‘Multipronged’ Plan May Allay Opioid Disparities for People of Color With Cancer

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Black and Hispanic patients are less likely to receive opioids than their White counterparts; bias training and logistical support may act as potential strategies to mitigate these disparities, according to an expert from Dana-Farber Cancer Institute.

Black and Hispanic patients with cancer were less likely to receive opioids and received lower daily doses and total doses compared with White patients near end of life (EOL), according to a study on opioid access and urine drug screening (UDS) published in the Journal of Clinical Oncology.

Adjusting for demographic and clinical factors, the study authors indicated that Black and Hispanic patients were less statistically likely to receive at least 1 opioid prescription near EOL compared with White patients between 2007 and 2019 (Black patients, –4.3 percentage points; 95% CI, ­–4.8 to –3.6; Hispanic patients, –3.6 percentage points; 95% CI, –4.4 to ­–2.9). Additionally, Black and Hispanic patients were less likely to receive long-acting opioids (Black patients, –3.1 percentage points; 95% CI, –3.6 to –2.8; Hispanic patients, –2.2 percentage points; 95% CI, –2.7 to –1.7) vs their White counter parts.

According to Andrea C. Enzinger, medical oncologist at Dana-Farber Cancer Institute, it is going to take "a very multipronged approach" to tackle the racial and ethnic disparities surrounding opioid access for patients with cancer near end of life.

According to Andrea C. Enzinger, MD, medical oncologist at Dana-Farber Cancer Institute, it is going to take "a very multipronged approach" to tackle the racial and ethnic disparities surrounding opioid access for patients with cancer near end of life.

“We're going to need to take a very multipronged approach to tackling these disparities,” study author Andrea C. Enzinger, MD, an assistant professor of medicine at Harvard Medical School and medical oncologist at Dana-Farber Cancer Institute, said in an interview with CancerNetwork®. “We also need more information about what the key drivers are. There needs to be some element of bias training for providers. We certainly also need more logistical support around getting patients of color help and filling the prescriptions that they may be given.”

Black and Hispanic patients, respectively, received 10.5 fewer morphine milligram equivalents per day (MMED; 95% CI, –12.8 to –8.2) and 9.1 (95% CI, –12.1 to –6.1) fewer MMEDs compared with White patients. In terms of total doses, Black and Hispanic patients received 210 fewer MMEs (95% CI, ­­–293 to –207) and 179 fewer MMEs (95% CI, ­–217 to –142), respectively. Additionally, Black patients were 0.5 percentage points (95% CI, 0.3-0.8) more likely to undergo UDS than White patients.

“[Patients] may face racial prejudices while trying to fill their prescriptions,” Enzinger continued. “They may have difficulty getting to the pharmacy, or difficulty with co-pays. There needs to be institutional initiatives to try to look at equity and hold [ourselves] accountable to that. I really hope that policymakers and insurers take a hard look at the added regulations and burdens that have [been] placed on opioid-prescribing with the goal of reducing misuse and addiction. They may also be placing an undue burden on patients with cancer who really need these medications—in particular, racial and ethnic minority patients.”

The study included a total of 318,549 non-Hispanic White, Black, and Hispanic patients older than 65 years who were continuously enrolled in fee-for-service Medicare for 12 or more months before death between January 1, 2007 to December 31, 2019.

Opioid prescription fillings 30 days or less before death or hospice enrollment were included in the review. The study authors determined the mean opioid daily dose in MMEDs by multiplying the total dose of each prescription filled near EOL by the sum of all prescriptions averaged over 30 days.

The authors further adjusted their disparity estimations by accounting for socioeconomic factors including dual-eligibility status, community-level deprivation, and rurality. The authors indicated dual-eligibility for Medicare and Medicaid as a marker for low income and determined community-level socioeconomic deprivation by assigning each patient a Social Deprivation Index (SDI) score based on their ZIP codes.

The mean patient age was 77.6 years. In the total population, the most common cancer diagnoses included lung cancer (33.3%), colorectal cancer (8.0%), pancreatic cancer (6.8%), and prostate cancer (6.6%).

Investigators also reported that opioid access differed based on documented sex, with White men being most likely and Black men being least likely to receive opioids. Compared with White women, White men filled a mean total dose of 150 MMEs more per patient (95% CI, 130-169), Black women filled 128 MMEs less (95% CI, 168-153), and Black men filled 153 MMEs less (95% CI, –195 to –110) at EOL.

“We all come into the field of oncology wanting to make a difference and provide high-quality, equitable care, but we all can have our own unconscious biases. It's on us to check those biases, to seek out training opportunities, and to really think with compassion and with a clear head when we're looking at a patient in front of us,” Enzinger said. “We can all be changemakers in our own spheres and clinics, thinking about the barriers that our patients face, and try to get the supportive care medications and help that they need to have a good quality of life at [EOL]."

Compared with White rural-dwelling patients had the greatest access to opioids near EO across all measures while Black urban-dwelling patients generally had the least amount of access to opioids. Additionally, compared with White dual-eligible patients, Black non–dual-eligible patients were less likely to fill any opioid near EOL (–13.1 percentage points; 95% CI, –14.0 to –12.1) and less likely to fill a long-lasting opioid (–5.9% percentage points; 95% CI, –6.6 to –5.3).

Black non–dual-eligible patients also had a daily opioid dose that was 15.0 MMEDs lower (95% CI, –18.7 to –11.2) and a mean total opioid dose that was 439.8 MMEs lower (95% CI, –484.8 to –394.7) compared with White dual-eligible patients. Overall, White dual-eligible patients received more opioids across all measures, whereas most measures of EOL opioid receipt did not differ by dual-eligibility status among Black and Hispanic patients.

Enzinger explained that further research will be conducted and emphasized the importance of examining opioid disparities in other patient subgroups.

“Our team is planning a number of follow-up studies; there are some important unanswered questions. This is the largest study to-date to look at the magnitude and the scope of opioid access disparities in cancer population but we're just looking at older populations with terminal cancer. It's important to highlight that the degree of disparities we see here are probably much larger if you look at younger populations or if you look at those with mixed-insurance types,” Enzinger concluded.

Reference

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

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