Patterns of regional variation of opioid prescribing in primary care in England: a retrospective observational study

Regional variation in potentially inappropriate medicine use in older adults. - A national register-based cross-sectional study on economic, health system-related and patient-related characteristics

BACKGROUND

Potentially inappropriate medicines (PIM), i.e. medicines in which the potential harms may outweigh the benefits, use may be associated with e.g. hospitalization, outpatient visits and health care costs. As regional institutions are often responsible for financing pharmaceuticals, understanding the regional variation of PIM use could help to tackle the associated problems and costs.

OBJECTIVE

To explore regional variation in PIM use among older adults and the association with regional health-system related, patient-related and economic characteristics and the frequency of PIM use.

METHODS

This is a nation-wide study based on the Finnish Prescription Register. PIM use was defined according to the Finnish Meds75+ database and regional characteristics derived from national statistics.

RESULTS

Variation at the hospital district level was large, with the largest difference between the most and least PIM prescribing being 45.2%. The factors associated with high PIM prescribing were a higher share of women and a higher number of private doctor visits per inhabitant in a municipality. The factor associated to lower PIM prescribing was a higher share of Swedish-speaking population. The studied factors explained 23% of the municipal-level variation in PIM.

CONCLUSIONS

Large regional differences may lead to regional inequality in prescribing and in the distribution of pharmaceutical costs. As only a small share of the variation was explained by economic, health system-related and patient-related factors, the key reasons may lie in unobserved prescribing practices.

Time trends and prescribing patterns of opioid drugs in UK primary care patients with non-cancer pain: A retrospective cohort study

BACKGROUND

The US opioid epidemic has led to similar concerns about prescribed opioids in the UK. In new users, initiation of or escalation to more potent and high dose opioids may contribute to long-term use. Additionally, physician prescribing behaviour has been described as a key driver of rising opioid prescriptions and long-term opioid use. No studies to our knowledge have investigated the extent to which regions, practices, and prescribers vary in opioid prescribing whilst accounting for case mix. This study sought to (i) describe prescribing trends between 2006 and 2017, (ii) evaluate the transition of opioid dose and potency in the first 2 years from initial prescription, (iii) quantify and identify risk factors for long-term opioid use, and (iv) quantify the variation of long-term use attributed to region, practice, and prescriber, accounting for case mix and chance variation.

METHODS AND FINDINGS

A retrospective cohort study using UK primary care electronic health records from the Clinical Practice Research Datalink was performed. Adult patients without cancer with a new prescription of an opioid were included; 1,968,742 new users of opioids were identified. Mean age was 51 ± 19 years, and 57% were female. Codeine was the most commonly prescribed opioid, with use increasing 5-fold from 2006 to 2017, reaching 2,456 prescriptions/10,000 people/year. Morphine, buprenorphine, and oxycodone prescribing rates continued to rise steadily throughout the study period. Of those who started on high dose (120-199 morphine milligram equivalents [MME]/day) or very high dose opioids (≥200 MME/day), 10.3% and 18.7% remained in the same MME/day category or higher at 2 years, respectively. Following opioid initiation, 14.6% became long-term opioid users in the first year. In the fully adjusted model, the following were associated with the highest adjusted odds ratios (aORs) for long-term use: older age (≥75 years, aOR 4.59, 95% CI 4.48-4.70, p < 0.001; 65-74 years, aOR 3.77, 95% CI 3.68-3.85, p < 0.001, compared to <35 years), social deprivation (Townsend score quintile 5/most deprived, aOR 1.56, 95% CI 1.52-1.59, p < 0.001, compared to quintile 1/least deprived), fibromyalgia (aOR 1.81, 95% CI 1.49-2.19, p < 0.001), substance abuse (aOR 1.72, 95% CI 1.65-1.79, p < 0.001), suicide/self-harm (aOR 1.56, 95% CI 1.52-1.61, p < 0.001), rheumatological conditions (aOR 1.53, 95% CI 1.48-1.58, p < 0.001), gabapentinoid use (aOR 2.52, 95% CI 2.43-2.61, p < 0.001), and MME/day at initiation (aOR 1.08, 95% CI 1.07-1.08, p < 0.001). After adjustment for case mix, 3 of the 10 UK regions (North West [16%], Yorkshire and the Humber [15%], and South West [15%]), 103 practices (25.6%), and 540 prescribers (3.5%) had a higher proportion of patients with long-term use compared to the population average. This study was limited to patients prescribed opioids in primary care and does not include opioids available over the counter or prescribed in hospitals or drug treatment centres.

CONCLUSIONS

Of patients commencing opioids on very high MME/day (≥200), a high proportion stayed in the same category for a subsequent 2 years. Age, deprivation, prescribing factors, comorbidities such as fibromyalgia, rheumatological conditions, recent major surgery, and history of substance abuse, alcohol abuse, and self-harm/suicide were associated with long-term opioid use. Despite adjustment for case mix, variation across regions and especially practices and prescribers in high-risk prescribing was observed. Our findings support greater calls for action for reduction in practice and prescriber variation by promoting safe practice in opioid prescribing.

