Community prescribing trends and prevalence in the last year of life, for people who die from cancer

Abstract

Background People who die from cancer (‘cancer decedents’) may latterly experience unpleasant and distressing symptoms. Prescribing medication for pain and symptom control is essential for good-quality palliative care; however, such provision is variable, difficult to quantify and poorly characterised in current literature. This study aims to characterise trends in prescribing analgesia, non-analgesic palliative care medication and non-palliative medications, to cancer decedents, in their last year of life, and to assess any associations with demographic or clinical factors. Methods This descriptive study, analysed all 181,247 prescriptions issued to a study population of 2443 cancer decedents in Tayside, Scotland (2013–2015), in the last year of life, linking prescribing data to demographic, and cancer registry datasets using the unique patient-identifying Community Health Index (CHI) number. Anonymised linked data were analysed in Safe Haven using chi-squared test for trend, binary logistic regression and Poisson regression in SPSSv25. Results In their last year of life, three in four cancer decedents were prescribed strong opioids. Two-thirds of those prescribed opioids were also prescribed laxatives and/or anti-emetics. Only four in ten cancer decedents were prescribed all medications in the ‘Just in Case’ medication categories and only one in ten was prescribed breakthrough analgesia in the last year of life. The number of prescriptions for analgesia and palliative care drugs increased in the last 12 weeks of life. The number of prescriptions for non-palliative care medications, including anti-hypertensives, statins and bone protection, decreased over the last year, but was still substantial. Cancer decedents who were female, younger, or had lung cancer were more likely to be prescribed strong opioids; however, male cancer decedents had higher odds of being prescribed breakthrough analgesia. Cancer decedents who had late diagnoses had lower odds of being prescribed strong opioids. Conclusions A substantial proportion of cancer decedents were not prescribed strong opioids, breakthrough medication, or medication to alleviate common palliative care symptoms (including ‘Just in Case’ medication). Many patients continued to be prescribed non-palliative care medications in their last days and weeks of life. Age, gender, cancer type and timing of diagnosis affected patients’ odds of being prescribed analgesic and non-analgesic palliative care medication.

Adherence to coprescribing of laxatives with opioids and associated characteristics in general practices in the Netherlands

“…The level of adherence in this study is in line with or slightly higher than in older studies both in the Netherlands [ 14 , 15 ] and outside [ 17 – 19 ], while more recent studies tend to show higher levels of adherence [ 16 , 20 ] However, while these studies only looked at overall adherence, we investigated practice variation. Since the upper level of the range of adherence is 88%, an increase in the overall level of adherence seems achievable.…”

“…The data used for this study are not recent (2014), but do show an overview of the adherence at that time. Looking at more recent literature, it can be assumed that adherence has improved since then, but that non-adherence is still prevalent [ 16 , 20 ]. We think it is unlikely that the reasons for non-adherence changed much over the past few years, as the context of prescribing, such as guidelines, has not changed, no national campaigns have been launched on this topic and behavioral change is typically a slow process.…”

“…In a more recent study among opioid initiators in the Netherlands, concomitant use of laxatives was found to be 74.8% [ 16 ]. Similar percentages have been reported in studies performed in the United States (55% [ 17 ] and 23% in patients with lung cancer [ 18 ]) and Switzerland (50% in noncancer and 67% in cancer populations) [ 19 ] Non-adherence to coprescribing of laxatives in opioid therapy remains an issue up to this day, as a recent study in palliative care has shown: one third of patients receiving opioids in the last year of their lives were not prescribed laxatives [ 20 ].…”

Age and cancer type: Associations with increased odds of receiving a Late Diagnosis in people with advanced cancer.

“…Receiving a late diagnosis denies patients dying from cancer the opportunity to receive good quality palliative care and timely anticipatory care planning, as well as time for putting affairs in order, spending time with loves ones, and coming to terms with their diagnosis. Among patients who die from cancer, those who received late diagnoses were less likely to be prescribed strong opioids and anticipatory palliative care medication, compared to those who were diagnosed earlier 12 . In the UK, most people who die from cancer wish to die at home and avoid unnecessarily aggressive treatment or hospitalisation at the end of their lives [13][14][15][16][17][18] .…”

Light-Induced Activation of a Specific Type-5 Metabotropic Glutamate Receptor Antagonist in the Ventrobasal Thalamus Causes Analgesia in a Mouse Model of Breakthrough Cancer Pain

“…This will be translated into immediate relief of pain with no systemic adverse effects. The pitfall of this strategy is the neurosurgical procedure required for the implantation of optic fibers in the CNS, but this may not be an “impassable barrier” for cancer patients with a limited life expectancy, considering that a substantial proportion of cancer decedents are not prescribed breakthrough medication during palliative care [ 5 ]. Here, optopharmacology may provide a means of intervening in BTcP.…”