Patterns of Opioid Prescription, Use, and Costs Among Patients With Advanced Cancer and Inpatient Palliative Care Between 2008 and 2014

Abstract

PURPOSE: An understanding of opioid prescription and cost patterns is important to optimize pain management for patients with advanced cancer. This study aimed to determine opioid prescription and cost patterns and to identify opioid prescription predictors in patients with advanced cancer who received inpatient palliative care (IPC). MATERIALS AND METHODS: We reviewed data from 807 consecutive patients with cancer who received IPC in each October from 2008 through 2014. Patient characteristics; opioid types; morphine equivalent daily dose (MEDD) in milligrams per day of scheduled opioids before, during, and after hospitalization; and in-admission opioid cost per patient were assessed. We determined symptom changes between baseline and follow-up palliative care visits and the in-admission opioid prescription predictors. RESULTS: A total of 714 (88%) of the 807 patients were evaluable. The median MEDD per patient decreased from 150 mg/d in 2008 to 83 mg/d in 2014 ( P < .001). The median opioid cost per patient decreased and then increased from $22.97 to $40.35 over the 7 years ( P = .03). The median MEDDs increased from IPC to discharge by 67% ( P < .001). The median Edmonton Symptom Assessment Scale pain improvement at follow-up was 1 ( P < .001). Younger patients with advanced cancer (odds ratio [OR[, 0.95; P < . 001) were prescribed higher preadmission MEDDs (OR, 1.01; P < .001) more often in the earlier study years (2014 v 2009: OR, 0.18 [ P = .004] v 0.30 [ P = .02]) and tended to use high MEDDs (> 75 mg/d) during hospitalization. CONCLUSION: The MEDD per person decreased from 2008 to 2014. The opioid cost per patient decreased from 2008 to 2011 and then increased from 2012 to 2014. Age, prescription year, and preadmission opioid doses were significantly associated with opioid doses prescribed to patients with advanced cancer who received IPC.

Cancer Patients' Perceived Difficulties Filling Opioid Prescriptions After Receiving Outpatient Supportive Care

“…One study reported a significant decreasing annual trend of opioid use in patients with advanced cancer who received inpatient palliative care (morphine equivalent daily dose of 150 mg/day in 2008 to 83 mg/day in 2014). 18 Another study showed that the amount of opioids prescribed to patients with cancer before referral to an outpatient palliative care clinic decreased to 40 mg/day in 2015 from 78 mg/ day in 2010. 19 Moreover, anecdotal patient reports to our clinic describing difficulties in filling opioid prescriptions make us suspicious that this may be a widespread problem.…”

“…Although the impact of the opioid epidemic and the recent regulatory changes on cancer patients' access to their opioid medications has been described, 15,16,18,19 there are a limited number of peer-reviewed studies that have evaluated cancer patients' perceived difficulties when filling their opioid prescriptions. Based on the previous limited literature, we hypothesized that after receiving outpatient supportive care, cancer patients perceive difficulties when filling their opioid prescription.…”

The prevalence, associated factors, clinical impact, and state of diagnosis of delirium in palliative care patients

“…This may be because our study recruited only newly referred palliative care patients, for whom the median morphine equivalent daily dose was only 11.25 mg. There has been reported to be a decreasing trend in the dosage of opioids prescribed for referred palliative care patients [37,38]. One study reported that cognitive dysfunction was associated with opioid doses exceeding a 400 mg morphine equivalent daily dose, which is far greater than the amount used for our population [39].…”

The Effectiveness of Cancer Pain Management in a Tertiary Hospital Outpatient Pain Clinic in Thailand: A Prospective Observational Study

“…MEDD taken in this study was approximately 20 mg/day in the beginning and increased to approximately 30 mg/day at the second follow-up. Reported values for median or mean MEDD in case series or outcome studies of patients with advanced cancer in the past decade include 83 mg/day at a center in the United States [30], 60 mg/day at a center in Korea [31], and 121-136 mg/ day at a center in Italy [32]. e low value of MEDD relative to published series from other countries did not appear to be due to reluctance among clinic staff to write for larger prescriptions.…”