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
ASCOpubs.org/journal/jop published in the December 2017 issue. This
is Dr. Nate Pennell for the Journal of Oncology Practice signing
off. Thanks for listening.