Incidence of Opioid-Associated Deaths in Cancer Survivors in the United States, 2006-2016: A Population Study of the Opioid Epidemic | Oncology | JAMA Oncology | JAMA Network
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Figure.  Opioid-Related Deaths per 100 000
Opioid-Related Deaths per 100 000

Deaths per 100 000 in the general population (blue) and in those with cancer as a contributing cause (orange). The solid lines are the data points, and the dashed lines are the best-fit lines for which the equations are listed and the R2 is calculated.

Table.  Patient Characteristics
Patient Characteristics
1.
Fisch  MJ, Chang  VT.  Striving for safe, effective, affordable care for cancer survivors with chronic pain: another kind of moonshot.   JAMA Oncol. 2016;2(7):862-864. doi:10.1001/jamaoncol.2016.0854PubMedGoogle ScholarCrossref
2.
de Moor  JS, Mariotto  AB, Parry  C,  et al.  Cancer survivors in the United States: prevalence across the survivorship trajectory and implications for care.   Cancer Epidemiol Biomarkers Prev. 2013;22(4):561-570. doi:10.1158/1055-9965.EPI-12-1356PubMedGoogle ScholarCrossref
3.
Chua  IS, Leiter  RE, Brizzi  KT,  et al.  US national trends in opioid-related hospitalizations among patients with cancer.   JAMA Oncol. 2019;5(5):734-735. doi:10.1001/jamaoncol.2019.0042PubMedGoogle ScholarCrossref
4.
van den Beuken-van Everdingen  MH, de Rijke  JM, Kessels  AG, Schouten  HC, van Kleef  M, Patijn  J.  Prevalence of pain in patients with cancer: a systematic review of the past 40 years.   Ann Oncol. 2007;18(9):1437-1449. doi:10.1093/annonc/mdm056PubMedGoogle ScholarCrossref
5.
Haider  A, Zhukovsky  DS, Meng  YC,  et al.  Opioid prescription trends among patients with cancer referred to outpatient palliative care over a 6-year period.   J Oncol Pract. 2017;13(12):e972-e981. doi:10.1200/JOP.2017.024901PubMedGoogle ScholarCrossref
6.
American Cancer Society Cancer Action Network and Patient Quality of Life Coalition. Summary of Opioid Access Research Project. Accessed September 5, 2018. https://www.fightcancer.org/sites/default/files/ACS%20CAN%20PQLC%20Opioid%20Research%20Project%20Key%20Findings%20Summary%20Memo%20FINAL.pdf
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    Research Letter
    May 7, 2020

    Incidence of Opioid-Associated Deaths in Cancer Survivors in the United States, 2006-2016: A Population Study of the Opioid Epidemic

    Author Affiliations
    • 1Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
    • 2Duke Palliative Care, Division of Medical Oncology, Duke Cancer Institute, Durham, North Carolina
    • 3Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
    JAMA Oncol. 2020;6(7):1100-1102. doi:10.1001/jamaoncol.2020.0799

    More than 40 000 people in the US died owing to opioids in 2016; the epidemic tops public health concerns. Opioids are commonly used for cancer-associated pain, and there has been a call for oncologists to become more aware of opioid-related risks and benefits.1 It is unknown, however, if opioid-related deaths in cancer survivors are rising at the same rate as in the general population.

    Methods

    Death certificate data were obtained from the National Center for Health Statistics (NCHS). Death certificates contain 1 underlying cause of death, up to 20 contributing causes, and demographic data. All deaths owing to opioids were included from 2006 through 2016; if present, cancer was noted as a contributing cause. Opioid-related death incidence was calculated from the US population and estimated cancer survivor population,2 both via NCHS data. To assess for differences, χ2 and R2 tests were used. Statistical significance was defined as α < .05 on a 2-sided significance level. All statistical analyses were performed with SPSS, version 21 (IBM). The Duke University Medical Center Institutional Review Board provided a waiver (Pro00045337) for this study, given that it is publicly available deidentified data. Informed consent is waived for publicly available, deidentified databases. Data were collected from May through August 2018, and analysis was completed in September 2019.

    Results

    From 2006 through 2016, there were 193 500 deaths owing to opioids in the general population and 895 in the cancer population. The number of opioid-related deaths increased from 5.33 to 8.97 per 100 000 people in the general population (P < .001; R2 = 0.99) and from 0.52 to 0.66 per 100 000 (P < .001; R2 = 0.24) in the cancer population (Figure).

    Demographic characteristics of cancer survivors with opioid-related deaths differed from those in the general population including higher education (12.7% vs 6.9% with at least a college degree), more women (38.5% vs 29.2%), fewer white individuals (82.3% vs 84.2%), more non-Hispanic individuals (94.5% vs 90.7%), and fewer single patients (24.2% vs 48.1%) (all P < .001; except race, P = .03) (Table). Cancer survivors also were older (median age, 57 years vs 42 years). The underlying primary cancer for those with opioid-related deaths was lung (22.3%), gastrointestinal (20.9%), head and neck (11.7%), and hematologic (11.3%), among others (Table).

