African-American cancer patients more likely to receive risky analgesics

1. African-American cancer patients with chronic kidney disease were more likely to receive morphine over oxycodone when compared to white patients.                                                          

Evidence Rating Level: 2 (Good) 

Study Rundown: Renal impairment is common among cancer patients, particularly African Americans, who are more likely to have comorbid diabetes or hypertension. As a result, providers must carefully consider whether to prescribe opioids with renally-cleared toxic metabolites for pain control in these patients. However, previous studies have suggested that these patients are at a higher risk for opioid treatment disparities compared to other treatment modalities. The purpose of this study was to evaluate the relationship between race versus insurance type on opioid prescription patterns in the setting of renal impairment.

At the conclusion of this study, the authors found that race was a strong predictor of the type of opioid prescribed even after controlling for insurance type. Furthermore, race was a significant independent predictor for severity of analgesia adverse effect, in addition to type of opioid. Based on these findings, the authors suggested that these patients are particularly vulnerable to variability in opioid prescribing practices, possible biases, and lack of knowledge of toxic metabolites. It should be noted that this was a small study that did not stratify by medication release forms or account for additional analgesics that may have been prescribed.

Click to read the study in JCO

In-Depth [retrospective cohort]: This study was a retrospective analysis of a prospective cohort study on analgesia for cancer pain. 182 patients diagnosed with solid tumors or multiple myeloma with cancer-related pain requiring opioids were included. The study authors limited inclusion of schedule II opioids to morphine and oxycodone. Outcomes measured included prescription of morphine or oxycodone, presence of impaired GFR, analgesic adverse effects, pain, and health insurance information. African-American patients had 79% lower odds of having private insurance compared to white patients (odds ratio, 0.21; 95% CI, 0.12 to 0.37; p < .001), but after controlling for insurance, these patients were significantly less likely to be prescribed morphine than oxycodone (p < 0.0007). Among patients with CKD, there was still a significant relationship between race and the type of opioid prescribed (odds ratio, 0.21; 95% CI 0.06-0.72; p < 0.012). Race was also associated with severity of analgesic adverse effects (p = 0.015), while the type of opioid prescribed predicted adverse effect severity after adjusting for race (p = 0.037). Race no longer predicted adverse effect severity after adjusting for type of opioid (p = 0.085).

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