Research shows that pain is a common byproduct of cancer and its treatment, with approximately 55% of patients undergoing active treatment experiencing pain, and more than 66% of patients with advanced disease experiencing pain. According to the ASCO guideline on the use of opioids for adults with pain from cancer or its treatment, “opioids should be offered to patients with moderate-to-severe pain related to cancer or active cancer treatment unless contraindicated.”
New data have shown that ASCO’s recommendation on the use of opioids is not being followed for all patients with cancer experiencing cancer-related pain. A large study by Enzinger et al published in the Journal of Clinical Oncology investigating the racial and ethnic disparities and trends in opioid access among older patients dying of cancer has found that Black and Hispanic patients are less likely than their White counterparts to receive opioids to manage pain in the final weeks of their life. The study also found that Black and Hispanic patients were more often subjected to urine screening tests for drugs than White patients. These disparities existed independently of patients’ socioeconomic status.
Study Methodology
The researchers examined opioid prescription orders made between 2007 and 2019 for 318,549 Medicare patients older than age 65 who had poor-prognosis cancers and were nearing the end of life, defined as 30 days before death or hospice enrollment. They estimated the effects of race and ethnicity on opioid access, controlling for demographic and clinical factors. Models were further adjusted for socioeconomic factors, including dual eligibility status, community-level deprivation, and whether the patients lived in rural or urban communities. Data was also examined for disparities in urine drug screening.
The researchers used point estimates and 95% confidence intervals in their results. Analyses were conducted using STATA software, version 17.0 and SAS software, version 9.4.
KEY POINTS
- Compared to White patients, Black patients were 4.3% less likely to receive any opioid for pain and 3.2% less likely to receive long-acting opioids near the end of life. Black and Hispanic patients also received lower doses of opioid medication in the final month of life than White patients.
- Black and Hispanic patients were more often subject to urine screening tests for drugs than White patients.
- These inequities were seen regardless of patients’ socioeconomic status.
Findings
The researchers found that White, Black, and Hispanic decedents experienced steady declines in end-of-life opioid access and rapid expansion of urine drug screening. Compared to White patients, Black and Hispanic patients were less likely to receive any opioid (Black: –4.3 percentage points, 95% confidence interval [CI] –4.8 to –3.6; Hispanic: –3.6 percentage points, 95% CI = –4.4 to –2.9) and long-acting opioids (Black: –3.1 percentage points, 95% CI = –3.6 to –2.8, Hispanic: –2.2 percentage points, 95% CI = –2.7 to –1.7).
Minority patients also received lower daily doses of morphine milligram equivalents per day (MMED; Black: –10.5 MMED, 95% CI = –12.8 to –8.2, Hispanic: –9.1 MMED, 95% CI = –12.1 to –6.1) and lower total doses of morphine milligram equivalents (MMEs; Black: –210 MMEs, 95% CI = –293 to –207, Hispanic: –179 MMEs, 95% CI = –217 to –142); Black patients were also more likely to undergo urine drug screening (0.5 percentage points; 95% CI = 0.3–0.8). Disparities in end-of-life opioid access and urine drug screening disproportionately affected Black men. Adjustment for socioeconomic factors did not attenuate the end-of-life opioid access disparities.
“There are substantial and persistent racial and ethnic inequities in opioid access among older patients dying of cancer, which are not mediated by socioeconomic variables,” concluded the study authors.
Identifying the Causes of Health Disparities in Cancer Care
“The disparities in urine drug screening are modest but important, because they hint at underlying systematic racism in recommending patients for screening,” said Alexi A. Wright, MD, MPH, Director, Gynecologic Oncology Outcomes Research at Dana-Farber Cancer Institute and a co-principal author of this study, in a statement. “Screening needs to either be applied uniformly or not at all for patients in this situation.”
The study authors are following up on the results of this study with research to identify the root causes of these inequities and target those causes with novel interventions.
Andrea C. Enzinger, MD, of Dana-Farber Cancer Institute, is the corresponding author of this study.
Disclosure: Funding for this study was provided by the Agency for Healthcare Research and Quality. For full disclosures of the study authors, visit ascopubs.org.