    Discussion

    Death from opioids as the primary cause as documented in death certificates is 10 times less likely to occur in cancer survivors vs the general population. In the past decade, there was a slight increase in opioid-related deaths in cancer survivors; however, it was not the sharp growth seen in the general population. These findings confirm prior research showing that opioid-related hospitalizations among patients with cancer are rare but slowly increasing over time.3 This may be because of increased survivorship rates with commensurately higher rates of chronic pain or increased abuse of opioid medications.

    Cancer survivors at risk for opioid overdose may be different from people in the general population, including being older with higher educational attainment; these differences may, in part, reflect the diagnosed cancer population. Additionally, some diagnoses may carry higher proportional risk; patients with head and neck cancer represent 12% of opioid-related deaths but less than 4% of new cancer diagnoses (Table).

    One-third of patients experience cancer-related pain after curative treatment,4 and prescribing restrictions tied to the opioid epidemic may be reducing access for both long-term survivors and those on active treatment. One study of patients referred to palliative care found that opioid doses decreased by almost half from 2010 to 2015,5 another found that the number of patients with cancer and survivors with opioid prescriptions decreased by more than half from 2016 to 2018, with almost half told that their treatment options were limited by laws, guidelines, or insurance coverage.6

    Our study is limited by its dependence on accurate documentation of cancer as a contributing cause when present. It may underestimate the number of opioid-related deaths in those on active cancer treatment if clinicians assume all deaths are owing to cancer as underlying cause; it may also underestimate survivor risk if cancer was a distant diagnosis and not noted at the time of an opioid-related death.

    In summary, opioid-related deaths in the cancer population are much rarer than in the general population. Continued care should be taken when treating cancer-related pain.

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    Article Information

    Accepted for Publication: February 21, 2020.

    Corresponding Author: Fumiko Chino, MD, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, PO Box 33, New York City, NY (chinof@mskcc.org).

    Published Online: May 7, 2020. doi:10.1001/jamaoncol.2020.0799

    Author Contributions: Dr F. Chino had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Study concept and design: All authors.

    Acquisition, analysis, or interpretation of data: F. Chino, J. Chino.

    Drafting of the manuscript: All authors.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: J. Chino.

    Administrative, technical, or material support: Kamal, J. Chino.

    Study supervision: J. Chino.

    Conflict of Interest Disclosures: Dr F. Chino reported receiving grants from Varian and the Chanel Endowment for Survivorship Research outside the submitted work. No other disclosures were reported.

    Meeting Presentation: Previously presented as a podium presentation at the ASCO Quality Care Symposium 2018 in Phoenix, Arizona.

    References
    1.
    Fisch  MJ, Chang  VT.  Striving for safe, effective, affordable care for cancer survivors with chronic pain: another kind of moonshot.   JAMA Oncol. 2016;2(7):862-864. doi:10.1001/jamaoncol.2016.0854PubMedGoogle ScholarCrossref
    2.
    de Moor  JS, Mariotto  AB, Parry  C,  et al.  Cancer survivors in the United States: prevalence across the survivorship trajectory and implications for care.   Cancer Epidemiol Biomarkers Prev. 2013;22(4):561-570. doi:10.1158/1055-9965.EPI-12-1356PubMedGoogle ScholarCrossref
    3.
    Chua  IS, Leiter  RE, Brizzi  KT,  et al.  US national trends in opioid-related hospitalizations among patients with cancer.   JAMA Oncol. 2019;5(5):734-735. doi:10.1001/jamaoncol.2019.0042PubMedGoogle ScholarCrossref
    4.
    van den Beuken-van Everdingen  MH, de Rijke  JM, Kessels  AG, Schouten  HC, van Kleef  M, Patijn  J.  Prevalence of pain in patients with cancer: a systematic review of the past 40 years.   Ann Oncol. 2007;18(9):1437-1449. doi:10.1093/annonc/mdm056PubMedGoogle ScholarCrossref
    5.
    Haider  A, Zhukovsky  DS, Meng  YC,  et al.  Opioid prescription trends among patients with cancer referred to outpatient palliative care over a 6-year period.   J Oncol Pract. 2017;13(12):e972-e981. doi:10.1200/JOP.2017.024901PubMedGoogle ScholarCrossref
    6.
    American Cancer Society Cancer Action Network and Patient Quality of Life Coalition. Summary of Opioid Access Research Project. Accessed September 5, 2018. https://www.fightcancer.org/sites/default/files/ACS%20CAN%20PQLC%20Opioid%20Research%20Project%20Key%20Findings%20Summary%20Memo%20FINAL.pdf
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