As the nation battles an escalating opioid-overdose crisis, which claims more than 100 lives per day, a new study presented at the 2018 ASCO Quality Care Symposium was designed to answer a heretofore unanswered question: How common are opioid-related deaths in patients with cancer?1
According to the lead study author, Fumiko Ladd Chino, MD, a radiation oncologist at the Duke University School of Medicine, the current wave of the opioid-overdose crisis is largely driven by overdoses due to synthetic opioids like fentanyl but also tramadol. In response, the government has enacted tougher new laws and regulations on opioid prescribing; however, these well-intentioned restrictions are reducing access to opioids, the mainstay of pain treatment for patients with cancer.
In practical terms, the volume of overdose deaths in patients with cancer is very small.— Fumiko Ladd Chino, MD
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To illustrate the unintended consequences of new prescribing laws, Dr. Chino cited a study in which the equivalent dose of morphine given to patients referred to an outpatient palliative care clinic decreased by almost half between 2010 to 2015.2 Moreover, opioid prescriptions for cancer survivors decreased by more than half in just the 2 years between 2016 and 2018. “About half of patients with cancer and survivors said that their oncologist told them that their treatment options were limited by laws, guidelines, or insurance coverage,” said Dr. Chino.
Dr. Chino pointed out that along with opioid shortages related to the new prescription regulations, opioid use still has an addiction stigma among many patients with cancer. “Our study looked at opioid-related deaths in patients with cancer and how that rate has changed over time,” she explained.
Dr. Chino and colleagues conducted a retrospective review of death certificate data from the National Center of Health Statistics, which contained a single underlying cause of death and up to 20 contributing causes of death. “All deaths due to opioids were included from 2006 to 2016. If present, cancer was noted as a contributing cause. We then calculated the opioid death incidence from the estimated cancer survivor population, as well as the total U.S. population,” she continued.
The researchers found that from 2006 to 2016, about 900 deaths were related to opioids in patients with cancer. However, this was compared with about 200,000 deaths in the noncancer population. Opioid deaths in both groups did increase over time, from about 5 to almost 9 per 100,000 patients in the general population and 0.5 to 0.7 per 100,000 in the cancer patient population. “In practical terms, the volume of overdose deaths in patients with cancer is very small. It increased from 59 in 2006 to 102 total in 2016,” noted Dr. Chino.
Parsing the Data
The researchers drilled into the data to determine a demographic profile of the overdose deaths, looking at specific differences in patients in the general population against those who were identified as patients with cancer. “We found that patients in the general population who overdose were younger than patients with cancer who overdose, 42 years vs 57 years, respectively. Interestingly, although the majority of patients in both populations who overdose are male, there were a higher portion of female overdose deaths in the cancer patient population,” said Dr. Chino.
She pointed out a small variant in the findings, according to race. For example, in comparison to the general population, the opioid overdoses were slightly less likely to be in white patients with cancer and more likely to be in Asian or African American patients. They also found that opioid overdoses in the patients with cancer were more frequent in those who were divorced or widowed.
Moreover, this group tended to have attained higher education than those in the general population. “In short, compared to the general population, in which about 7% of those who overdosed on opioids had a college degree, it was approximately 13% in the patients with cancer—almost double,” said Dr. Chino.
The researchers looked at five cancer sites in opioid related deaths: lung, gastrointestinal, head and neck, hematologic, and genitourinary. “We compared the percentage of the new diagnosis of a specific type of cancer with the incidence or prevalence of that cancer, as well as the mortality of that cancer. For example, lung cancer represents about 13% of new diagnoses each year and about 25% of total cancer deaths. For our population of patients with cancer, approximately 22% in the overdose group had lung cancer,” explained Dr. Chino.
According to Dr. Chino’s data, most of the cancers the researchers looked at fit somewhere between incidence and mortality, except for head and neck cancer, which represents about 4% of new diagnoses, yet only 2% of cancer deaths, but it represents about 12% of the opioid overdoses in the patients with cancer cohort. Dr. Chino stressed that this outlier site in the cancer group indicates that there are certain patient populations that may need careful risk assessment and closer monitoring than others. She noted a few potential limitations to the study, such as deaths due to intentional overdose in states with Death with Dignity laws and death certificate inaccuracies.
This illuminating study found that deaths from opioid abuse as the primary cause of death are about 10 times less likely to occur in patients with cancer. “Many patients with cancer are fearful of taking opioids for their pain given concerns for opioid overdose, which is driven by news of the opioid epidemic. To date, opioids for cancer pain have been excluded form restrictive prescribing laws, and the low rates of opioid overdoses in our patient population should reinforce this continued exclusion,” concluded Dr. Chino. ■
DISCLOSURE: Dr. Chino reported no conflicts of interest.
1. Chino F: Opioid-associated deaths in patients with cancer: A population study of the opioid epidemic over the past 10 years. 2018 ASCO Quality Care Symposium. Abstract 230. Presented September 28, 2018.
2. Haider A, Zhukovsky DS, Meng YC, et al: Opioid prescription trends among patients with cancer referred to outpatient palliative care over a 6-year period. J Oncol Pract 13:e972-e981, 2017.