, or those with advanced disease -- for whom preserving opioid access is of utmost importance," they say.

Review of Medicare Claims Data

During the past decade, multiple legislative and policy efforts have led to a clampdown on inappropriate opioid prescribing while there has been an unprecedented spike in opioid deaths. Although cancer was sometimes excluded from the new regulations, oncologists faced additional prescription hurdles, and reports began to emerge of restricted access for patients with cancer, the authors comment.

To get an idea of how these issues have played out nationally, the Yale team turned to Medicare Part D claims data. Their investigation included more than 300 million opioid prescriptions during a 5-year period from 21,041 oncologists and 723,861 nononcologists, including 4115 palliative care physicians.

Reductions were driven primarily by a 30% drop in hydrocodone-acetaminophen prescribing likely related to its reclassification as a schedule II substance in 2014, as well as similar declines in long-acting opioid prescriptions, especially oxycodone.

These reductions corresponded to a 23.1% increase in gabapentin prescriptions among nononcologists and a 5.9% increase among oncologists. Gabapentin was prescribed as an alternative to opioids, although the "evidence regarding [gabapentin] efficacy in treating cancer-related pain has been mixed," the authors noted.

Opioid prescribing increased by 15.3% (from 241.9 to 278.9 opioids per 100 beneficiaries; P<.001) among palliative care providers, "suggesting that oncologists and non-oncologists may be referring their patients with chronic pain to specialty care for symptom management," Dr Enzinger and Dr Wright say in their editorial.

Shift to Palliative Care

The new regulatory burdens "likely disincentivize oncologists from prescribing, potentially shifting this responsibility to palliative care," the editorialists comment.

"Palliative care is still a relatively small, and primarily hospital-based specialty," they write. "[w]hether it is capable of taking over pain management for all of these patients remains to be seen."

The editorialists were also concerned that opioid access might be more difficult now for patients with cancer than it was in 2017, when the study's data window closed.

"It is important to note that opioid regulations have increased substantially since the tail end of the study period, when the [Centers for Disease Control and Prevention] published influential guidelines on opioid therapy for chronic non-cancer pain [in April 2016].... Following these guidelines, more than half of states have implemented 7-14 day limits on initial opioid prescriptions, and several commercial pharmacies followed suit with their own restrictions," they note.

"It will therefore be critical to continue monitoring trends in oncologists' opioid prescribing as more recent data becomes available. To protect access cancer patients' access, it is critical for policy solutions to lessen rather than add to oncology providers' workload," they say.

The study received no external funding. The authors and editorialist have disclosed no relevant financial relationships.

J Natl Cancer Inst. Published online August 12, 2020.

