By Pat Anson, PNN Editor

The number of cancer patients seeking treatment for pain in U.S. emergency departments has doubled in recent years, according to a large new study that further documents the harm caused to patients by misguided efforts to reduce opioid prescribing.

The study, conducted by a team of cancer researchers, looked at health data from 2012 to 2019 for millions of patients who had a cancer diagnosis and were not in remission.  Of the 35 million visits made to an emergency department (ED) by those patients, over half were deemed preventable – meaning the visits could have been avoided if the patient has received proper care earlier.

By a wide margin, pain was the most likely reason for a preventable ED visit. The number of cancer patients who went to an ED for poorly controlled pain rose from nearly 1.2 million in 2012 to 2.4 million in 2019. About a quarter of them had pain so severe they were admitted.  

“Consistent with previous studies, we found that pain was the most common presenting symptom (36.9%) in ED visits among patients with cancer and that the number of patients with cancer who visited an ED because of pain more than doubled over the study period,” lead author Amir Alishahi Tabriz, MD, a research scientist at the Moffitt Cancer Center in Florida, reported in JAMA Network Open.

“A possible explanation could be the unintended consequences of the efforts within the past decade to decrease overall opioid administration in response to the opioid epidemic.”

“I am not at all surprised by their result, as they are consistent with what I’m hearing from colleagues across the U.S.,” says Chad Kollas, MD, a palliative care physician and longtime critic of the 2016 CDC opioid guideline, which discouraged the prescribing of opioids for pain.

The CDC guideline was only intended for primary care physicians treating non-cancer pain, but it was quickly adopted throughout the U.S. healthcare system, including the field of oncology. Previous studies have documented how opioid prescriptions and doses declined for cancer patients, with the Cancer Action Network warning in 2019 that there has been “a significant increase in cancer patients and survivors being unable to access their opioid prescriptions.”

One of the most egregious cases involved April Doyle, a California woman with Stage 4 terminal breast cancer.  In 2019, Doyle posted a tearful video online after a pharmacist refused to fill her opioid prescription. She died about a year later, after the cancer metastasized into her lungs, spine and hip. 

“Unfortunately, the systematic misapplication of the 2016 Guideline created harms for patients due to reduced access to pain care and increased risk of suicide after nonconsensual or excessively rapid opioid tapers. These harms are predictable features of policy changes based on misguided calls for unfocused reductions in opioid prescribing,” Kollas told PNN.

Even if a cancer patient goes to an emergency room for pain relief, the odds of them — or any other patient — getting an opioid is dwindling. A new study by the National Center for Health Statistics found that the percentage of ED visits that ended with an opioid prescribed at discharge fell from 21.5% in 2010 to just 8.1% in 2020.

‘I Blame the CDC’

After years of complaints and bureaucratic delays, the CDC finally revised its opioid guideline in 2022 to more explicitly exclude patients undergoing cancer treatment, palliative care and end-of-life care. But many cancer patients felt it was too little, too late.

“My Mother had stage 4 terminal lung cancer. She was in horrible bone pain and her cancer doctor told her to take Tylenol for pain. We made several trips to the ER in the middle of the night just to manage her pain,” one woman told us. “She could not even enjoy her last moments on this earth with her family because of horrible cancer pain. As it spread all over, I could not help her. I am a nurse who watched her die miserably and I blame the CDC.”

“I live with stage 4 cancer and can't get any pain medication. I can't get any doctors to help me treat my pain,” another nurse told PNN. “My experience helps me understand why people become suicidal because they can't live with the pain anymore.”

“Stop making doctors afraid to treat pain adequately! I need a higher strength opioid for my chronic pain and my doctor will not up my strength because of that fear,” said another patient. “My husband has Stage 4 cancer and they refuse to up his strength as well. This is a crime against humanity!”

In another large study that looked at racial and ethnic disparities in the treatment of Medicare patients with advanced cancer, researchers saw a steady decline in opioid prescriptions and a rapid expansion in urine drug testing from 2007 to 2019. Their findings, published in the Journal of Clinical Oncology, show that less than a third of late-stage cancer patients received an opioid for pain control in 2019 and only 9.4% received a long-acting opioid near the end of life.

Black and Hispanic cancer patients were less likely to receive opioids than their White counterparts. They were also more likely to get smaller doses than White patients.

"Over the past decade, there has been a seismic shift in prescribing practices and sharp declines in access to these medications for patients with cancer,” said lead author Andrea Enzinger, MD, a gastrointestinal oncologist and assistant professor at Harvard Medical School. “Our findings are startling because everyone should agree that cancer patients should have equal access to pain relief at the end of life."