Open Access Open Access  Restricted Access Subscription or Fee Access

Opioids for outpatients with cancer in their last year of life: A nationwide pharmacoepidemiological study

Siri Brelin, MD, Olav M. Fredheim, MD, PhD, Jon H. Loge, MD, PhD, Svetlana Skurtveit, PhD, Tom B. Johannesen, MD, PhD, Nina Aass, MD, PhD, Stig Ottesen, MD, PhD, Marianne J. Hjermstad, PhD


Objective: Opioids are the main pharmacological treatment for moderate-to-severe cancer pain. Few longitudinal studies have examined the prescription prevalence (PP) of opioids to patients with cancer. The aims of the study were to examine 1) changes in the PP of opioids from 2005 to 2009 among outpatients with cancer who were in their last year of life and 2) associations between the PP of opioids and medical and sociodemographic factors.

Design: Retrospective, registry-based, national study.

Patients: This study used data on all patients with cancer who died 2005-2009, combining the following three complete nationwide registries; prescription data from the Norwegian Prescription Database, data on cancer diseases from the Cancer Registry of Norway, and sociodemographic data from Statistics Norway.

Results: The study population consisted of 44,579 adults (mean age 72 years at death, 54 percent males). The opioid PP increased from 74 to 82 percent during the study period. Oxycodone had the highest PP, and increased from 39.8 to 48.5 percent during the period, whereas the PP of morphine declined from 29.0 to 27.3 percent. The PP for fentanyl remained stable at 17 percent. The PP of opioids increased toward death with higher PP during the last 3 months of life compared to previous 3-month periods. Older patients (>60) were less likely to receive opioids, while prostate or pancreatic cancer increased the odds for opioid prescriptions (p < 0.001, Odds ratio [OR] 2.60 and OR 1.98, respectively).

Conclusion: The PP increased yearly during the study period. Use of oxycodone increased while that of morphine decreased.


opioids, cancer pain, end of life, pharmacoepidemiology

Full Text:



World Health Organization: WHO's cancer pain ladder for adults. Available at Accessed July 22, 2014.

Hamunen K, Laitinen-Parkkonen P, Paakkari P, et al.: What do different databases tell about the use of opioids in seven European countries in 2002? Eur J Pain. 2008; 12: 705-715.

Jarlbaek L, Andersen M, Hallas J, et al.: Use of opioids in a Danish population-based cohort of cancer patients. J Pain Sympt Manag. 2005; 29: 336-343.

Greco MT, Roberto A, Corli O, et al.: Quality of cancer pain management: An update of a systematic review of undertreatment of patients with cancer. J Clin Oncol. 2014; 32: 4149-4154.

Higginson IJ, Gao W: Opioid prescribing for cancer pain during the last 3 months of life: Associated factors and 9-year trends in a nationwide United Kingdom cohort study. J Clin Oncol. 2012; 30: 4373-4379.

Costantini M, Ripamonti C, Beccaro M, et al.: Prevalence, distress, management, and relief of pain during the last 3 months of cancer patients’ life. Results of an Italian mortality followback survey. Ann Oncol. 2009; 20: 729-735.

Jarlbaek L, Hansen DG, Bruera E, et al.: Frequency of opioid use in a population of cancer patients during the trajectory of the disease. Clin Oncol (R Coll Radiol). 2010; 22: 199-207.

Chinellato A, Terrazzani G, Debetto P, et al.: Retrospective analysis of opioid prescriptions in cancer patients in a northern Italian region. Br J Clin Pharmacol. 2006; 62: 130-133.

World Health Organization: Cancer Pain Relief: With a guide to opioid availability. Available at Accessed June 22, 2014.

Hanks GW, Conno F, Cherny N, et al. Morphine and alternative opioids in cancer pain: The EAPC recommendations. Br J Cancer. 2001; 84: 587-593.

Wiffen PJ, Wee B, Moore RA: Oral morphine for cancer pain. Cochrane Database Syst Rev. 2013; 7: CD003868.

Caraceni A, Hanks G, Kaasa S, et al. Use of opioid analgesics in the treatment of cancer pain: Evidence-based recommendations from the EAPC. Lancet Oncol. 2012; 13: e58-e68.

The Norwegian Directorate of Health: Nasjonalt handlingsprogram med retningslinjer for palliasjon i kreftomsorgen. Available at Accessed January 9, 2016.

Quigley C: Opioid switching to improve pain relief and drug tolerability. Cochrane Database Syst Rev. 2004: CD004847.

Larsen IK, Smastuen M, Johannesen TB, et al.: Data quality at the Cancer Registry of Norway: An overview of comparability, completeness, validity and timeliness. Eur J Cancer. 2009; 45: 1218-1231.

Norway S: Norwegian Standard Classification of Education, revised 2000. Available at Accessed June 22, 2014.

WHO Collaborating Centre for Drug Statistics Methodology, Norwegian Institute of Public Health: Available at Accessed June 22, 2014.

WHO Collaborating Center for Pain Policy and Palliative Care (PPSG) PI: Morphine Manifesto. Available at Accessed January 9, 2016.

Fredheim OM, Dale O, Kaasa S, et al.: Morphine or oxycodone tablets for pain? Tidsskr Nor Laegeforen. 2010; 130: 1479-1481.

Maltoni M, Scarpi E, Modonesi C, et al.: A validation study of the WHO analgesic ladder: A two-step vs three-step strategy. Support Care Cancer. 2005; 13: 888-894.

Paulsen O, Klepstad P, Rosland JH, et al.: Efficacy of methylprednisolone on pain, fatigue, and appetite loss in patients with advanced cancer using opioids: A randomized, placebo-controlled, double-blind trial. J Clin Oncol. 2014; 32(29): 3221-3228.

Gao W, Gulliford M, Higginson IJ: Prescription patterns of analgesics in the last 3 months of life: a retrospective analysis of 10202 lung cancer patients. Br J Cancer. 2011; 104: 1704-1710.

Barbera L, Seow H, Howell D, et al.: Symptom burden and performance status in a population-based cohort of ambulatory cancer patients. Cancer. 2010; 116: 5767-5776.

Rustoen T, Fossa SD, Skarstein J, et al.: The impact of demographic and disease-specific variables on pain in cancer patients. J Pain Sympt Manag. 2003; 26: 696-704.

Cleeland CS, Gonin R, Hatfield AK, et al.: Pain and its treatment in outpatients with metastatic cancer. N Engl J Med. 1994; 330: 592-596.

Goudas LC, Bloch R, Gialeli-Goudas M, et al.: The epidemiology of cancer pain. Cancer Invest. 2005; 23: 182-190.

Portenoy RK, Thaler HT, Kornblith AB, et al.: Symptom prevalence, characteristics and distress in a cancer population. Qual Life Res. 1994; 3: 183-189.

Brescia FJ, Portenoy RK, Ryan M, et al.: Pain, opioid use, and survival in hospitalized patients with advanced cancer. J Clin Oncol. 1992; 10: 149-155.

Joynt M, Train MK, Robbins BW, et al.: The impact of neighborhood socioeconomic status and race on the prescribing of opioids in emergency departments throughout the United States. J Gen Intern Med. 2013; 28: 1604-1610.

Svendsen K, Fredheim OM, Romundstad P, et al.: Persistent opioid use and socio-economic factors: A population-based study in Norway. Acta Anaesthesiol Scand. 2014; 58: 437-445.

van den Beuken-van Everdingen MH, de Rijke JM, Kessels AG, et al.: High prevalence of pain in patients with cancer in a large population-based study in The Netherlands. Pain. 2007; 132: 312-320.



  • There are currently no refbacks.