During End-of-Life Cancer Care, Patients of Color Less Likely To Receive Opioid Treatment

Andrea Enzinger, MD

During end-of-life (EOL) care, patients of color were much less likely to receive treatment with opioids than White patients, according to a study of 318,548 Medicare patients with poor prognoses cancers published in the Journal of Clinical Oncology. In addition, Black patients, despite being prescribed lower doses of opioids, were more likely to undergo urine drug screenings (UDS).¹

Findings from the study showed that Black patients were 4.3 percentage points (95% CI, ­–4.8 to –3.6) less likely to receive any opioid and 3.1 percentage points (95% CI, –3.6 to –3.8) less likely to receive long-acting opioids near EOL compared with White patients. The differences were similar for Hispanic patients, who were 3.6 percentage points (95% CI, –4.4 to -2.9) less likely to receive any opioid and –2.2 percentage points (95% CI, –2.7 to –1.7) less likely to receive long-acting opioids compared with White patients. Investigators noted that by 2019, only 32.7% of patients overall received any opioid, and only 9.4% received a long-acting opioid near EOL.

“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,” lead author Andrea Enzinger, MD, an assistant professor of Medical Oncology with Dana-Farber Cancer Institute (DFCI), in Boston, Massachusetts, said in a news 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.”

In 2021, Enzinger et al determined that the proportion of patients with poor prognosis cancers receiving at least 1 opioid prescription near EOL dropped from 42.0% (95% CI, 41.4%-42.7%) in 2007 to 35.5% (95% CI, 34.9%-36.0%) by 2017. The proportion of these patients who received at least 1 long-acting opioid prescription declined from 18.1% (95% CI, 17.6%-18.6%) to 11.5% (95% CI, 11.1%-11.9%).³

In this new study, Enzinger et al examined trends in opioid prescription fills and potency as measured by morphine milligram equivalents (MMEs) per day (MMEDs) near EOL, defined as 30 days before death or hospice enrollment. The study included White (n = 272,358), Black (n = 29,555), and Hispanic (n = 16,636) Medicare decedents older than 65 years with poor-prognosis cancers who died from 2007 to 2019. Compared with White patients, Black and Hispanic patients were more likely to live in the South, urban areas, and the most deprived Social Deprivation Index quintile as measured community-level socioeconomic deprivation.¹

The mean patient age was 77.6 years; 18.2% of the cohort were aged 85 years or older. Lung cancer was the most common malignancy in all racial groups. Investigators found that the racial cohorts were equally likely to have chronic illness such as acute myocardial infarction, ischemic heart disease, and chronic obstructive pulmonary disease.

Black and Hispanic decedents received fewer opioids at lower doses than White decedents throughout the study except in 2019. In that year, access to long-acting opioid was the same between Hispanic and White patients.

In keeping with the 2021 results, the proportion of patients near EOL receiving any opioid decreased from 42.2% to 32.7% over the study period. Patients receiving long-acting opioids declined from 17.9% to 9.4%.

The mean daily dose fell from 84.6 MMED to 51.8 MMED for all patients, and the total dose of opioids filled per decedent, averaged across those who did and did not fill an opioid prescription, fell from 1067 to 508 MME. Although dose levels fell for all patients, investigators found that Black and Hispanic patients received even weaker doses than their White counterparts.

Among those who filled at least 1 opioid prescription, Black patients received daily doses that were 10.5 MMEs lower (95% CI, –12.8 to –8.2) than White patients. Hispanic patients received daily doses that were 9.1 MMEs lower (95% CI, –12.1 to –6.1). Investigators said the difference was roughly equivalent to receiving 25 fewer 5-mg oxycodone tablets in the final month of life, which Enzinger said represented “a meaningful amount of pain control.”

Black patients were required to submit to UDS more often than White or Hispanic patients throughout the study period. From 2007 to 2019, the proportion of patients undergoing UDS in the 180 days before death or entry to hospice care increased from 0.6% to 6.7% for White patients compared with 1.0% to 7.9% for Black patients. Urine testing increased from 0.5% to 6.8% for Hispanic patients.

“The disparities in UDS are modest but important, because they hint at underlying systematic racism in recommending patients for screening,” senior author Alexi Wright, MD, MPH, a physician and director of Gynecologic Oncology Outcomes Research at DFCI, said in a news release. “Screening needs to either be applied uniformly or not at all for patients in this situation.”

Investigators noted that Black men were particularly affected by these disparities. White men were most likely and Black men were least likely to receive opioids. Black men and women and Hispanic women received statistically fewer opioids than White men and women across all measures.

Furthermore, compared with White women, White men filled a mean total opioid dose near EOL that was 150 MMEs more per decedent (95% CI, 130-169). In contrast, Black women filled 128 MMEs less (95% CI, 168-153) and Black men filled 153 MMEs less (95% CI, –195 to –110).

The disparities in treatment existed even after correcting for measures of poverty, community-level deprivation, or rurality. Notably, rural White patients were most likely to receive opioids, and Black patients living in urban areas were the least likely.

Investigators assessed dual-eligibility for Medicare and Medicaid as an indicator of low income. White dual-eligible patients received the most opioids across all measures, and Black non–dual-eligible patients generally received the least. Compared with White dual-eligible patients, Black non–dual-eligible patients were 13.1 percentage points (95% CI, –14.0 to –12.1) less likely to fill any opioid near EOL and 5.9 percentage points (95% CI, –6.6 to –5.3) less likely to fill a long-acting opioid. Furthermore, Black patients received lower daily and mean total opioid dose.

According to most measures of EOL, opioid receipt did not differ by dual-eligibility for Black patients. White non–dual-eligible patients, however, received more opioids across all measures.

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 online 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/3kaT8T4
3. Enzinger AC, Ghosh K, Keating NL, Cutler DM, Landrum MB, Wright AA. US trends in opioid access among patients with poor prognosis cancer near the end-of-life. J Clin Oncol. 2021;39(26):2948-2958. doi:10.1200/JCO.21.00476