Study: In Final Months, Older Cancer Patients Pain Under-Addressed

A new study conducted in the United Kingdom has found an increasing trend in opioid prescribing by general practitioners for cancer pain during a patient’s final 3 months of life. However, data also revealed that older patients had a significantly lower chance of receiving opioids to address cancer pain compared with patients aged 50 years or younger.

“The incidence of cancer is increasing and pain is one of the most common symptoms, affecting around two-thirds of patients with advanced cancer,” said coauthor Irene J. Higginson, BMBS, PhD, professor of palliative care, policy and rehabilitation at King’s College London. “Therefore, achieving good pain control in cancer is paramount and central to the work of clinicians, oncologists, family physicians, geriatricians, surgeons, general internists, and many others.”

However, despite guidelines, little information exists on actual opioid prescribing practice for cancer pain. Higginson and colleagues conducted a population-based cohort study using data from the United Kingdom General Practice Research Database on almost 30,000 patients with one of five different cancers who died between 2000 and 2008. They examined opioid prescription rates during the final 3 months of life. The results of their study were published online in the Journal of Clinical Oncology.

About 44% of patients in the study received at least one prescription for opioids in the last 3 months of life. Data from 2000 to 2008 showed a steady increase in the prescription of opioids with 49.9% of patients receiving a prescription in the last 3 months of life by 2008.

Among the most frequently prescribed opioids were morphine (33.4%), diamorphine (11.6%), fentanyl family (10.2%), and oxycodone (5.6%).  The frequent use of morphine and diamorphine is consistent with accepted practice in the United Kingdom, but differs from the United States, where hydrocodone and oxycodone are more commonly prescribed, Higginson said, despite the fact that they are “more expensive alternatives and are not generally thought to be more effective.”

When the researchers looked at prescription habits in specific patient populations they found that women were slightly more likely to receive opioids than men, and that the proportion of patients who received opioids decreased with increasing age. Sixty percent of patients aged 60 years of younger received prescriptions. In contrast, only 30% of patients aged 80 years or older received an opioid prescription. Those patients aged 50 years or younger had an even greater chance of receiving pain treatment compared with older patients.

Higginson said that the findings from this study have implications both for everyday practice and for policy. First, older cancer patients should be targeted specifically for improvements in their pain control and care. Second, clinicians need to be educated about the correct use of opioids in cancer, including the use of the common types of these drugs, and to ask patients with advanced cancer regularly about pain or use standardized assessment tools, she said.

“For policy there is an important need to consider correct opioid prescribing to help patients with pain,” Higginson said. “The new US Food and Drug Administration Risk Evaluation and Mitigation Strategy considers misuse, but needs to have a greater emphasis on the skilled prescription of opioids to help cancer patients with pain.”