Racial and Ethnic Disparities in Opioid Access and Urine Drug Screening Among Older Patients With Poor-Prognosis Cancer Near the End of Life

Abstract

Purpose: To characterize racial and ethnic disparities and trends in opioid access and urine drug screening (UDS) among patients dying of cancer, and to explore potential mechanisms.

Methods: Among 318,549 non-Hispanic White (White), Black, and Hispanic Medicare decedents older than 65 years with poor-prognosis cancers, we examined 2007-2019 trends in opioid prescription fills and potency (morphine milligram equivalents [MMEs] per day [MMEDs]) near the end of life (EOL), defined as 30 days before death or hospice enrollment. We estimated the effects of race and ethnicity on opioid access, controlling for demographic and clinical factors. Models were further adjusted for socioeconomic factors including dual-eligibility status, community-level deprivation, and rurality. We similarly explored disparities in UDS.

Results: Between 2007 and 2019, White, Black, and Hispanic decedents experienced steady declines in EOL opioid access and rapid expansion of UDS. Compared with White patients, Black and Hispanic patients were less likely to receive any opioid (Black, -4.3 percentage points, 95% CI, -4.8 to -3.6; Hispanic, -3.6 percentage points, 95% CI, -4.4 to -2.9) and long-acting opioids (Black, -3.1 percentage points, 95% CI, -3.6 to -2.8; Hispanic, -2.2 percentage points, 95% CI, -2.7 to -1.7). They also received lower daily doses (Black, -10.5 MMED, 95% CI, -12.8 to -8.2; Hispanic, -9.1 MMED, 95% CI, -12.1 to -6.1) and lower total doses (Black, -210 MMEs, 95% CI, -293 to -207; Hispanic, -179 MMEs, 95% CI, -217 to -142); Black patients were also more likely to undergo UDS (0.5 percentage points; 95% CI, 0.3 to 0.8). Disparities in EOL opioid access and UDS disproportionately affected Black men. Adjustment for socioeconomic factors did not attenuate the EOL opioid access disparities.

Conclusion: There are substantial and persistent racial and ethnic inequities in opioid access among older patients dying of cancer, which are not mediated by socioeconomic variables.

FIG 1.

Annual trends in opioid access and UDS among White, Black, and Hispanic poor-prognosis cancer decedents near EOL. Unadjusted annual trends in opioid access among patients with poor-prognosis cancers near EOL, by race and ethnicity: (A) the proportion of decedents with poor-prognosis cancers filling any opioid near EOL, by race and ethnicity; (B) the proportion filling a long-acting opioid near EOL; (C) mean opioid dose in MMEDs among patients filling at least one opioid; and (D) the mean total dose of opioids (in morphine milligram equivalents) filled by patients with poor-prognosis cancers near EOL. All trends are presented separately for non-Hispanic White, non-Hispanic Black, and Hispanic decedents. Near EOL is considered the 30 days before death or hospice enrollment. EOL, end of life; MMEDs, morphine milligram equivalents per day; UDS, urine drug screening.

FIG 2.

Racial and ethnic disparities in EOL opioid access by patient sex: the adjusted absolute differences by race, ethnicity, and sex (A) in the probability of filling any opioid near EOL; (B) in the probability of filling a long-acting opioid near EOL; (C) in opioid dose in MMED among patients filling an opioid prescription near EOL; and (D) in the total dose of opioids filled per decedent near EOL in MMEs. White women are the reference group for all analyses. Circles reflect the adjusted correlation coefficients and the error bars reflect the 95% CIs from regression models. For all analyses, EOL was defined as the last 30 days before death or hospice. Bold text and asterisk indicates the presence of a statistically significant, negative interaction between Black race and male sex. For all outcomes, the negative effect of being Black on EOL opioid outcomes is disproportionately large for men. EOL, end of life; MME, morphine milligram equivalent; MMED, morphine milligram equivalent per day.

FIG 3.

Racial and ethnic disparities in EOL opioid access by rurality: the adjusted absolute differences by race, ethnicity, and urban/rural status (A) in the probability of filling any opioid near EOL; (B) in the probability of filling a long-acting opioid near EOL; (C) in opioid dose in MMED among patients filling an opioid prescription near EOL, and (D) in the total dose of opioids filled per decedent near EOL in MMEs. White rural patients are the reference group for all analyses. Circles reflect the adjusted correlation coefficients and the error bars reflect the 95% CIs from regression models. For all analyses, EOL was defined as the last 30 days before death or hospice. Bold text and asterisk indicates the presence of a statistically significant positive interaction between race, ethnicity, and urban status. EOL, end of life; MME, morphine milligram equivalent; MMED, morphine milligram equivalent per day.

FIG 4.

Racial and ethnic disparities in EOL opioid access by Medicaid dual-eligibility: (A) the adjusted absolute differences by race, ethnicity, and Medicaid dual-eligibility in the probability of filling any opioid near EOL; (B) in the probability of filling a long-acting opioid near EOL; (C) in opioid dose in MMED among patients filling an opioid prescription near EOL; and (D) in the total dose of opioids filled per decedent near EOL in MMEs. White dual-eligible patients are the reference group for all analyses. Circles reflect the adjusted correlation coefficients and the error bars reflect the 95% CIs from regression models. For all analyses, EOL was defined as the last 30 days before death or hospice. Bold text and asterisk indicates the presence of a statistically significant negative interaction between race, ethnicity, and Medicaid dual-eligibility. EOL, end of life; MME, morphine milligram equivalent; MMED, morphine milligram equivalent per day.

FIG A1.

Annual trends in UDS among patients with poor-prognosis cancers by race and ethnicity presents the proportion of patients with poor-prognosis cancer filling at least one opioid prescription, who also had one or more claims for a presumptive urine drug test in the 180 days before death or hospice enrollment. UDS, urine drug screening.

FIG A2.

Racial and ethnic disparities in UDS by patient sex, urban/rural status, and Medicaid dual-eligibility: (A) the adjusted absolute differences in the proportion of decedents undergoing UDS by race, ethnicity, and sex. White women are the reference group. *Statistically significant positive interactions were observed between Black and male, and Hispanic and male. (B) The adjusted absolute differences in UDS by race, ethnicity, and urban/rural status. White rural-dwelling patients are the reference group. (C) The adjusted absolute differences of UDS by race, ethnicity, and dual-eligibility for Medicare and Medicaid. White dual-eligible patients are the reference group. *We observed statistically significant negative interactions between Hispanic ethnicity and dual-eligibility. Circles reflect the adjusted correlation coefficients and the error bars reflect the 95% CIs from regression models. For all panels, UDS was assessed in the 180 days before death or hospice enrollment, and restricted to patients filling ≥ 1 opioid prescriptions. UDS, urine drug screening.