Public policy intended to reduce opioid abuse and addiction appear to have the unintended consequence of limiting hospice patients’ access to these often necessary pain management drugs. Misapplication of current U.S. Centers for Disease Control & Prevention (CDC) guidelines for opioid prescribing is a likely contributor to this problem.
Recent research spearheaded by the Oregon State University (OSU) College of Pharmacy examined the medical records of 2,500 hospital patients who were discharged to hospice between 2010 and 2018. Findings indicate that opioid prescriptions for hospice patients are on a downward trend (a 12% decline), while the use of less powerful, non-opioid medications is rising. Researchers expressed concern that these trends mean that many hospice patients are being under-treated for pain. The findings appeared in the Journal of Pain & Symptom Management.
“Even among patients prescribed opioids during the last 24 hours of their inpatient hospital stay, opioid prescribing upon discharge decreased,” said Jon Furuno, lead author of the study and associate professor and the interim chair of the Oregon State Department of Pharmacy Practice. “It seems unlikely that patients would merit an opioid prescription on their last day in the hospital but not on their first day in hospice care, and it’s well documented that interruptions in the continuity of pain treatment on transition to hospice are associated with poor patient outcomes.”
In addition to OSU, the researchers included personnel from Oregon Health & Science University, the Dana Farber Cancer Institute, Ariadne Labs, the University of Massachusetts Medical School and the University of Maryland School of Pharmacy.
Patients whose records were examined during the study had an average age of 65, and more than 50% had been diagnosed with cancer. Factors contributing to the 12% decline in opioid prescriptions to these patients included a lack of timely and accurate pain assessments, concerns regarding addiction, and caregiver concerns about making mistakes in administering the drugs, as well as public policies intended to curb abuse, the study indicated.
Pain management is a cornerstone of hospice care and can have a substantial impact on patient and family satisfaction. A 2014 study found patients and families view pain and symptom management as their top priority related to quality of hospice care. With consumers and referral organizations paying increased attention to publicly reported quality data, dissatisfaction with pain treatment can hurt an organization’s bottom line.
The CDC in 2016 released guidelines to reduce the unnecessary or illicit use of opioids. In response to reports of misapplication of opioid prescribing guidelines, CDC has clarified that those guidelines do not apply to end-of-life care, palliative care, or treatment of pain related to cancer.
Common misunderstandings about the guidelines relate to their recommendation to reduce opioid dosage to 90 morphine milligram equivalents (MME), as well as limits on how long a patient can receive opioid therapy. Payor and pharmacy policies do not always recognize the exemptions for hospice and palliative care, resulting in delayed or inadequate access to medications for those patients.
“There are some concerns, however, that indiscriminate adoption or misapplication of these initiatives may be having unintended consequences,” Furuno said. “The CDC Prescribing Guideline and the other initiatives weren’t meant to negatively affect patients at the end of their lives. Our results quantify a decrease in opioids among patients who are often in pain and for whom the main goal is comfort and quality of life.”