Rationalisation of long-term high-dose opioids for chronic pain: development of an intervention and conceptual framework

There has been a large increase in the number of prescriptions for opioid drugs in the United Kingdom over the last 20 years or more and the prescribing of opioids in high doses continues to increase. Much opioid prescribing is for chronic non-cancer pain (CNCP) despite serious doubts about the long-term effectiveness of opioids for this indication. Clinical experience is that there are increasing numbers of patients who are on high dosages of opioid drugs over sustained periods which provide limited or no pain relief while having significant negative effects on functioning and quality of life. The aim of this article is to bring readers' attention to some clinical observations of the CNCP population with high doses and to describe an intervention to reduce these doses. Many of these patients have no clinical features of addiction; we suggest that those who show little or no substance misuse behaviours are best understood as a distinct clinical population who have different treatment needs. In order to understand and treat these patients, a model is required which, rather than seeing the problem as lying solely with the patient, focuses on the interaction between the individual and his or her environment and seeks a change in what the patient does every day, rather than a simple, and largely unattainable, goal of symptom elimination. The clinician authors worked together to develop an intervention based upon approaches taken from both pain management and psychiatric practice. A detailed description of this rapid opioid reduction intervention (RORI) is provided along with some preliminary outcome data.

Causes and consequences of the opioid epidemic in the Netherlands: a population-based cohort study

Over the past decade opioid use has risen globally. The causes and consequences of this increase, especially in Europe, are poorly understood. We conducted a population-based cohort study using national statistics on analgesics prescriptions, opioid poisoning hospital admissions and deaths in the Netherlands from 2013 to 2017. Pain prevalence and severity was determined by using results of 2014-2017 Health Interview Surveys. Between 2013 and 2017 the proportion of residents receiving opioid prescription rose from 4.9% to 6.0%, and the proportion of those receiving NSAIDs decreased from 15.5% to 13.7%. Self-reported pain prevalence and severity remained constant, as 44.7% of 5,119 respondents reported no pain-impeded activities-of-daily-living in 2014 (aRR, 1.00 [95% CI, 0.95-1.06] in 2017 vs 2014). Over the observation period, the incidence of opioid poisoning hospitalization and death increased from 8.6 to 12.9 per 100,000 inhabitants. The incidence of severe outcomes related to opioid use increased, as 3.9% of 1,343 hospitalized for opioid poisoning died in 2013 and 4.6% of 2,055 in 2017. We demonstrated that NSAIDs prescription decreased and opioid prescription increased in the Netherlands since 2013, without an increase in pain prevalence and severity. Consequently, the incidence of severe outcomes related to opioids increased.

Health outcomes and costs in patients with osteoarthritis and chronic pain treated with opioids in Spain: the OPIOIDS real-world study

Objective:

The objective of this study was to analyze health outcomes, resource utilization, and costs in osteoarthritis patients with chronic nociceptive pain who began treatment with an opioid in real-world practice in Spain.

Methods:

We designed a non-interventional, retrospective, longitudinal study with 36 months of follow-up using electronic medical records (EMRs) from primary care centers, of patients aged 18+ years who began a new treatment with an opioid drug in usual practice for chronic pain due to osteoarthritis. Health/non-health resource utilization and costs, treatment adherence, pain change, cognitive functioning, and dependence for basic activities of daily living (BADL) were assessed.

Results:

A total of 38,539 EMRs [mean age (SD); 70.8 (14.3) years, 72.3% female; 53.3% hip/knee, 25.0% spine, and 21.7% other sites] were recruited. A total of 19.1% of patients remained on initial opioid at 36 months, without significant differences by osteoarthritis site (p = 0.125). Mean total adjusted cost was €17,915, with 27.7% corresponding to healthcare resources and 72.3% to lost productivity. Hospital admissions for osteoarthritis-related surgical interventions accounted for 15.8% of total healthcare cost. A slight mean pain reduction was observed: –1.3 points, –16.9%, p < 0.001, with increases in cognitive deficit (+3.3%, p < 0.001) and moderate to total dependence for BADL (+15.6%, p < 0.001) in a median duration of opioid use of 203 days (IQR: 89–696).

Conclusions:

In real-world practice in Spain, opioid use in osteoarthritis was high, but with low adherence. There were meaningful increases in resource use and costs for the National Health System. Pain reduction was modest, whereas cognitive impairment and dependence for BADL increased significantly.

Central nervous system (CNS) medications and polypharmacy in later life: cross-sectional analysis of the English Longitudinal Study of Ageing (ELSA)

OBJECTIVES

Many central nervous system (CNS) medications are considered potentially inappropriate for prescribing in older people; however, these medications are common in polypharmacy (≥5 medicines) regimens. This paper aims to determine the prevalence of CNS drug classes commonly taken by older people. Furthermore, this paper aims to determine whether polypharmacy and other factors, previously found to be associated with overall polypharmacy, are associated with the most common CNS drug classes.

