A recent study conducted between 2007 and 2019 aimed to identify the prevalence of racial and ethnic disparities in opioid access in black, Hispanic, and white cancer patients. The study found substantial gaps in the ability to receive opioids, but socioeconomic factors did not play a role in this inequality.
Some of the largest observed disparities related to the number of opioids received, disparities in long-acting opioids, and daily dosage.
cancer network® talk to the lead author Andrea C. Enzinger, M.D.He is an assistant professor of medicine at Harvard Medical School and a physician at the Dana-Farber Cancer Institute.
Enzinger described the results of this trial, the barriers that have yet to be overcome, and where research is headed.
cancer network®: Can you discuss the racial and ethnic disparities in opioid access for cancer patients experiencing the end of life?
engine gar: Finding that significant inequalities in access to prescription opioids are widening among older cancer patients with Medicare insurance. Since 2007, he has studied more than 300,000 black, white, and Hispanic patients with a poor prognosis who died during 2019.
For example, looking at the proportion of patients who filled out one or more opioid prescriptions in the first month of life, black patients were approximately 4.3% less likely than white patients to fill out an opioid prescription, and Hispanic patients were similarly less likely to fill one. There was a difference.
It may sound like a low number, but remember that by 2019, just over 30% of patients were prescribed opioids. He differs by 4.3% between black and white patients, a meaningful difference when the prevalence in the overall cohort is approximately 30%.
Long-acting opioids are important for relieving severe and persistent pain caused by advanced cancer. Black patients were approximately 3.2 points less likely than white patients to replace long-acting opioids in the last months of life. Differences between Hispanic and white patients are similar.This means that by 2019 only about 9% of patients will [dying of cancer] Since he was on long-acting opioids in the last months of his life, a difference of over 3% is very large.
We also found that when patients of color filled their prescriptions, they took less. It is useful to examine the difference in mean total doses met by patients of color and patients of white color. As just one example, black patients ingested or filled approximately 200 mg of morphine equivalents at the first month of life more than white patients, which is equivalent to approximately 28 5 mg oxycodone tablets. [That’s] The average black patient takes about one less tablet per day compared to the average white patient. Again, similar differences were found between Hispanic and white populations.
Which findings were the most surprising?
Sadly, when I participated in this study, I expected to see a disparity in access. This is because it has been shown across conditions and settings, including pediatric populations and fracture patients. [or] postoperative pain. The amazing thing is that this is a population that wants to see no disparities among the dying.
Prescription opioids have many downsides. [after] Tooth extraction, which we know can lead to substance abuse and addiction. [However]because these are dying patients, it is difficult to defend disparities. [those of] the size we observed.
Another surprising and perplexing finding was that when we looked not only at race and ethnicity, but especially at interactions between patient gender and race, we found significant differences. It was dramatically more affected by inequality and opioid access compared to other groups.
For example, looking at differences between white and black men in access to prescription opioids, black men were about 6 percent less likely to replenish opioids in the last months of their lives. more than 4% less likely to meet Looking at the difference in total dosage, they had about 300 mg less morphine equivalent than Caucasian men in the last months of their lives.
All inequalities widened significantly when black men were examined.
Are there any plans to continue this research?
Our team is planning some follow-up investigations. There are some important unanswered questions. This is the largest study to date to examine the size and extent of opioid access disparities in cancer patient populations.
We are just beginning to look at the elderly population with terminal cancer, and if we look at younger populations and those with mixed types of insurance, the degree of disparity we see in them is probably much greater. We are interested in examining disparities between young people and those who may have Medicaid or commercial insurance.
it was [also] I am interested in examining different stages of cancer treatment. for example, [we want to examine disparities] During definitive cancer treatment or after surgery. It is important to know where the disparities are most extreme. Another thing our team is looking at is mechanics. why is this happening?
We sought to examine some possible mechanisms by running models that adjusted for patient characteristics and the communities in which they lived. [are] community?we [were] Is this all due to structural factors? Adjusting for that, poverty, and whether the patient lived in an urban or rural community made no difference in the magnitude of the disparities we saw.
What strategies do you think could be implemented to mitigate these disparities?
Addressing these disparities requires a multi-pronged approach. I also need more information about what the major drivers are. We need an element of bias training for providers.
Also, more logistical support is needed in terms of getting color patients to help fill out their prescriptions. [Patients] You may face racial prejudice while trying to fill your prescription.they [also] Sometimes it is difficult to go to a pharmacy, and sometimes it is difficult to pay out-of-pocket.
[Further]needs institutional initiative [toward] equity, and [the institutions need to] take responsibility for them. We hope that policy makers and insurers will seriously consider all the additional regulations and burdens they add to opioid prescribing, with the goal of reducing misuse and addiction. [Inadvertently]may also place an undue burden on cancer patients who need these drugs. [especially] Patients of racial and ethnic minorities.
reference
Enzinger AC, Ghosh K, Keating NL, et al. Racial and ethnic disparities in opioid access and urine drug screening in elderly patients with poor prognosis near the end of life. J Clin On CallPublished online January 10, 2023. doi:10.1200/JCO.22.01413