Study Highlights

  • Data for this analysis came from the Centers for Medicare and Medicaid Services Part D prescriber dataset for all physicians between January 1, 2013, and December 31, 2017.
  • The dataset included more than 300 million opioid prescriptions from 21,041 oncologists and 723,861 nononcologists, including 4115 palliative care physicians.
  • Prescribing rate was defined as the annual number of drug claims (original prescriptions and refills) per beneficiary.
  • The association between time and per provider opioid and gabapentinoid prescribing rate among oncologists and nononcologists on a national and state level was estimated using population-averaged multivariable negative binomial regression.
  • From 2013 to 2017, the national opioid prescribing rate decreased by 20.7% among oncologists (going from 68.5 to 54.3 opioids per 100 beneficiaries; P<.001) and by 22.8% among nononcologists (from 49.5 to 38.2 opioids per 100 beneficiaries; P<.001).
  • This change in opioid prescribing patterns was mostly driven by decreased prescribing of hydrocodone-acetaminophen (30% decrease) and long-acting opioids, particularly oxycodone.
  • In the same period, gabapentin prescribing increased by 5.9% (P<.001) among oncologists and by 23.1% (P<.001) among nononcologists, respectively.
  • Among palliative care providers, opioid prescribing increased by 15.3% (241.9 to 278.9 opioids per 100 beneficiaries; P<.001).
  • From 2013 to 2017, opioid prescribing among oncologists decreased (P<.05) in 43 states, and opioid prescribing decreased more among oncologists than nononcologists in 5 states (P<.05).
  • Some Southern states, including Arkansas, Louisiana, and Alabama, had high baseline opioid prescribing rates in 2013 with little subsequent decrease in opioid prescribing, whereas Northeast states such as Maine, New Hampshire, and Massachusetts had low baseline opioid prescribing rates in 2013, with continued large decreases thereafter.
  • On the basis of their findings, the investigators concluded that between 2013 and 2017, opioid prescribing rate steadily and statistically significantly decreased among US oncologists as well as nononcologists, whereas gabapentin prescribing among oncologists and opioid prescribing among palliative care providers increased modestly.
  • The 5-year study period included 1 year after publication of the Centers for Disease Control and Prevention opioid prescribing guidelines in March 2016.
  • The similar declines in opioid prescribing among oncologists and nononcologists suggest that opioid-prescribing legislation and guidelines intended for the noncancer population are being applied inappropriately to patients with cancer.
  • Government legislation, prescribing guidelines, and other strategies to control opioid overprescribing are essential to reduce opioid misuse but may inadvertently restrict opioid access among cancer survivors.
  • Concerns are increasing regarding inadequate opioid prescribing and reduced access to effective pain management among cancer survivors living with chronic pain.
  • The decrease in hydrocodone-acetaminophen prescribing may be partly explained by its reclassification in 2014 from schedule III to schedule II, given the plateau, rather than a further reduction after 2014 in hydrocodone-acetaminophen prescribing.
  • The decrease in long-acting opioid prescribing may be explained by the association between these drugs and unintended overdoses, and/or by increased regulation of long-term opioids, including requirements for signed opioid treatment agreements between physicians and patients and insurance-based barriers such as prior authorizations.
  • The increase in opioid prescribing among palliative care providers, who are uniquely equipped to manage the complex physical and emotional needs of patients with chronic pain, suggests that oncologists and nononcologists may be referring their patients with chronic pain to specialty care for symptom management.
  • The increase in gabapentin prescribing accompanying the national decline in opioid prescribing among oncologists and nononcologists likely reflects the desire of clinicians to prescribe nonopioid alternatives in the context of the opioid epidemic.
  • Although gabapentinoids are thought to be safe and effective alternatives to opioids and may be more commonly prescribed as opioid alternatives in younger adults with cancer, evidence is mixed regarding their efficacy in treating cancer-related pain.
  • Among-state variation in opioid prescribing rates may be caused by greater regulatory pressures and differences in patient and provider attitudes toward opioids in the Northeast.
  • Because Vermont, New Hampshire, Maine, and other states with the greatest decrease in opioid prescribing among oncologists have few oncologists relative to other states, large decreases in opioid prescribing among a small number of providers may greatly affect prescribing patterns within the state.
  • The greater decline in opioid prescribing among oncologists vs nononcologists in 5 states may relate to prescriber preferences, palliative care referral patterns, and regulatory programs associated with reduced opioid prescriptions among cancer survivors.
  • The investigators recommend further research, including more recent prescriber data, to evaluate how these prescribing changes have affected the care of patients with cancer.
  • Study limitations include those inherent in retrospective dataset analyses; possible lack of generalizability beyond the Medicare population with a Part D plan; exclusion of nurse practitioners, physician assistants, and specialties that treat benign as well as oncologic conditions; suppressed data; lack of patient-level information; and lack of data on dose and pill count per claim.
  • An accompanying editorial notes that this study therefore cannot determine whether the reductions in opioid prescribing observed were appropriate or inappropriate, as answering this question would require knowing whether decreased prescribing occurred in patients receiving active treatment, cancer survivors, or those with advanced disease.
  • The editorial also warns that opioid access for patients with cancer may be more difficult now than in 2017, when the study ended.
  • The new regulatory burdens may hinder oncologists from prescribing opioids, and palliative care is still a relatively small, primarily hospital-based specialty that may be incapable of assuming pain management for all these patients.

Clinical Implications

  • Between 2013 and 2017, opioid prescribing rate steadily and statistically significantly decreased among US oncologists as well as nononcologists, whereas gabapentin prescribing among oncologists and opioid prescribing among palliative care providers increased modestly.
  • The similar declines in opioid prescribing among oncologists and nononcologists suggest that opioid-prescribing legislation and guidelines intended for the noncancer population are being applied inappropriately to patients with cancer.
  • Implications for the Healthcare Team: Government legislation, prescribing guidelines, and other strategies to control opioid overprescribing are essential to reduce opioid misuse but may inadvertently restrict opioid access among cancer survivors. The healthcare team should communicate in interdisciplinary team meetings the need for individualized review for patients with cancer and their opioid requirements.

 

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