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Receiving a cancer diagnosis can be a trigger for feelings of depression and anxiety, and you also need to manage pain. But mental health conditions may not only increase opioid use but also risk of death. Learn how this common pain medication may become deadly when you're depressed
The need to properly screen pain patients for underlying mental health conditions before prescribing opioids is not a subject that gets much attention, despite the growing concern over the use of opioids in the U.S. But a large-scale retrospective study has shined a discomforting spotlight on the link between common mental health conditions and increased risk of death from opioids prescribed to treat chronic pain.
Conducted by a team of researchers from the University of Virginia School of Medicine, the focus study[i] analyzed more than 10,000 women with first-time breast cancer diagnoses that were hormone receptor-positive, meaning cancer that grows in response to estrogen and/or progesterone.[ii]
The focus group included first-time users of a commonly prescribed therapy for hormonal cancers called adjuvant endocrine therapy (AET), which is associated with painful side effects in some patients. This study aimed to understand the relationship among opioid use, risk of death and mental health conditions among breast cancer patients.
Nearly Half of Cancer Survivors Struggle With Mental Health
Breast cancer is one of the most commonly diagnosed cancers among women in the U.S. and is responsible for more than 40,000 deaths annually.[iii] AET is credited with improved breast cancer survival rates and is part of the American Society of Clinical Oncology's (ASCO) practice guidelines for preventing recurrence of breast cancer.[iv] However, AET is also associated with adverse effects such as musculoskeletal and joint pain[v] that are often addressed by prescriptions for opioid pain medications.
In a prior study, co-author Xi Tan found evidence suggesting that AET is significantly associated with opioid use among breast cancer survivors.[vi] It was also known that prolonged opioid use is associated with lower survival rates in breast cancer survivors.[vii] This led the research team to focus on how a mental health comorbidity (secondary chronic condition) may impact risk of death for survivors on an AET regimen who are using opioids for pain management.
According to researchers, approximately 40% of patients with breast cancer have some type of mental health condition.[viii] Anxiety and depression are considered normal responses to a cancer diagnosis, which can obscure diagnosis as a serious co-risk factor when it comes to opioid use.
The focus study, published in the July 2019 Journal of Oncology Practice, spotlights the need for physicians to use increasing caution when prescribing opioids to patients with any type of mental health condition. It also speaks to the need for true informed consent for patients who may not fully understand the increased risks of their mental health on potential health outcomes, including an increased risk of death.
Study Highlights Depression's Association With Negative Health Outcomes
With a keen awareness of these multiple risk factors, the research team asked the question, Is there an association between mental health conditions such as anxiety and depression with opioid use and survival in elderly breast cancer survivors using AET?
Methods for this retrospective cohort study involved analyzing medical case histories on 10,452 adult women who received a new and primary diagnosis of breast cancer between 2007 and 2011. Data was obtained from the SEER-Medicare linked database. SEER refers to the Surveillance, Epidemiology, and End Results program of the National Cancer Institute, a source of epidemiologic information on the incidence and survival rates of cancer in the U.S.[ix]
Patients met the study criteria if they initiated AET within one year of their cancer diagnosis. The final requirement for inclusion was that patients had a two-year-or-greater follow-up period after the date of filling their first AET prescription. The study measured those patients who also had a clinical diagnosis of a mental health condition and who used opioids after starting AET and their subsequent health outcomes at the end of the study period. Researchers were specifically interested in survival rates for this population group.
Opioid use among the focus group was defined as "yes" or "no" based on intake of any oral and transdermal opioids during the two-year period after the initiation of AET. Commonly prescribed opioids include codeine, fentanyl, hydrocodone, hydromorphone, meperidine, morphine, methadone, oxycodone, xymorphone, tapentadol, tramadol and pentazocine, as well as any combinations of these drugs.
Researchers took a conservative approach to determining the mental health comorbidity factor. Participants were placed in this group if they had received treatment for depression and/or anxiety for at least two days as an outpatient, or at least one day as an inpatient before receiving their cancer diagnosis. If participants did not meet this stipulation, they were placed in the "no mental health comorbid" test group.
