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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