Background: While ongoing efforts to decrease opioid use have dramatically altered the prescribing landscape, the impact on patients with cancer is not well understood. We examined trends in new and persistent opioid use in opioid-naïve older patients with and without cancer in the United States. Methods: This retrospective cohort study used SEER-Medicare linked data for patients with solid tumors malignancies diagnosed from 2012 through 2017, and a random sample of patients without cancer. We included patients who did not receive opioids for 3 months prior to the diagnosis or randomly assigned index date. We identified new opioid use (claim in 0-90 days after diagnosis/index date), early persistent opioid use (claims in days 0-90 and 91-180), and long-term persistent opioid use (claims in days 0-90 and 91-180 and months 13-15). Further analysis focused on 4 clinical strata: non-cancer, metastatic cancer, cancer treated with surgery alone, and cancer treated with surgery plus chemotherapy and/or radiotherapy ("surgery+"). We calculated relative changes in the predicted probability of opioid use from 2012 to 2017 based on a logit model adjusted for patient demographics. Results: We identified 238,470 eligible patients with cancer (mean age 76.3 years). Among patients with cancer, 46.4% had new opioid use; use was higher among those receiving surgery+ (70.6%), those treated with surgery alone (58.8%) and those with metastatic cancer (50.0%), compared to patients without cancer (6.9%). From 2012 to 2017, the predicted probability of new opioid use declined in all groups, with lower relative decline in the cancer subgroups (6.8% surgery+; 9.5% surgery alone; 10.2% metastatic cancer) compared to the non-cancer comparator (24.7%). For instance, in patients with metastatic cancer, predicted probability of new use decreased from 52.4 to 47.1% (10.2%) vs. 8.0 to 6.0% (24.7%) in patients without cancer. Relative decline in predicted probability of long-term persistent opioid use was lower in the surgical cancer strata (44.2% surgery+; 46.1% surgery alone) vs. the non-cancer comparator (54.0%). Conclusions: While opioid use remains common in patients with cancer, new and persistent opioid use declined over time in all patients, though with steeper relative declines in non-cancer compared to cancer populations. Our study suggests important but tempered effects of the changing opioid climate on patients with cancer.

*Restricted to patients alive at 1 year. **Sub-group analyses restricted to non-metastatic disease.