In a study reported in the Journal of Clinical Oncology, Enzinger et al found that the prescription of opioids for cancer pain dropped markedly in the recent past among patients with poor-prognosis disease near the end of life, with the frequency of pain-related emergency department visits increasing over the same period.

As stated by the investigators, “Heightened regulations have decreased opioid prescribing across the United States, yet little is known about trends in opioid access among patients dying of cancer.”

Study Details

Medicare part D data from 270,632 Medicare fee-for-service decedents with poor-prognosis cancers were used to assess trends from 2007 to 2017 in opioid prescription fills and opioid potency (morphine milligram equivalents per day [MMED]) near the end of life. End of life was defined as the 30 days before death or hospice enrollment. Administrative claims data were used to assess trends in pain-related emergency department visits near the end of life.

Key Findings

Over the study period, the proportion of decedents with poor-prognosis cancers receiving one or more opioid prescription(s) near the end of life decreased by 15.5%—from 42.0% to 35.5%—and the proportion receiving one or more long-acting opioid prescription(s) decreased by 36.5%—from 18.1% to 11.5%. Among decedents receiving opioids near the end of life, the mean daily dose decreased by 24.5%, from 85.6 MMED to 64.6 MMED.  

In the combined population of decedents who did or did not receive opioids near the end of life, the total amount of opioids prescribed per decedent decreased by 38.0%, from 1,075 to 666 morphine milligram equivalents. Annual decreases in the number of prescriptions filled per decedent near the end of life were 4.1% for all opioids, 6.3% for long-acting opioids, 1.3% for strong short-acting opioids, and 0.5% for weak short-acting opioids. The mean daily dose per prescription fell 2.2% annually for long-acting opioids, 1.9% for strong short-acting opioids, and 7.8% for weak short-acting opioids.

Sensitivity analyses showed similar reductions in opioid use in the 60 and 90 days before death or hospice, among patients enrolled vs not enrolled in hospice, and when the end-of-life period was defined as the 30 days before death without censoring the hospice period. The proportion of patients with pain-related emergency department visits near the end of life increased by 50.8%, from 13.2% to 19.9%.

The investigators concluded, “Opioid use among patients dying of cancer has declined substantially from 2007 to 2017. Rising pain-related emergency department visits suggest that end-of-life cancer pain management may be worsening.”

Andrea C. Enzinger, MD, of Dana-Farber Cancer Institute, is the corresponding author for the Journal of Clinical Oncology article.

Disclosure: The study was supported by a grant from the Agency for Healthcare Research and Quality. For full disclosures of the study authors, visit ascopubs.org.