Patients with Gastrointestinal Cancers Face Inequities in End-Of-Life Pain Management Due to Race, Poverty

There are persistent racial and ethnicity-based inequities in end-of-life pain management, specifically affecting end-of-life access to and utilization of opioids for patients with gastrointestinal cancers, researchers have found.

“Black patients, Hispanic patients and (patients in) other racial groups, (when) compared to White patients, had decreased odds of filling an opioid prescription near the end of life, and even if they did fill their prescription, they were more likely to receive lower doses versus White patients,” study co-author Dr. Timothy M. Pawlik told CURE. “So, the data seemed to suggest that there was a disparity in opioid access and average daily doses among White versus non-White patients, and that this effect was particularly accentuated in areas of high poverty.”

Utilizing the data of 48,631 Medicare beneficiaries from 2008 to 2016 near end-of-life, defined in the study as “30 days before death of hospice enrollment” (6,551 patients with liver cancer, 13,559 with pancreatic cancer, 5,486 with gastric cancer and 23,035 with colorectal cancer) linked with county-level poverty information from the American Community Survey and the U.S. Department of Agriculture from 2000 to 2015, researchers found “markedly decreased odds of filling an opioid prescription near EOL” for Black, Asian, Hispanic patients and patients from other racial groups, according to findings published in Annals of Surgical Oncology.

Researchers further noted the disparity among daily doses and said disparities regarding both access and dosage were reduced in areas with intermittent high poverty and persistent poverty for Asian and Hispanic patients, as well as those from other racial groups, but those disparities were heightened among Black patients.

“All of these patients had cancer, so to some degree, their medical element was similar. What was dissimilar is the lived environment. Some people lived in a high poverty area, some people lived in a low poverty area, some people were White, some people were non-White, and these other factors impacted access and overall utilization of opioids,” said Pawlik, the Urban Meyer III and Shelley Meyer chair for cancer research and the chair of the department of surgery at the Ohio State University Wexner Medical Center and James Comprehensive Cancer Center in Columbus, Ohio.

The retrospective nature of the study, which utilized large amounts of data, made determination of true causation of these trends difficult, Pawlik explained.

“A lot of this is looking at association, looking at trends, and then to use these data to maybe call into question some implicit bias that that we may have (regarding) people and patients who maybe belong to a certain racial or ethnic group, that implicitly we're treating them differently. Or (for) a patient who from a high socioeconomic status versus a low socioeconomic status, that we may be treating them differently,” Pawlik said. “Some of this could be implicit bias, some of this could be more structural in nature, with regards to some of the legacy around racism and classism, if you will, in the United States.

“And so, I think that's what these data highlight. These are the data. And so now, we have to look at this, and there do seem to be some race- or ethnic-based disparities, there do seem to be some persistent poverty disparities. And really, this highlights the need for implicit bias training and also more targeted interventions to overcome some of these different disparities that we're finding at the end of life for patients who have gastrointestinal cancers.”

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