Opioid Use by Breast Cancer Survivors May Lead to Higher Rates of Death
After analyzing the data, researchers found that mental health comorbidities such as depression and anxiety were associated with higher hazards of mortality in women with breast cancer. According to study authors, "these differences were statistically significant."[x] In addition, breast cancer survivors with mental health comorbidities were more likely to use opioids than survivors without mental health challenges, which suggests the increased risk of death may be related to opioid use.
Researchers also performed a secondary analysis of the groups by stratification according to their opioid use. In both groups, the survivor group that used opioids had a higher hazard of mortality. Research indicates that patients with breast cancer and comorbid mental health conditions have higher opioid use and reduced survival rates overall.[xi]
According to a paper published in the peer-reviewed journal Oncology, AET "provides substantial benefit by reducing breast cancer recurrences and improving associated mortality in early-stage endocrine-responsive breast cancers (estrogen receptor - and/or progesterone receptor-positive)."[xii] Since this standard of treatment has a high risk of associated pain, it is incumbent upon physicians to evaluate integrative pain therapies that treat the whole person. Opioids cannot be a one-size-fits-all prescription for pain.
Researchers suggested that physicians limit the prescription of opioids and instead encourage AET patients with associated pain to engage alternative therapies like massage, acupuncture, cognitive behavioral or physical therapy and other holistic methods for dealing with pain. For minor to moderate pain, you can also explore the opioid-like effects of certain foods on GreenMedInfo.com's natural health database.
[i] Mental Health Comorbidities and Elevated Risk of Opioid Use in Elderly Breast Cancer Survivors Using Adjuvant Endocrine Treatments. Raj Desai, et al. Journal of Oncology Practice 2019 15:9, e777-e786. doi: 10.1200/JOP.18.00781
[ii] WebMD, Breast Cancer, Reference, Types of Breast Cancer, https://www.webmd.com/breast-cancer/breast-cancer-types-er-positive-her2-positive#1
[iii] Siegel RL, Miller KD, Jemal A: Cancer statistics, 2018. CA Cancer J Clin 68:7-30, 2018
[iv] Burstein HJ, Lacchetti C, Anderson H, et al: Adjuvant endocrine therapy for women with hormone receptor-positive breast cancer: American Society of Clinical Oncology clinical practice guideline update on ovarian suppression. J Clin Oncol 34:1689-1701, 2016
[v] Runowicz CD, Leach CR, Henry NL, et al: American Cancer Society/American Society of Clinical Oncology breast cancer survivorship care guideline. CA Cancer J Clin 66:43-73, 2016
[vi] Tan X, Camacho TF, LeBaron VT, et al: Opioid use among female breast cancer patients using different adjuvant endocrine therapy regimens. Breast Cancer Res Treat 165:455-465, 2017
[vii] Mental Health Comorbidities and Elevated Risk of Opioid Use in Elderly Breast Cancer Survivors Using Adjuvant Endocrine Treatments. Raj Desai, et al. Journal of Oncology Practice 2019 15:9, e777-e786. doi: 10.1200/JOP.18.00781
[viii] Mehnert A, Brahler E, Faller H, et al: Four-week prevalence of mental disorders in patients with cancer across major tumor entities. J Clin Oncol 32:3540-3546, 2014
[x] Mental Health Comorbidities and Elevated Risk of Opioid Use in Elderly Breast Cancer Survivors Using Adjuvant Endocrine Treatments. Raj Desai, et al. Journal of Oncology Practice 2019 15:9, e777-e786. doi: 10.1200/JOP.18.00781
[xi] Mental Health Comorbidities and Elevated Risk of Opioid Use in Elderly Breast Cancer Survivors Using Adjuvant Endocrine Treatments. Raj Desai, et al. Journal of Oncology Practice 2019 15:9, e777-e786. doi: 10.1200/JOP.18.00781
[xii] Cancer Network, Oncology, Extending Adjuvant Endocrine Therapy in Breast Cancer: Who, What, Why? Accessed: 9 Mar 2020, https://www.cancernetwork.com/breast-cancer/extending-adjuvant-endocrine-therapy-breast-cancer-who-what-why
 Mental Health Comorbidities and Elevated Risk of Opioid Use in Elderly Breast Cancer Survivors Using Adjuvant Endocrine Treatments. Raj Desai, et al. Journal of Oncology Practice 2019 15:9, e777-e786. doi: 10.1200/JOP.18.00781