Racial and Ethnic Disparities in Opioid Access and Urine Drug Screening Among Older Patients With Poor-Prognosis Cancer Near the End of Life

Abstract

PURPOSE To characterize racial and ethnic disparities and trends in opioid access and urine drug screening (UDS) among patients dying of cancer, and to explore potential mechanisms. METHODS Among 318,549 non-Hispanic White (White), Black, and Hispanic Medicare decedents older than 65 years with poor-prognosis cancers, we examined 2007-2019 trends in opioid prescription fills and potency (morphine milligram equivalents [MMEs] per day [MMEDs]) near the end of life (EOL), defined as 30 days before death or hospice enrollment. We estimated the effects of race and ethnicity on opioid access, controlling for demographic and clinical factors. Models were further adjusted for socioeconomic factors including dual-eligibility status, community-level deprivation, and rurality. We similarly explored disparities in UDS. RESULTS Between 2007 and 2019, White, Black, and Hispanic decedents experienced steady declines in EOL opioid access and rapid expansion of UDS. Compared with White patients, Black and Hispanic patients were less likely to receive any opioid (Black, –4.3 percentage points, 95% CI, –4.8 to –3.6; Hispanic, –3.6 percentage points, 95% CI, –4.4 to –2.9) and long-acting opioids (Black, –3.1 percentage points, 95% CI, –3.6 to –2.8; Hispanic, –2.2 percentage points, 95% CI, –2.7 to –1.7). They also received lower daily doses (Black, –10.5 MMED, 95% CI, –12.8 to –8.2; Hispanic, –9.1 MMED, 95% CI, –12.1 to –6.1) and lower total doses (Black, –210 MMEs, 95% CI, –293 to –207; Hispanic, –179 MMEs, 95% CI, –217 to –142); Black patients were also more likely to undergo UDS (0.5 percentage points; 95% CI, 0.3 to 0.8). Disparities in EOL opioid access and UDS disproportionately affected Black men. Adjustment for socioeconomic factors did not attenuate the EOL opioid access disparities. CONCLUSION There are substantial and persistent racial and ethnic inequities in opioid access among older patients dying of cancer, which are not mediated by socioeconomic variables.

Examining Racial and Ethnic Inequities in Opioid Prescribing and Risk Screening Among Patients With Advanced Cancer

“…10,14,15 However, anecdotal reports and preliminary studies suggest that they might have also affected the clinically appropriate and necessary use of opioids among those with cancer. [16][17][18][19] This is of particular concern among older adults, who comprise nearly two thirds of all newly diagnosed cases of cancer 20,21 and among vulnerable groups found to be at increased risk for pain undertreatment, such as racial and ethnic minoritized individuals and those with socioeconomic and geographic deprivation. 22,23 The retrospective study by Enzinger et al 19 that accompanies this editorial reports on racial and ethnic disparities in the number, type (long-acting versus short-acting), and strength of opioids received and in rates of urine drug screening (UDS), among Black, Hispanic, and White older adults with poor prognosis cancers near the end of life (defined as #30 days before death or hospice enrollment).…”

“…[16][17][18][19] This is of particular concern among older adults, who comprise nearly two thirds of all newly diagnosed cases of cancer 20,21 and among vulnerable groups found to be at increased risk for pain undertreatment, such as racial and ethnic minoritized individuals and those with socioeconomic and geographic deprivation. 22,23 The retrospective study by Enzinger et al 19 that accompanies this editorial reports on racial and ethnic disparities in the number, type (long-acting versus short-acting), and strength of opioids received and in rates of urine drug screening (UDS), among Black, Hispanic, and White older adults with poor prognosis cancers near the end of life (defined as #30 days before death or hospice enrollment). In addition, they evaluated the impact of socioeconomic variables on these disparities on the basis of data from the Centers for Medicare and Medicaid Services administrative database on a random sample of Medicare beneficiaries in the United States.…”

“…In the article that accompanies this editorial, Enzinger et al 19 report on racial and ethnic disparities in the number, type, and strength of opioids received and in the rate of urine drug screening tests undertaken among Black, Hispanic, and White older adults with poor prognosis cancers near the end of life. To our knowledge, it is the first large-scale study of sociodemographic disparities in opioid prescribing for patients with advanced cancer in the wake of the opioid epidemic and the first to focus on patients near the end of life, identifying important care inequities that can inform future efforts for improvement.…”

“…10,14,15 However, anecdotal reports and preliminary studies suggest that they might have also affected the clinically appropriate and necessary use of opioids among those with cancer. 16–19 This is of particular concern among older adults, who comprise nearly two thirds of all newly diagnosed cases of cancer 20,21 and among vulnerable groups found to be at increased risk for pain undertreatment, such as racial and ethnic minoritized individuals and those with socioeconomic and geographic deprivation. 22,23…”

“…The retrospective study by Enzinger et al 19 that accompanies this editorial reports on racial and ethnic disparities in the number, type (long-acting versus short-acting), and strength of opioids received and in rates of urine drug screening (UDS), among Black, Hispanic, and White older adults with poor prognosis cancers near the end of life (defined as ≤30 days before death or hospice enrollment). In addition, they evaluated the impact of socioeconomic variables on these disparities on the basis of data from the Centers for Medicare and Medicaid Services administrative database on a random sample of Medicare beneficiaries in the United States.…”