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Jan 16, 2018

Dr. Eduardo Bruera talks with Dr. Pennell about the changes in type and dose of opioid prescriptions among patients referred by oncologists to an outpatient palliative care clinic.

Related Article: Opioid Prescription Trends Among Patients With Cancer Referred to Outpatient Palliative Care Over a 6-Year Period

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Hello, and welcome back to the ASCO Journal of Oncology Practice podcast. This is Dr. Nate Pennell, medical oncologist at the Cleveland Clinic and consultant editor for the JOP. Now, overuse and abuse of opioid medications in the United States has become a huge public health problem, and efforts to reduce the misuse of opioid prescriptions by physicians is a major part of efforts to combat the problem.

However, as we know in the world of cancer care where we're all practicing, opioid medications represent some of the bread and butter tools that we use to control cancer-related pain for our patients, and we want to make sure that these are available when we need to use them. So how does the national opiate epidemic impact opiate prescribing for cancer patients?

Joining me today to talk about this topic is Dr. Edgardo Rivera, Professor and Chair of the Department of Palliative Care, Rehabilitation, and Integrative Medicine at MD Anderson Cancer Center. We'll be discussing his group's recent paper "Opioid prescription trends among patients with cancer referred to outpatient palliative care over a six-year period."

Dr. Rivera, thank you for joining us for the podcast.

Thank you very much for inviting me.

So I know this didn't go into this very much in your paper, but can you talk a little bit about the scope of the problem with prescription opioids? Why is this such a major issue that needs to be addressed?

Yes, there has been, clearly, an increase in the number of opioid-related serious adverse effect events and deaths, and a lot of those are prescription opioids. And so there has been increased awareness of the size of the problem and the fact that prescribed opioids are associated with at least a significant proportion of those severe side effects and deaths. And so there have been a number of measures that have been implemented by federal and state organizations that are likely to impact the prescribing behavior by physicians.

What kind of regulatory controls have been put in place?

Well, perhaps the first major step was the rescheduling of hydrocodone that happened to be the most prescribed opioid, and also the most prescribed drug in the United States, to a schedule II opioid in October of 2014, followed by the CDC guidelines on pain management with opioids that excluded cancer, but it had strong recommendations about side effects that, of course, were applicable to cancer.

Also, the surgeon general letter to all physicians practicing in the United States that was a very, very strong message about the problem of opioids. And I guess, finally, the recent declaration by the president of the opioid crisis described as a public health emergency in the United States. So all these measures are likely to have significant impact on the way oncologists and other specialists assess and manage cancer pain.

And I know that many of these regulations specifically tried to exclude cancer patients, or at least make them somewhat of a special category. But it sounds like from your group's perspective, you're still worried about potential risks for our cancer patients and their ability to access these drugs.

That's correct. Our hypothesis was that since there has been this very, very significant increase awareness and also some vigilance at multiple levels about opioid use, including the, of course, mandated in many states and recommended in all states checking for multiple prescribers in every state database, we felt that this might have impact on the way patients were receiving their opioid prescriptions. And so that's the hypothesis that we had, that is that over time we would see a reduction in the overall amount of opioid prescribed to patients before they were referred to a supportive care program.

Oh, that makes perfect sense. So can you just tell me a little bit about the design of your study? How did you do this?

Yes. We wanted an inception point, and the one we chose was the moment in which the patient was referred to the supportive and palliative care program. And what we did is we determined the total morphine equivalent daily dose that patients were receiving at the moment of being seen in consultation by the supportive and palliative care team between the years 2010 and the years 2015. So we reviewed a total of 750 patients that were referred in each of those years to determine not only the amount of opioids they were receiving by their own oncologist at the moment of referral, but also the type of opioids to see if there had been any modification in the type of opioids.

OK, well, that makes perfect sense. And so what did you find?

What we found out is that every single year between 2010 and 2015, there was a reduction in the overall opioid dose that those patients were given by their oncologist at the moment of referral to palliative care and supportive care. The reduction went from approximately 78 milligrams of morphine equivalent per day by the year 2010 to about 40 milligrams, that is, about half by 2015 at the moment of referral.

