Hydrocodone prescriptions decreasing, study shows

The effectiveness of opioids in treating cancer pain has been well established over the years. But today’s opioid epidemic that began slowly in the late 1990s has led to changes in state and federal regulations about how and when opioid drugs are prescribed.

“Opioids are essential to controlling cancer patients’ pain,” said Ali Haider, M.D., assistant professor of Palliative, Rehabilitation and Integrative Medicine. “More than half of patients who undergo active cancer treatment or have advanced, metastatic or terminal-stage cancer report experiencing pain.”

Haider is principal investigator of a new study that evaluates the impact of recent regulatory changes on the type and dose of opioids that are prescribed by oncologists. Specifically, the study looked at changes in the type and dose of opioids prescribed to patients who were referred by oncologists to an outpatient palliative care clinic during the past six years.

“Undertreated cancer pain is associated with several physical and psychosocial symptoms that can impact quality of life,” Haider explained. “We wanted to know if stricter regulations were impacting the ability of cancer patients to find adequate pain relief.”

Haider and fellow researchers reviewed the electronic health records of 750 patients referred to MD Anderson’s outpatient palliative care clinic between Jan. 1 and April 30 each year from 2010 through 2015. Patients ranged in age from 51 to 67, and 87 percent had advanced cancer. Researchers made note of the opioid types and dosages prescribed for each patient. To do this, they used a tool that equates the many different opioids into one standard value. This standard value is based on morphine and its potency, and is referred to as morphine equivalent daily doses (MEDD). Calculating doses in this way converts all opioids to an equivalent of one medication – morphine – which allows ease of comparison and risk evaluations.

Haider and fellow researchers found that MEDD decreased during the past six years among patients who were referred by their oncologists to an outpatient palliative care clinic. Hydrocodone, Haider said, was the most commonly prescribed opioid until 2015. However, the drug’s reclassification in 2014 to a schedule II opioid – those with the most stringent prescription limits – caused a shift in how doctors were prescribing it. Prescriptions for hydrocodone went down and those for tramadol, a schedule IV opioid with less stringent prescription limits, went up. This may help explain the decrease in MEDD, Haider said.  

“Some factors that may have contributed to this observed trend include increased regulatory scrutiny related to the prescription opioid epidemic and opioid-related deaths in the United States; therefore, it is possible that oncologists are less comfortable prescribing and titrating opioids to treat cancer pain," he said.

Haider stressed that the study’s findings are observational, and that more research is needed to better understand the reason for these trends.