Pain is reported by 25% to 89% of breast cancer (BC) patients during the disease process. This pain, which may be due to disease progression, surgery, or drug treatment, can range from mild to severe and can be of short or long duration. Little is known about how this pain is managed in the outpatient setting.
A retrospective, administrative claims data study utilizing information from the National Ambulatory Medical Care Survey (NAMCS), which is a national probability cross-sectional sample survey of office-based medical care services, was conducted to examine pain management practices and the factors associated with the prescription of pain medications, especially opioids, in women with BC. The study analyzed NAMCS data obtained between 2011 to 2016.
Women aged 18 and older years were included in the study if—based on either International Classification of Disease-9 (ICD-9) or ICD-10 codes—BC was their primary diagnosis. The medications were classified using the American Hospital Formulary Service (AHFS) classification and included opioids, nonopioids (e.g., nonsteroidal anti-inflammatory agents, acetaminophen, salicylates), and combinations of both drug classes. Adjuvant analgesics included the anticonvulsants (e.g., barbiturates), antidepressants (e.g., selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, tricyclic antidepressants), and corticosteroids.
Between 2011 and 2016, 23.95 million office visits were made by women with a primary diagnosis of BC. Of this group, over one-half (50.81%) were aged 40 to 64 years. One-third (32.81%) of visits occurred in the Northeast region, with almost all (95.65%) occurring in metropolitan areas. The vast majority of patients (83.7%) were identified as White. Most of these patients (84.93%) were seen in general and family practice settings. Depression and diabetes were the most common comorbidities.
During these visits, over one-quarter (27.12%, or about 6.5 million women) received pain medications. Among the total study population, 15.16% received opioids, 17.13% were prescribed nonopioid analgesics, and 22.7% received adjuvant therapies. Over one-tenth (10.27%) of patients received combination analgesics. Tramadol and oxycodone were the most prescribed opioids (3.75% and 1.57%, respectively). Ibuprofen, followed by naproxen, were the most prescribed nonsteroidal anti-inflammatory agents (3.73% and 1.27%, respectively). Benzodiazepines, followed by glucocorticoids, were the frequently prescribed adjunctive therapies (7.61% and 6.98%, respectively).
Factors significantly associated with the decreased prescribing of analgesics included residing in the Northeast as opposed to the West (odds ratio [OR] = 0.31, 95% CI -0.10 to 0.99), being White as opposed to Black (OR = 0.5, 95% CI 0.3-0.85) and being seen by nonprimary care physicians rather than primary care physicians (OR = 0.37, 95% CI 0.15-0.94). Being on Medicaid or other state-based payment programs as opposed to having private insurance (OR = 2.38, 95% CI 1.15-4.93), being prescribed adjuvant medications versus not receiving these agents (OR = 4.74, 95% CI 3.10-7.24), and visiting general or family practice specialties compared with other specialties (OR = 3.18, 95% CI 1.22-8.29) were associated with increased prescribing of pain medications.
The only two factors that were significantly associated with opioid prescribing were geography and medical specialty. Women living in the Northeast, Midwest, and South were 94-fold (OR = 0.06, 95% CI 0.01-0.29), 85-fold (OR = 0.15, 95% CI -0.04 to 0.62) and 76-fold (OR = 0.24, 95% CI 0.06-0.92) less likely to receive opioids than those residing in the West. General and family practice clinicians were significantly more likely to prescribe opioids compared with other disciplines (OR = 6.76, 95% CI 1.71-26.70).
This study provided a clear picture of pain medication usage among women with BC and can assist pharmacists in targeting deprescribing efforts geared at both patients and providers.
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