Monitoring Opioid Prescription Trends in Palliative Care

Monitoring Opioid Prescription Trends in Palliative Care

Dr. Eduardo Bruera

“Opioid Prescription Trends Among Patients With Cancer Referred to Outpatient Palliative Care Over a 6-Year Period”

Journal: Journal of Oncology Practice

DOI: 10.1200/JOP.2017.024901


Purpose: In the United States, opioid regulations have become increasingly stringent in recent years. Increased regulatory scrutiny, in part, is related to heightened awareness through literature and a recent media blitz on the opioid prescription epidemic. These regulations have the potential to impact prescription trends by health care providers. Our objective was to evaluate changes in the type and dose of opioid prescriptions among patients who are referred by oncologists to an outpatient palliative care clinic.

Materials and Methods: We reviewed the electronic health records of 750 patients who were seen as new consultations at The University of Texas MD Anderson Cancer Center’s outpatient palliative care clinic between January 1 and April 30 each year from 2010 through 2015. Data collected included demographics, cancer type and stage, symptom assessment, performance status, opioid type, and opioid dose defined as the morphine equivalent daily dose (MEDD).

Results: Median age was 59 years (interquartile range [IQR], 51 to 67), 383 (51%) were female, 529 (70%) were white, and 654 (87%) of patients had advanced cancer. In 2010, median MEDD before referral was 78 mg/d (IQR, 30 to 150); however, by 2015, the MEDD had progressively decreased to 40 mg/d (IQR, 19 to 80; p = 0.001). Hydrocodone was the most common opioid prescribed between 2010 and 2015; however, after its reclassification as a schedule II opioid in October 2014, the use of tramadol, a schedule IV opioid, increased (p < 0.001).

Conclusion: During the past several years, the MEDD prescribed by referring oncologists has decreased. After hydrocodone reclassification, the use of tramadol with less stringent prescription limits has increased.

Author Perspective

Eduardo Bruera, MD, The University of Texas MD Anderson Cancer Center

Q: How would you like to see the results of your study applied to the field of palliative care?

Dr. Bruera: Our findings show that patients referred to palliative care by their oncologists are receiving a lower opioid dose, and that hydrocodone is used less frequently after its reclassification as a schedule II opioid. Our findings suggest an association between concerns regarding the opioid crisis and type and dose of opioids prescribed for cancer pain.

Q: What about these data surprised you?

Dr. Bruera: We were surprised by the magnitude of the changes in opioid prescription. The median morphine equivalent opioid dose decreased by about 50% in only 6 years, and there was a significant increase in the use of several strong opioids and an increase in mild nonschedule II opioids such as tramadol.

Q: Given your results about the trend in dose reduction, how might studies like yours be used in future legislation and/or advocacy?

Dr. Bruera: Our findings suggest that oncologists are experiencing barriers to opioid prescription for cancer-related pain. Among others, some examples include risk evaluation and mitigation strategy for extended-release and long-acting opioids issued by the U.S. Food and Drug Administration, mandatory sharing of prescription data with state-run prescription drug monitoring programs, frequent denial of payment by insurers, and the request for additional information from pharmacies and hospital committees. There are also recommendations for universal screening of patients for risk factors for nonmedical use of opioids using validated tools.

These measures have an impact on the time and resources of oncology clinics, and many clinics may not be able to re-engineer their practice to meet these requirements. More research is needed to better understand which are the main barriers and the best way to overcome them in daily practice. Our findings suggest that supportive and palliative care clinics will receive patients with cancer who are requiring opioids earlier and in larger numbers in the future. Those clinics are also likely to face increased burden of care.

It will be important for oncology outpatient programs and supportive and palliative care programs to develop clinical pathways to ensure that patients receive their starting opioid prescriptions safely and effectively, and that those patients who present with refractory symptoms or elevated risk for nonmedical opioid use are referred to the supportive care. Our team is currently in the process of designing such a study.