Many patients who die of cancer receive no or delayed prescriptions for strong opioid medications—the recommended treatment for cancer-related pain, reports a study in PAIN®, the official publication of the International Association for the Study of Pain (IASP). The journal is published by Wolters Kluwer.
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.
Led by Lucy Ziegler, PhD, of the University of Leeds, the researchers used UK Cancer Registry Data to study about 4,600 cancer patients who died between 2005 and 2012 and who received at least one prescription for an analgesic (pain medication). The analysis focused on the extent and duration of treatment with strong opioids—morphine and related drugs, regarded as the most effective treatment for pain in patients with advanced cancer. The authors cite UK statistics showing overall opioid prescribing increased by 466 percent between 2000 and 2010, but only by 16 percent increase for patients with cancer.
Overall, 48 percent of patients received at least one prescription for strong opioids in the year before they died. Another 25 percent 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 percent 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 percent more likely to receive a strong opioid.
For patients receiving strong opioids, the median time between receiving a strong opioid and death was nine weeks. By six weeks before death, just 30 percent of patients had been prescribed a strong opioid. That doesn't match up with previous studies reporting that severe pain can occur "much earlier in the cancer trajectory."
Older patients were more likely to have late opioid prescribing (defined as later than nine weeks before death). After other factors were taken into account, patients aged 60 or older were about two to four times more likely to be in the late-prescribing group, compared with those aged 50 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 under-treatment of cancer pain and suggests that many more patients with advanced cancer and pain may benefit from a strong opioid analgesic," Dr. Ziegler and colleagues conclude. 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," Dr. Ziegler and coauthors conclude. "One mechanism to achieve this is through earlier integration of palliative care to improve pain control and begin to address the inequalities evidenced here."
Article: “Opioid prescribing for patients with cancer in the last year of life: a longitudinal population cohort study.” (doi: 10.1097/j.pain.0000000000000656)
PAIN is IASP's official journal. Published monthly, PAIN presents original research on the nature, mechanisms, and treatment of pain. Available to IASP members as a membership benefit, this peer-reviewed journal provides a forum for the dissemination of multidisciplinary research in the basic and clinical sciences. It is cited in Current Contents and Index Medicus.
About the International Association for the Study of Pain
IASP is the leading professional organization for science, practice, and education in the field of pain. Membership is open to all professionals involved in research, diagnosis, or treatment of pain. IASP has more than 7,000 members in 133 countries, 90 national chapters, and 20 special interest groups (SIGs). IASP brings together scientists, clinicians, health-care providers, and policymakers to stimulate and support the study of pain and translate that knowledge into improved pain relief worldwide.
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