Opioid Use in Patients with Cancer: Developing and Implementing an Evidence-Based Strategy

The opioid crisis has disproportionately impacted the Commonwealth of Kentucky. One in 10 Kentucky counties use 3-4 times the national average of prescription opioids per capita. Further, the crisis has significant impact on rural and socioeconomically disadvantaged populations, and 40% of Americans with opioid use disorder are covered by Medicaid. Numerous state efforts from the Kentucky Department of Medicaid Services (DMS) and the state legislature—as well as national efforts from the Centers for Disease Control and Prevention, the Food and Drug Administration, and others—have attempted to address the role of prescription opioids in creating and sustaining the crisis in the US. However, despite the progress that has been made in the past few years, a notable exclusion still remains in nearly every publication, statute, and policy: patients with cancer. Opioid use in non-cancer pain has been criticized based on lack of high quality, long term data supporting increased functionality. However, data on opioid use in patients with cancer suffers the same limitation: there is not evidence that opioids improve long-term function in this population. The subsequent dichotomy, as described by Peppin and Schatman, is that either (1) it does not matter if patients with cancer suffer from opioid-related adverse reactions, including death and/or substance use disorder, but it does matter if patients without cancer develop these problems; or (2) it does not matter if patients with non-cancer pain suffer, because they are not “worth” the effort of adding opioids to their regimen. Given increased long-term survival rates for a number of cancers, the distinction between opioid use for cancer vs. non-cancer pain begins to blur. Kentucky has one of the highest rates of colorectal cancer in the country, and commercially insured opioid-naïve patients undergoing surgery for colorectal cancer continue to use long-term opioids in up to 15% of cases nationally. Among similar patients undergoing the same procedures for non-cancer indications, the rate of new long-term opioid use is substantially lower. The hypothesis of this project is that Kentucky Medicaid patients undergoing surgery for cancer have a higher rate of persistent postoperative opioid analgesic use than patients undergoing similar surgeries without cancer, and that this persistent opioid analgesic use results in claims-based measurable negative patient health outcomes and higher costs. The specific aims of this project are: 1. To characterize variation and clinical and economic impacts of chronic opioid use after curative intent colon cancer surgery in the Kentucky Medicaid population. 2. To implement and evaluate a multi-phase targeted strategy to reduce opioid use and associated negative outcomes in patients undergoing curative intent colon cancer surgery at a large academic medical center providing care to most rural Kentuckians. 3. To identify policy and future research implications of the findings to the Medicaid program and Commonwealth of Kentucky. As our management of the disease of cancer continues to evolve and improve, symptomatic management of patients afflicted by this disease must to the same. While opioids continue to play an important role in the management of pain, a diagnosis of cancer does not protect patients against the long-term risks of opioids that continue to impact our state and the Medicaid population.