Opioid tapering and discontinuation for head and neck cancer (HNC) survivors.
Authors: Salz Talya , Mishra Meza Akriti , Moryl Natalie , Kriplani Anuja , Tringale Kathryn Ries , Flory James , Bradshaw Patrick T , Jinna Sankeerth , Lipitz-Snyderman Allison 
Published: September 2024

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Background:
Older HNC survivors often experience post-treatment pain, and they fill opioid prescriptions more often than similar cancer-free adults for the first 5 years after HNC diagnosis. To better understand whether ongoing opioid use is likely explained by continued opioid prescribing from the time of cancer treatment, we aimed to quantify the extent to which opioids prescribed near the end of treatment are reduced in dose (tapered) and discontinued after treatment completion.
Methods:
Using linked Surveillance, Epidemiology, and End Results (SEER) registry and Medicare claims data, we identified adults age >65 diagnosed 2014-2017 with stage I-III HNC with ≥6 months treatment-free follow-up prior to censoring at further treatment, new cancer, hospice, 3 months prior to death, or end 2019. We evaluated the presence of a new or ongoing opioid prescription 2 weeks following treatment completion (baseline) and calculated daily baseline dose in morphine milligram equivalents (MME). Among those with an opioid prescription (“on opioids”) at baseline, we described cross-sectional metrics of opioid receipt and dose every 30 days: proportion of survivors on opioids (who were also on opioids the prior month), initial and current dose of opioids for those currently on opioids, and proportion of survivors on opioids whose dose declined ≥50% from baseline.
Results:
Among 5135 HNC survivors, 894 were on opioids at baseline (average daily dose 44 MME). By 1 month, 29% of survivors on opioids at baseline (N=260) had a current opioid fill, and 7% had an opioid dose <50% of the baseline dose. Discontinuation of opioids increased each month; median daily dose each month ranged from 44 MME at 30 days to 60 MME at 180 days. Those who remained on opioids over 6 months had the highest opioid dose than those who discontinued earlier (median 45 MME at 90 days; Table).
Conclusions:
About 1 in 6 HNC survivors had an opioid prescription filled at the end of cancer treatment, and opioids were generally discontinued within a few months. Given the low median dose at baseline, the limited evidence of tapering likely results from low initial opioid doses rather than a failure to taper from long-term or high-dose use. Opioid use among older treatment-free HNC survivors that is apparent years after treatment completion is unlikely to result from inadequate tapering. Instead, it may be due to new or worsening cancer-related pain, as well as to non-cancer pain.

Dose reduction and discontinuation (N=894).

Days after baseline
Off opioids
On opioids
Starting dose in MME among those on opioids
Current dose in MME among those on opioids
Tapered to <50% starting dose

N (%)

N (%)

Median (IQR)

Median (IQR)

N (%)

30
634 (71)
260 (29)
53 (30, 80)
44 (29, 60)
61 (7)

60
772 (86)
122 (14)
45 (30, 67.5)
44 (29, 60)
15 (2)

90
820 (92)
74 (8)
58 (30, 90)
45 (29, 60)
7 (1)

120
838 (94)
56 (6)
60 (30, 90)
45 (25, 60)
7 (1)

150
849 (95)
45 (5)
56 (30, 65)
48 (29, 60)
2 (<1)

180
856 (96)
38 (4)
51 (30, 65)
60 (30, 90)
1 (<1)