Well, was there a change in the overall amount of opioids that were being prescribed to the number of patients who received opioids during that period?

Well, that's a very important point. There was an overall reduction in the dose that each of those patients was receiving at the moment of referral. There was also a modification in the type of opioids. So there was a significant increase in the use of tramadol that is a non-schedule II opioid, and there was a significant reduction of fentanyl and hydromorphone that are two schedule II opioids. So we noticed that there had been both a reduction in the overall amount of opioid that these patients were given, and also a trend towards using the weaker opioid that are under less stringent regulation.

That's very interesting. So do you think this was due to just an increased awareness of the opiate overuse epidemic and the concern over overuse of opiates?

Well, this is a very important question that you're posing to us. What we are convinced by our findings is that the medication prescription, the opiate prescription by oncologists has changed, and it generally has decreased. Now, there are perhaps three main possible explanations.

One of them is that there has been a reduction in what might be perceived as overtreatment before. Some people might be getting a bit more than they actually needed or with a little bit less vigilance. The second possible explanation would be that there is currently an under-prescription and that people, maybe they're not getting what they might need.

And the third explanation is that some of the oncologists are choosing to refer their patients to supportive and palliative care for opiate management due to the increased complexity of prescribing these drugs, sees their needing to check the state data bases and also there are sometimes difficulties by issuers and pharmacies with filling those prescriptions. So there are clearly some barriers that exist now that were not present five or six or seven years ago, and our impression is that rather than having curtailed overtreatment, oncologists are finding the barriers difficult in their practice, and they're choosing to perhaps take advantage of colleagues to manage the patients a little bit earlier than they were before.

So that actually could be considered a benefit to this whole process if, perhaps, patients are receiving earlier or more broad use of palliative care experts. So do you think that this is leading to under-treatment of patients, or perhaps just more judicious use of the pain medicines that are available?

Well, you're posing a wonderful question, that is, the impact might be different in different places. In places where supportive care programs are available, then this might be one way to get those patients earlier access to this integrated practice between supportive and palliative care and oncology. Unfortunately, in places where those services are not available that are still the majority in the United States, this might mean that perhaps some of these patients might have a little bit more difficulty accessing the type and dose of opioid they might need. Of course, we need to do a little bit more research on this, but I guess it suggests that unless the supportive and palliative care programs are available, oncologists are a little bit more reluctant to prescribe.

Well, that's pretty concerning because, as you said-- I'm lucky to work in a place with very good palliative care departments at the Cleveland Clinic, and I know that, obviously, MD Anderson has a wonderful department there, but many patients in the United States don't have access to that. So where do you think this is going in the future? I don't think that we're likely to see less of a focus on prescribing opiates over the next five or 10 years. How are we going to protect the patients and make sure that they're getting adequate treatment?

I think this is a wonderful point, and I think ASCO has already issued what we believe is a very useful guideline, specifically in the case of cancer survivors. And I think a number of organizations, including ASCO, are working, making sure that oncologists feel safe prescribing opioids for the initiation of cancer pain management in their own patients, feeling safe and comfortable doing so. And I guess there will be need to educate our leaders and basically clarify that the vast majority of cancer patients adhere to their prescribed opioids, and opioids continue to be the most useful drugs for the management of cancer-related pain.

So there will be need for some advocacy, and that's already starting to happen, and also to make sure that our oncologists feel safe and that their practice is emphasized, it is supported so that the contact with supportive and palliative care is important. It will always be necessary, particularly when the pain does not respond well, but the right and the autonomy of oncologists to prescribe opioids will have to be present for many, many years to come.

All right, well, Dr. Rivera, thank you so much for joining us today.

Thank you. Bye-bye.

And I want to thank all of you out there who joined us for this podcast. The full text of the paper is available at published in the December 2017 issue. This is Dr. Nate Pennell for the Journal of Oncology Practice signing off. Thanks for listening.