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Feb 14, 2019

Welcome to the ASCO Daily News podcast. I'm Alex Carolan, and joining me today is Dr. Sriram Yennu, an associate professor in the Department of Palliative Care, Rehabilitation, and Integrative Medicine at the University of Texas MD Anderson Cancer Center. Dr. Yennu works within the Division of Cancer Medicine. Today, Dr. Yennu will discuss opioid prescription use and cost among patients with advanced cancer in inpatient palliative care from an article he authored in the Journal of Oncology Practice. Dr. Yennu, welcome to the podcast.

Thank you, Alex.

The trend of opioid use in cancer is different than in other diseases because of unique pain brought on from the disease. Dr. Yennu, what do your findings on opioid prescription use tell us about that?

Yeah, I think this is a very important topic for the cancer patients, especially in the metastatic setting. Cancer pain is one of the most debilitating symptoms, distressing for the patient. And a lot of times, the patient is very much unable to do things, what they like to do, socialize. And from the research, what we found from our previous studies was that about 60% to 90% of the patients have moderate to severe pain. And from the WHO recommendations and other recommendations, opioids are used for pain control as the first line of choice.

And what we also found in the previous studies is that 75% of the patients, especially in the metastatic state setting, are on prescribed opioids. So this article really focuses on the patterns of opioid use. In the inpatient setting, whenever the patients with metastatic cancer are admitted in the hospital, they are being treated for pain, and we are looking at the opioids used. And more than 50% of the patients that are admitted in the hospital in the metastatic setting are seen by the palliative care unit. And so we looked into the patterns done by a single team that is a palliative care team in managing pain in this setting.

What we found in this study is that whenever we prescribe opioids over a period of time -- we have been in the service at MD Anderson as a single team since 1999. We looked in for the patterns from 2007 to 2014. We found that the amount of opioids used has decreased. One thing for sure is that, though the amount of opioid use decreased, when they were admitted, the amount of opioids is increased, mainly because we wanted to manage their pain better. And a lot of times, the amount of opioids used at their home was not optimal. So that's the reason.

The other important findings, what we found is the cost of the opioids from 2007 to 2014 has, in general, decreased. Actually, the pattern of the opioid cost decreased from 2007 to 2011, but because of the cost of fentanyl and other opioids after 2011, they were showing a striking trend in the opioid cost after 2011 to 2014. And these are some of the interesting findings for us because in the last, at least, three to four years, we have been having some trouble with access to opioids in the inpatient setting. There have been shortages, and the main reason is because of the recent drug overdose deaths.

As you know, in non-cancer setting, the drug overdose deaths has been an epidemic trend. So they have been administrating opioids to the cancer patients, and this is resulting in significant pain issues. And this pattern that we are describing in this paper will be helping the policy makers. Cancer patients still need opioids, you should still provide some access to opioids rather than restricting it. And also, understand that the opioid addiction is a problem, but in cancer patients, pain control is a huge burden.

That's very interesting. And your study's results found that for patients between the years 2008 and 2014, age, prescription year, and pre-admission opioid doses were significantly associated with opioid doses prescribed to patients with advanced cancer who received inpatient palliative care. How can health care professionals apply these results to real life practice?

Yeah. I think let's go one point at a time. Younger age was associated with higher opioid use, and this can be taken into consideration that patients who are younger have a higher symptom expression, they can tolerate opioids better compared to older age. The main reason that older age patients cannot tolerate is because of the volume of distribution of the older patients are far less.
So in general, the prescribers, that is, the palliative care clinicians, usually prescribe less opioids to older patients and that could be one of the major reasons. And the other thing could be that the amount of expression, as well as the association of pain in older patients was low. But I think we need to do further studies on why age is an important factor in the opioid prescription. The other is the earlier prescribing years. Because of more advances in cancer pain management, the more lately we have been using less opioids. That could be one of the important thing.

One of the things that we are doing more is screening for patients with substance abuse. We are also setting up something very important, that is personalizing pain goals. So each patient should be customized or personalized to a given pain situation so that they can function optimally and have lower distress. And also the use of adjuvant medications has been also advanced since the earlier time we started prescribing. For instance, 2007 compared to 2014, the adjuvants are better.

In addition to that, the non-pharmacological interventions has also increased. With the epidemic, there is more impetus to use non-pharmacological interventions, like using of acupuncture, hypnotherapy, physical therapy, and other aspects which are supposed to be helping now. There is more evidence, so we are using more of that. So that's actually helping using better armamentarium to treat the pain compared to just opioids alone. So that's the reason earlier prescription years was associated with higher opioid use.

And the other thing is that patients who are higher pre-admission opioid doses have higher doses of prescribed opioids. This is really intuitive. A lot of times, if you have more pain, you have small, less symptom burden, you are already using a lot of opioids. So you will have a tendency to use more opioids during the inpatient admission. So that's one of the reasons why we feel that the patients who are using old opioids before they're getting admitted have higher tendency to use more opioids.

So these are very important findings, and whenever a prescribing clinician takes care of the patient in the inpatient setting, especially in the metastatic cancer setting, if you use these factors into perspective, then you can able to optimize being better. For instance, if you are a senior patient using very high doses of opioids when they're older, than you need to be very careful. Is there a way that we can cut down the opioids?

Is there a way that we are not diagnosing something which is important, like a fracture or something like that, so that we can stabilize it? And they are using high opioids now. There could be other reasons, like, is the patient having opiate addiction or something like that? Or is the patient been more anxious? Or is the patient expressing wrong because the patient has delirium? Those are the factors that I would be looking to if I am a prescribing clinician in the inpatient setting in a metastatic cancer patient when I look into the results of this study.

And with findings that the opioid cost per patient decreased from 2008 through 2011 and increased in 2012 through 2014, how can we apply this information to our 2019 opioid cost trends?

This is a very important finding. One caveat is that we didn't include the administration cost. We just used the cost of the opioids. The cost of the opioids definitely decreased from 2007 to 2011, mainly because the amount of opioids decreased significantly. And a lot of this is to do with the better screening and better assessment, and also in terms of the prescribing patterns.

But the costs from 2011 to 2014 increased, and this is mainly because of the increased use of fentanyl and hydromorphone and these medications were more expensive after 2011. And that's something you want to be very aware of. And if you are a policy maker and you are worried about costs of medications, this is where you want to put some emphasis on when you are trying to be discussing in Congress or any other place, is the cost of medications are increasing and it is a increased burden for the patients.
With opioids complicated use within the treatment of different diseases, how can this study mitigate what it describes as undertreated, intractable pain because of opioid underuse?
The opioid use was the first line of choice for the cancer pain, and especially in the metastatic setting. With the advances we have in terms of assessment, screening the patients better, screening patients with opioid addiction, and also personalizing pain goals, use of adjuvant medication, use of non-pharmacological pain procedures, like using acupuncture, using hypnosedation, using various other strategies which have been now having more evidence. For instance, there is more evidence now to use acupuncture, there's more evidence to use hyponotherapy.
So using all of these will mitigate the amount of opioid use, it could also mitigate the amount of opioid induced neurotoxic side effects, and help the patient to have a better quality of life. Because the patient before had no other choice but to take opioids for cancer pain. Now with the advent of all these different strategies and advances, we can use opioids but to a lesser extent and only if necessary.

Again, my guest today has been Dr. Sriram Yennu. Thank you for joining us.

Thank you, Alex.

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