Opioid Distribution for Terminal Cancer Patients Not Equal for Certain Races and Ethnicities

Alexi Wright, MD, MPH

Patients with cancer and a poor/terminal prognosis who were Black or Hispanic were less likely to be prescribed opioids and long-acting opioids for cancer-related pain, and were given lower daily doses and lower total doses compared with White patients, according to an epidemiologic analysis.¹

Data revealing the disparities in opioid distribution were from 318,549 Medicare recipients in the Centers for Medicare & Medicaid Services (CMS) administrative database who died between January 1, 2007, and December 31, 2019. The analysis focused on patients who were 66 years of age or older and were enrolled in the Medicare parts A, B, and D during the 12 months before their death.

"Most previous studies of inequities in cancer pain management were conducted before the full scope of the opioid crisis was recognized and regulations to curb opioid prescribing were put in place," says the study lead author, Andrea Enzinger, MD, a gastrointestinal oncologist, and a researcher in the Population Sciences department at Dana-Farber Cancer Institute, in a press release.² "Over the past decade, there has been a seismic shift in prescribing practices and sharp declines in access to these medications for patients with cancer. But we know very little about the current state of disparities in access in this environment of increased regulation, and about the magnitude of disparities among patients with terminal cancer."

The study population was predominantly female (51.7%), and most patients (43.8%) were between the ages of 65 and 74 years old. The most common malignancy among patients was lung cancer (33.3%), and very few patients had melanoma (1.4%). Overall, the cancer types included were gastrointestinal cancers, hematologic cancers, genitourinary cancers, breast cancer, and gynecologic cancers. Most patients presented with a preexisting illness. The most common comorbidities observed in the study were ischemic heart disease (65.8%), rheumatoid or osteoarthritis (61.3%), and chronic kidney disease (55.1%).¹

The highest percentage of patients were treated in Southern state (38.8%), but a significant proportion of patients were treated in the Mid-West (25.1%) and Northeast (20.7%). Moreover, most patients were from urban or large rural areas (76.3% and 11.6%, respectively).

Study results showed that patients who identified as Black or Hispanic were statistically less likely than White patients to receive at least 1 opioid prescription near the end of their life. For Black the difference was –4.3 percentage points compared with White patients (95% CI, –4.8 to –3.6), and for Hispanics, the difference was –3.6 percentage points compared with White patients (95% CI, –4.4 to –2.9).

Regarding receipt of at least 1 long-acting opioid prescription, there was a difference of –3.1 percentage points among Black patients vs White (95% CI, –3.6 to –2.8) and a 2.2 percentage point difference among Hispanic patients vs White (95% CI, –2.7 to –1.7).

Data on patients who filled at least 1 opioid prescription showed that Black patients filling of daily doses were 10.5 morphine milligram equivalents (MMEs) lower (95% CI, –12.8 to –8.2) than White patients. For the Hispanic population, daily doses were 9.1 MMEs lower (95% CI, –12.1 to –6.1) compared with White patients.

Investigators also pointed out the Black males are disproportionately impacted by the opioid distribution disparity. “We found that Black men were far less likely to be prescribed reasonable doses than White men were," explained, Alexi Wright, MD, MPH, a gynecologic oncologist and a researcher in the Division of Population Sciences at Dana-Farber and the lead study author, in the press release.² “And Black men were less likely to receive long-acting opioids, which are essential for many patients dying of cancer. Our findings are startling because everyone should agree that cancer patients should have equal access to pain relief at the end of life.”

In addition, investigators identified disparities in urine drug screening where Black patients had more frequent drug tests than White patients.¹

"The disparities in urine drug screening are modest but important, because they hint at underlying systematic racism in recommending patients for screening," said Wright.² "Screening needs to either be applied uniformly or not at all for patients in this situation."

Finding the cause of these disparities will require more research, and Dana-Farber will be continuing their investigation and developing interventions to mitigate the issues. One possible reason for the opioid distribution disparity may be socioeconomic status, according to the study. It was shown that patients with public insurance (Medicare and Medicaid) were less likely to receive opioids compared with patient who had private insurance. Moreover, certain patient characteristics such urban dwelling based residential segregation as wells as dual eligibility for Medicare and Medicaid, which indicates low income.^1,2

_REFERENCES:

_{1. Enzinger AC, Ghosh K, Keating NL, et al. Racial and ethnic disparities in opioid access and urine drug screening among older patients with poor-prognosis cancer near the end of life. J Clin Oncol. Published January 10, 2023. doi: 10.1200/JCO.22.01413}

_{2. Study finds racial inequities in access to opioids among older patients with cancer near end of life. News release. Dana-Farber Cancer Institute. January 10, 2023. Accessed January 11, 2023. https://bit.ly/3CHZY9g}