Risk Factors for Persistent Opioid Use

The radiation oncologists determined that the rates of persistent posttreatment opioid use among the VA cohort varied by type of cancer and prior opioid use. Significant findings included:

  • Patients with prostate cancer patients had the lowest rate of opioid use (5.3%).
  • The highest rate of opioid use (19.8%) was observed in patients with liver cancer.
  • The main variable for persistent opioid use after cancer treatment was the patient’s history of opioid use before a cancer diagnosis. 1

Risk factors first reported in the San Diego study were younger age, white race, BMI, unemployment at the time of cancer diagnosis, lower median income, use of chemotherapy, increased comorbidity, and tobacco use. Substantially increased odds of persistent opioid use were associated with patients who had a history of prior alcohol abuse, nonopioid drug abuse, chronic or intermittent opioid abuse, and depression.1

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Study limitations included whether research on mostly male military veterans would translate to a civilian population of both sexes. Also, veterans who saw combat were exposed to mental and physical trauma at higher rates than the general population, and this could increase their risk for opioid dependence or abuse. Furthermore, this population is more likely to have health insurance and are therefore less likely to be financially insecure than the general population.1

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Managing patients at risk

The authors note that the absolute rate of persistent opioid use, abuse, and dependence was relatively low among the cohort of VA cancer survivors, especially among those who were opioid-naïve. They believe that improved risk stratification will allow for personalized risk assessment and improve the safety of pain management in cancer survivors. The lite model of the Cancer Opioid Risk Tool was validated in an independent test cohort. A more robust validation of the newer full tool will require a prospective study.

Strategies that can help clinicians better manage patients at risk of persistent opioid use include establish a signed treatment agreement, utilize periodic urine drug testing, educate patients and their caregivers on the risks of abuse and/or misuse, offer referrals to pain and palliative medicine specialists, and avoid high risk formulations while minimizing lower total daily medication doses.


1. Vitzthum LK, Riviere P, Sheridan P, et al. Predicting persistent opioid use, abuse and toxicity among cancer survivors [published online November 22, 2019].  J Natl Cancer Inst. doi: 10.1093/jnci/djz200

2. World Health Organization. Cancer Pain Relief : With a Guide to Opioid Availability.

2nd ed. Geneva, Switzerland; 1996. https://apps.who.int/iris/bitstream/handle/10665/37896/9241544821.pdf?sequence=1&isAllowed=y. Accessed January 13, 2020.

3. Paice JA, Portenoy R, Lacchetti C, et al. Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2016;34(27):3325-3345.