Most prior authorization requests for long-acting pain relievers for cancer patients are eventually approved, but the process can result in unnecessary delays, and patients who are denied may experience uncontrolled pain, according to research presented at the American Society of Clinical Oncology Annual Meeting (ASCO 2024) in Chicago.

“The vast majority of prior authorization requests for long-acting pain medication result in approvals, suggesting that the process—which can delay essential pain management—is largely unnecessary,” the study authors concluded.

Pain is a common symptom of cancer and a side effect of treatments such as surgery and radiation. Uncontrolled pain can lead to treatment breaks, disease progression and decreased quality of life. Guidelines recommend long-acting opioids for severe chronic cancer pain, but due to the potential for addiction and abuse, access to many strong pain drugs is strictly controlled.

Prior authorization means doctors must obtain approval from insurance companies or other payers before prescribing a medication. An ASCO survey of providers last year found that prior authorization delays necessary care, worsens cancer care outcomes and diverts clinicians from caring for their patients.

Fumiko Chino, MD, of Memorial Sloan Kettering Cancer Center, and colleagues conducted an analysis of denials of pain medications due to prior authorization at an urban comprehensive cancer center. In particular, they looked at outpatient requests from 2023 for long-acting opioids, such as buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone, oxymorphone or tapentadol. They performed chart reviews two weeks after prior authorization requests and summarized provider notes and patient communications.

A total of 1,752 new long-acting opioid prescriptions for 982 patients required prior authorization. Of these, 1,567 (89%) requests were ultimately approved through the prior authorization process, 99 (6%) were denied, 81 (5%) were canceled and six (0.3%) remained unresolved. The researchers previous found that the median delay was about two days.

Most long-acting opioids requiring prior authorization were prescribed by pain specialists, with cancer-related chronic pain being the most common indication (61%). Oxycodone was most frequently prescribed (31%), followed by fentanyl (29%), hydromorphone (12%) and methadone (8%). Long-acting morphine was denied most often (16% of requests), followed by buprenorphine (12%) and hydromorphone (7%); fentanyl had the fewest denials (3%).

The 99 denials affected 62 patients, including one individual who was denied seven times. Reviews of these individuals’ medical records revealed a median of two, and up to eight, provider notes mentioning pain or prior authorization barriers. Providers documented poor pain control, weight loss and the need to “try and fail” other medications before approval.

The charts also documented a median of one, and up to five, patient call or message about these issues. Patient messages mentioned uncontrolled pain and unmanageable side effects, “with some literally begging for relief,” according to the researchers.

Fourteen patients—nearly a quarter (23%)—ended up in the emergency room or were admitted to the hospital for a pain crisis or failure to thrive. Seven people (11%) were recorded as paying out of pocket for pain medications after prior authorization denials.

“An improved, transparent prior authorization process is essential for adequately treating chronic cancer-related pain,” the study authors recommended.

Click here to read the study abstract.
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