Opioids May Improve Survival for Hospice Patients

Opioids May Improve Survival For Hospice Patients

Opioids May Improve Survival for Hospice Patients

It is well established that hospice correlates with survival improved by days to months among the subset of patients who meet admission criteria.1-12 Of course, the goal of hospice is neither to shorten nor prolong life. Hospice works to maximize quality of life during a very important time of life. Effective symptom control is a large part of this mission, and opioids are commonly used in hospice to manage severe pain and painful breathing. Some raise concerns that opioids may hasten death among hospice patients, and these concerns may result in restricted use of opioids during end-of-life care.13,14 To the contrary, the data suggests that opioids are not harmful in hospice cases and may even be associated with longer survival.14-20 

High Doses of Opioids Correlate with Improved Survival Among Hospice Patients

Among patients who have a longer life expectancy, opioid prescriptions come with a higher mortality risk. Hospice patients, on the other hand, are different. They tend to experience severe pain that needs prompt management, and they already have a life expectancy of six months or less. A growing body of research now demonstrates that even the high doses of opioids needed to control pain for dying patients do not bear a negative impact on the survival of hospice patients with advanced illness.14-20 In fact, in hospice, increasing opioid dosage to the amount needed for pain control has been associated with a 54% greater survival time.14

Combining Opioids, Antipsychotics, and/or Anxiolytics is Associated with Improved Survival in Hospice

It may be appropriate to make this question about more than opioids alone. In hospice, opioid prescriptions are often combined with antipsychotics and/or anxiolytics. The drugs each have potential for respiratory depression, which occurs more often at night. Would their combined effect hasten death for hospice patients? A study published recently in the Journal of Pain and Symptom Management finds that none of the drugs alone or in combination change the percentage of deaths that occur at night.17 Similarly, they do not shorten survival. In fact, the combination correlates with survival improving by more than 100% (11 vs. 5-day survival on average). The combination was more strongly associated with improved survival than each drug alone. Their results provide further evidence that advanced symptom control correlates with improved survival among hospice patients.

Studies that Do Not find an Association Between Opioid Use and Greater Survival in Hospice

This body of evidence is not entirely concordant. For instance, Portenoy et al. did not find a strong association between survival and opioid dose, but resultantly concluded there is no need to withhold opioids properly titrated to the patient’s pain in the hospice setting.21

Separately, Sheriff et al. performed a study that was very small in terms of their hospice cohort (11 patients). They found that opioid prescriptions were associated with decreased survival among hospice patients with heart failure.22 The effects of opioids among hospice patients with heart failure merit further investigation in larger studies.

Conclusion

The data is still coming in. Science may discover specific instances where opioid prescriptions in hospice do reduce survival. In the meantime, and for most hospice patients, the preponderance of the evidence points to the conclusion that opioids properly dosed for effective pain control do not harm the hospice patient and may even be associated with the improved survival patients have in hospice.  

References

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  12. Forster L, Lynn J. The use of physiologic measures and demographic variables to predict longevity among inpatient hospice applicants. Am J Hosp Care. 1989; 6: 31-34.
  13. Sheriff HM, Arundel C, Gill GS, Tummala LS, Zeng Q, Theisen-Toupal JC, Morgan CJ, Faselis C, Allman RM, Singh S, Ahmed A. Opioid use and outcomes in hospitalized older patients with heart failure receiving and not receiving hospice referrals. American Journal of Therapeutics. 2020 Jul;27(4):e356.
  14. Azoulay D, Jacobs JM, Cialic R, Mor EE, Stessman J. Opioids, survival, and advanced cancer in the hospice setting. Journal of the American Medical Directors Association. 2011 Feb 1;12(2):129-34.
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  17. Golčić M, Dobrila-Dintinjana R, Golčić G, Čubranić A. The Impact of Combined Use of Opioids, Antipsychotics, and Anxiolytics on Survival in the Hospice Setting. Journal of Pain and Symptom Management. 2018 Jan 1;55(1):22-30.
  18. Thorns A, Sykes N. Opioid use in last week of life and implications for end-of-life decision-making. The Lancet. 2000 Jul 29;356(9227):398-9.
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  22. Sheriff HM, Arundel C, Gill GS, Tummala LS, Zeng Q, Theisen-Toupal JC, Morgan CJ, Faselis C, Allman RM, Singh S, Ahmed A. Opioid use and outcomes in hospitalized older patients with heart failure receiving and not receiving hospice referrals. American Journal of Therapeutics. 2020 Jul;27(4):e356.
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