Review Shows Discrepancies in Narcotics Prescription Trends for Cancer Pain Management

Jennifer Fernandez

Pain management specialists are rarely consulted to help assess pain in patients with cancer, leading oncologists to often prescribe narcotics, according to findings from a review that was presented at the 2024 ASCO Quality Care Symposium.¹ The review also found that narcotic prescriptions for patients with cancer were more likely to come from only oncology providers vs only pain management providers.

“Different prescribing providers make distinct drug choices and follow different prescription patterns. Evaluating guideline concordance and the knowledge of appropriate pain management strategies among oncology providers is an area for further exploration,” Jennifer Fernandez, a senior business intelligence analyst from McKesson and The US Oncology Network, and coinvestigators, wrote in the poster.

The review looked at 15 physician group practices from 2016 to 2022 and evaluated prescriptions, drug administration, and episode data. Additionally, because The US Oncology network participated in the oncology care model, narcotic prescription patterns were also evaluated.

Overall, there were 304,951 episodes for the 127,296 unique patients with cancer, and 38.6% of the episodes and 55% of patients had narcotics prescribed.

When evaluating prescription type, oral or topical treatment given in 1 day to 10 days of supply was prescribed by oncology providers (26.1%), pain management providers (5.1%), and all other providers (29.4%). For an 11-day to 30-day supply, prescriptions written were 62.8%, 91.4%, and 45.7%, respectively. All other days of supply included 1.2%, 0.8%, and 1.4% for pain management prescriptions written.

For injectables, the number of prescriptions written was 9.8% by oncology providers, 2.7% by pain management providers, and 23.5% by all other providers.

Specifically, different drugs were prescribed by the various providers. Hydrocodone plus acetaminophen was prescribed by 27.5% of oncology providers, 33.4% by pain management providers, and 22.3% by all other providers. Fentanyl was prescribed by 15.6%, 10.8%, and 17.4%; tramadol was prescribed by 9.5%, 7.7%, and 16.7%; and oxycodone was prescribed by 13.8%, 15.8%, and 9.0%, respectively.

Additional drugs prescribed included morphine by 11.2% of oncology providers, 9.1% of pain management providers, and 9.7% of all other providers; oxycodone plus acetaminophen in 6.0%, 10.0%, and 5.8%; and hydromorphone in 5.0%, 3.4%, and 6.0%.

Of the 304,951 episodes, 30.7% had narcotics prescribed by an oncology provider only vs 4.8% had them prescribed by a pain management provider only. Additionally, 41.5% of episodes had narcotics prescribed by more than 1 provider and 41.5% had more than 1 narcotic prescribed.

The investigators noted that there were 7 drugs accounted for in about 87.5% of narcotic prescriptions, but the individual drug choices varied widely between providers.

“Pain management in patients with cancer is a crucial aspect of their overall care aiming to alleviate suffering and enhance their quality of life. However, the involvement of multiple care providers during cancer treatment can lead to complex and varied approaches to pain medication prescribing,” Fernandez and coinvestigators wrote.

In December 2022, ASCO put together a recommendation for the use of opioids for adults who have pain related to cancer treatment.² The guidelines assessed 7 clinical questions including:

1. In what circumstances should opioids be offered?

2. Which opioids should be offered?

3. How should opioids be initiated and titrated?

4. How should opioid-related adverse events be prevented or managed?

5. How should opioid use be modified in patients with renal or hepatic impairment?

6. How should breakthrough pain be managed?

7. When and how should opioids be switched (rotated)?

Some of the recommendations that came from these guidelines include: offering opioids to patients with moderate to severe pain related to cancer or treatment; offering opioids approved by the FDA, which is deemed suitable for those who are candidates; and that opioids should be initiated at the lowest possible dose to achieve acceptable results.

References

1. Fernandez J, Neeb J, Indurlal P, Wilfong LS, et al. Prescribing comfort: understanding pain medication prescribing patterns in cancer care. JCO Oncol Pract. 2024(10):22. doi.10.1200/OP.2024.20.10_suppl.22
2. Paice JA, Bohlke K, Barton D, et al. Use of opioids for adults with pain from cancer or cancer treatment: ASCO guideline. J Clin Oncol. 2022;41(4). doi.10.1200/JCO.22.02198