U.S. Opioid Prescribing Trends for Adolescent and Young Adult Cancer Patients in Last Year of Life, 2002 – 2016: A Study from the Clare Project

Thesis (Master's)--University of Washington, 2018Research Objective/Background: Moderate to severe cancer pain affects most cancer patients, including >70,000 adolescent and young adult (AYA) cancer patients diagnosed annually between the ages of 15 – 39. Opioid medications are often used to treat cancer-related pain, especially in the last year of life. Yet, limited pain management research at end of life for AYA populations is available on a national scale to understand variation and trends, especially for opioid prescription patterns. Study Design: We conducted a retrospective cohort study of AYAs with a cancer claim at ages 15– 39 years from 2002– 2016 who were enrolled in a health insurance plan for at least 365 days before death. All patients were commercially insured by one of the largest US health insurers, and in Optum administrative data, a purchased dataset. Data included medical service claims, outpatient pharmacy services and patient information. We extracted data on all filled prescriptions for opioid and opioid partial analgesics based on National Drug Classification codes for every deceased patient during the 30 and 365 days prior to death and describe opioid prescription patterns and trends. We classified opioid prescriptions using the following established categories to examine prescriptions by type and strength: (1) Extended Release/Long Acting (ER/LA) Schedule II opioid, (2) short-acting Schedule II opioid, and (3) short-acting non-Schedule II opioid. Principal Findings: Our cohort included 4,217 deceased AYA cancer patients; we excluded individuals who were not enrolled for the entire year prior to death (n=989) and individuals with no prescription records (n=189). Mean age at death was 33.6 years and 51% were women. In the last year of life, 30.5% of patients were prescribed ≥ 1 or more ER/LA opioid, 54.1% were prescribed ≥ 1 Schedule II opioid and 24.6% were prescribed ≥ 1 non-Schedule II opioid. ER/LA opioids, considered the strongest opioid category, were prescribed closer to death than other opioid categories; for patients who received at least 1 ER/LA opioid prescription, the median interval between first prescription during the last year of life and death was 22.3 weeks (IQR 10.7 – 41.9). Age at death was significantly related to a later (closer to death) first ER/LA opioid prescription, p = .004. Compared to patients age 15-19 at death, patients who were older at death (35-39 and 40-52) tended to receive an earlier first ER/LA prescription in the year before death. Results were similar for Schedule II opioids, where patients who were older at death tended to receive an earlier first Schedule II opioid prescription, p