Compassion Inequities and Opioid Dependence: A Matched Case-Control Analysis of Inpatient Pain Management for Patients With a History of Opioid Use Disorder Hospitalized for Cancer-Related Pain

Abstract

The casualties suffered during the opioid epidemic galvanized the development of guidelines intended to reduce inappropriate opioid prescribing. Although acute cancer-related pain was excluded from these recommendations, studies have demonstrated reduced opioid prescribing for cancer patients in recent years, even those hospitalized with advanced disease. It's unclear how the stigma of opioid use disorder (OUD) may further affect inpatient pain management (PM) for patients with advanced cancer. We performed a matched case-control analysis to test the hypothesis that patients with a history of OUD would receive lower quality care for acute cancer-related pain compared to those with no history of OUD.Charts from 105 patients with locally advanced or metastatic cancer and a documented history of OUD admitted to a single institution from 2015-2020 were retrospectively reviewed. Hospitalizations were excluded if patients refused opioid treatment or did not have acutely worsening cancer pain on admission. Forty hospitalizations met inclusion criteria. Each hospitalization was matched in a 1:1 ratio by patient age, gender, smoking/alcohol use, and disease extent. Home milligram morphine equivalent per day (MME/day) was calculated from the patient's home medication list at the time of admission. Admission MME/day refers to the average administered MME/day over the course of hospitalization, or if PM specialty was consulted, the average MME/day prior to PM consult. Post-consult MME/day refers to the average MME/day given after PM consult. Wilcoxon signed rank test was performed for statistical comparison.A total of 80 hospitalizations (40:40) were matched for 25 patients with a history of OUD and 31 patients with no history of OUD. The median age was 37.5 years (IQR 35-53.8). Cancer was locally advanced for 30% of admissions and metastatic or relapsed for 70% of admissions. The median overall survival was 3.2 months (95% CI 1.91-5.209, P = 0.13) and was not statistically significant between groups. Patients with OUD had a significantly lower median change from home to admission MME/day compared to controls (-3 vs. 37, P < 0.01) and were more likely to have decreased or no change in admission MME/day (OR 7.9, 95% CI 2.8-22.2, P < 0.01) regardless of whether OUD was in documented remission. Similarly, the median change from home to discharge MME/day was lower for patients with OUD (0 vs. 55, P < 0.01). For patients with PM consult, the change from home MME/day to post-consult MME/day did not differ compared to matched controls (26.7 vs 37.5 MME/day, P = .82).Our results suggest that the stigma of opioid dependence impedes the delivery of compassionate care. Stigma-reduction strategies and early involvement of pain specialists are critical for improving the quality of care for patients with advanced cancer.