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2023 HSR&D/QUERI National Conference Abstract

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1101 — Risk Factors for New Persistent Opioid Use Among Veterans Treated for Early-Stage Cancer

Lead/Presenter: Marilyn Schapira
All Authors: Schapira MM (Center for Health Equity Research and Promotion, Philadelphia), Moyo P, Brown University Leonard C, University of Pennsylvania Hubbard R, University of Pennsylvania Chhatre S, Center for Health Equity Research and Promotion, Philadelphia and the University of Pennsylvania Jayadevappa R, University of Pennsylvania Jason Prigge, Center for Health Equity Research and Promotion, Philadelphia Roberts C.B, Center for Health Equity Research and Promotion, Philadelphia Meisel Z, University of Pennsylvania Parikh R, University of Pennsylvania Paulson C, Michael J. Crescenz VA Medical Center, Philadelphia, PA and the University of Pennsylvania Krouse R, Michael J. Crescenz VA Medical Center, Philadelphia, PA and the University of Pennsylvania Suda K, Center for Health Equity Research and Promotion, Pittsburgh Kuma P, Michael J. Crescenz VA Medical Center, Philadelphia, PA Peter Groeneveld, Center for Health Equity Research and Promotion, Philadelphia and the University of Pennsylvania

Objectives:
Guidelines for safe opioid prescribing typically exclude patients with a diagnosis of cancer. However, cancer survivors may face increased risk of opioid use disorder (OUD) and its adverse effects. The objectives of this study were to 1) determine the incidence of new persistent opioid use (NewPersOU) and unsafe opioid prescribing practices (UnsafeOPP) among Veterans who underwent definitive surgery for early stage cancer, and 2) identify patient, clinical, and system level factors associated with these outcomes. We hypothesized that a higher level of opioids used during cancer treatment would be associated with increased risk of NewPersOU and UnsafeOPP.

Methods:
We conducted a retrospective cohort study of Veterans with a new diagnosis of early stage cancer. Inclusion criteria were a diagnosis of early stage cancer between 1/2015 and 12/2016, being opioid naïve in the year prior to diagnosis, and receipt of definitive surgical therapy. Primary outcomes were 1) NewPersOU defined as > = 1 opioid prescription 90-180 days post treatment, and 2) UnsafeOPP defined as the days of overlap in opioid and benzodiazepine prescriptions in the 13-month follow-up period. Data sources included the VA Corporate Data Warehouse and the Master Veteran Person Index. Opioid exposure attributable to treatment was defined as the cumulative oral or topical Morphine Milligram Equivalents (MMEs) prescribed from 31 days prior to 14 days post index cancer surgery. Multivariate analyses were conducted to evaluate factors associated with NewPersOU and UnsafeOPP.

Results:
We identified 9213 Veterans who met study criteria. Sixty-six percent were >65 and 33% were 45 to 64 years of age; 98% were male, 76% were White, 18% Black or African American, 2% other race, and 5% of Hispanic Ethnicity. At diagnosis, 19% were stage 0, 30% stage I, 33% stage 2, and 18% stage 3. Cancer types included prostate (29%), colorectal (26%), bladder (25%), lung (14%) and other (7%). Among the cohort, 10.7% had NewPersOU with receipt of >1 opioid prescription in the 90-180 days post-treatment. In bivariate analysis, factors associated with higher incidence of NewPersOU were being in the highest quartile of comorbidity as measured by the Elixhauser score (13.5%), a diagnosis of lung cancer (12.8%), and receiving chemotherapy (17.9%). In a multivariate survival analysis, exposure to the upper quartile of morphine milligram equivalents of opioids vs. none in the treatment period was associated with higher incidence of NewPersOU (HR 1.59, 95% CI: 1.27 to 1.99, p-value < 0.001). Four percent of the cohort had UnsafeOPP defined as 1 or more days of overlap in prescriptions for benzodiazepines and opioids. In a multivariate model there was no association between opioid exposure in the treatment period and the outcome of UnsafeOPP.

Implications:
Over 1 in 10 cancer patients treated with surgery developed new persistent opioid use after their surgery. Patients with lung cancer, multiple comorbidities, and those who received adjuvant chemotherapy were at even higher risk.

Impacts:
While well-intentioned, the exclusion of cancer patients from guidelines to prevent OUD among patients in need of perioperative pain control potentially places these patients at risk of adverse outcomes from opioids.