Concerns allayed for hospice patients given opioids

Opioid use is not the bogey man feared by some

Opioid use for patients with advanced illness has been the focus of controversy and misconceptions, even among health care practitioners, an expert notes.

"There were concerns that opioid use and escalating doses of opioids may be contributing to hastening death," says Russell K. Portenoy, MD, chairman of the department of pain medicine and palliative care and chief medical officer of Continuum Hospice Care of Beth Israel Medical Center in New York, NY.

"This controversy has been going on for many years, including in the palliative care community, where there are concerns that in some cases, opioid use is being used by physicians to hasten death without being overt about it," Portenoy says.

"In the context of controversy and profound ethical discussion around it, it's important to get some data," Portenoy says.

This is what led Portenoy and co-investigators to study data from end-of-life patients to see if opioid use had an impact on shortening patients' lives.

"Is opioid use associated with shorter life expectancy than those who don't get opioids?" Portenoy says. "This can only be determined during observational studies, and those studies in palliative care patients are difficult to do because they're ill, it's hard to get consent, and it's difficult to keep patients in the study and obtain reliable information."

Investigators examined two hypotheses: The first was whether merely being treated with opioids would be associated with shortened survival, and the second was whether larger doses or increases in opioid doses would be associated with a higher likelihood of dying, Portenoy says.

"If you accept the notion that respiratory depression is a potential complication of opioids, then it makes sense to suspect that opioids were associated with a shortened survival," Portenoy says.

The study's findings suggested that opioid use plays a weak and limited role in impacting survival, and that clinicians should not withhold appropriate doses from the hospice population out of concerns of its impact on longevity.

The answer was found in a large observational study by the National Hospice & Palliative Care Organization called the National Hospice Outcomes Project.

"That project collected data on over 1,300 patients admitted to hospices around the country," Portenoy says. "A large variety of data was collected, including data on use of opioids to treat pain in patients who were hospice patients."

Some of the patients included in the study died before the study concluded, and this allowed investigators to empirically evaluate their end of life, he notes.

"My colleagues and I took the opportunity to do a secondary analysis of the dataset, with the purpose to evaluate in multivariate analysis the relationship between survival and opioid treatments," Portenoy says. "We looked specifically at different aspects of opioid use and change in dose."

They found a statistical association with duration of survival and the dose of opioid the patient was on, but not with the percent change in dose.

In the multivariate analysis, the amount of variance in survival that could be explained by this factor was very small, between six and 10 percent, Portenoy says.

"So the bottom line is this finding resonates nicely with clinical experience," he adds. "People taking higher doses of opioids are people with more extensive disease or more complications of disease, so it's not surprising that higher doses of opioid is a marker of people who are sicker and whom might be likely to die sooner."

But the fact that investigators saw no relationship to survival when there was an increased dose, and that the overall dose impact was less than 10 percent of the difference in survival, suggest that opioids contribute very little — if at all — to the timing of death in a hospice population, Portenoy says.

"And so from the perspective of the relationship between this study and ongoing concerns and controversies out there for the past couple of decades, this study provides reassurance that using opioids to treat pain in advanced illness is medically appropriate and should not be restrained by concerns about shortening lives," Portenoy says.

"Moreover, those who make assumptions that opioid therapy is contributing to hastening death should be reassured that in real medical processes, this isn't going to hasten death," he adds.

"Among pain specialists, it's a given that opioids are stigmatized drugs," Portenoy says. "There's a varied degree of undertreatment, and it's a phenomenon with multiple generators."

Among the barriers to effective opioid use are physicians who conduct poor assessments and have inadequate knowledge of drug therapy, he says.

"Another set relates to patients and families," Portenoy says. "Studies have indicated that concerns about side effects and addiction causes patients to take fewer drugs than prescribed or to not describe their pain accurately."

The third set of barriers to effective opioid use are system issues, although in hospice care these are largely managed by the hospice and are not the main problem, he adds.

Portenoy hopes that his study, and others with similar findings that may follow, will contribute to a lessening of the stigma associated with opioids and result in a greater willingness by patients to use the drugs when needed, he says.

"We're doing further analyses of this dataset to understand the nature of pain and how it might be better managed," Portenoy says.

Need More Information?

  • Russell K. Portenoy, MD, Chairman, Department of Pain Medicine and Palliative Care; Chief Medical Officer, Continuum Hospice Care, Beth Israel Medical Center, First Avenue at 16th Street, New York, NY 10003. Telephone: (212) 844-1505.