DESIGN

Cross-sectional study.

SETTING

English Longitudinal Study of Ageing (wave 6).

PARTICIPANTS

7730 participants (≥50 years).

MAIN OUTCOME MEASURES

Adjusted Odds Ratios (OR) and 95% confidence intervals (CI) for CNS drug classes.

RESULTS

31% of the sample were currently taking ≥5 medications (polypharmacy), of whom 58% (n=1362/2356) were taking CNS medicines as part of their regimen. The most common CNS drug classes in polypharmacy regimens were non-opioid analgesics, opioid analgesics, tricyclic and related antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) (34.6%, 13.2%, 10.9% and 10.4%, respectively). Compared with people currently taking 1-4 prescribed medicines, polypharmacy was associated with adjusted ORs of 5.71 (95% CI: 4.29 to 7.61, p<0.01) for opioid analgesics, 3.80 (95% CI: 3.25 to 4.44, p<0.01) for non-opioid analgesics, 3.11 (95% CI: 2.43 to 3.98, p<0.01) for TCAs and 2.30 (95% CI: 1.83 to 2.89, p<0.01) for SSRIs. Lower wealth was also associated with the aforementioned CNS drug classes.

CONCLUSION

Opioid and non-opioid analgesics were the most prevalent classes of CNS medicines in this study. Polypharmacy is strongly associated with the aforementioned classes of analgesics. Polypharmacy is also associated with TCAs and SSRIs, although to a lesser extent than for analgesics. For all CNS medicine classes, polypharmacy may need to be considered in relation to reducing the risk of potential adverse events. After adjustment, lower wealth is associated particularly with analgesics, highlighting that socioeconomic factors may play a role in the prescribing of CNS medicines. These findings provide a baseline for future research into this area.

Spatial heterogeneity and socioeconomic determinants of opioid prescribing in England between 2015 and 2018

BACKGROUND

Opioid overdoses have had a serious impact on the public health systems and socioeconomic welfare of several countries. Within this broader context, we focus our study on primary care opioid prescribing in England from 2015 to 2018, particularly the patterns of spatial variations at the community level and the socioeconomic and environmental factors that drive consumption.

METHODS

Leveraging open data sources, we combine prescription records with aggregated data on patient provenance and build highly granular maps of Oral Morphine Equivalent (OME) prescribing rates for Lower Layer Super Output Areas (LSOA). We quantify the strength of spatial associations by means of the Empirical Bayes Index (EBI) that accounts for geographical variations in population density. We explore the interplay between socioeconomic and environmental determinants and prescribing rates by implementing a multivariate logistic regression model across different temporal snapshots and spatial scales.

RESULTS

We observe, across time and geographical resolutions, a significant spatial association with the presence of localized hot and cold spots that group neighboring areas with homogeneous prescribing rates (e.g., EBI = 0.727 at LSOA level for 2018). Accounting for spatial dependency effects, we find that LSOA with both higher employment deprivation (OR = 62.6, CI 52.8-74.3) and a higher percentage of ethnically white (OR = 30.1, CI 25.4-35.7) inhabitants correspond to higher prescribing rates. Looking at educational attainment, we find LSOA with the prevalent degree of education being apprenticeship (OR = 2.33, CI 1.96-2.76) a risk factor and those with level 4+ (OR = 0.41, CI 0.35-0.48) a protective factor. Focusing on environmental determinants, housing (OR = 0.18, CI 0.15-0.21) and outdoor environment deprivation (OR = 0.62, CI 0.53-0.72) indices capture the bi-modal behavior observed in the literature concerning rural/urban areas. The results are consistent across time and spatial aggregations.

CONCLUSIONS

Failing to account for local variations in opioid prescribing rates smooths out spatial dependency effects that result in underestimating/overestimating the impact on public health policies at the community level. Our study suggests a novel approach to inform more targeted interventions toward the most vulnerable population strata.

The Effects of Opioids on Cognition in Older Adults With Cancer and Chronic Noncancer Pain: A Systematic Review

CONTEXT

Opioids are prescribed to manage moderate-to-severe pain and can be used with older adults; however, they may lead to several adverse effects, including cognitive impairment.

OBJECTIVES

To identify, appraise, and synthesize evidence on the impact of opioids on cognition in older adults with cancer/chronic noncancer pain, and screening tools/neuropsychological assessments used to detect opioid-induced cognitive impairment.

METHODS

A systematic literature review following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (international prospective register of systematic reviews registration: CRD42018092943). MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane Library, and Web of Science were searched up to December 2018. Randomized controlled trials, quasi-experimental studies, and observational studies of adults aged 65 years and older with cancer/chronic noncancer pain taking opioids were included. A narrative synthesis was conducted.

RESULTS

From 4036 records, 10 met inclusion criteria. Five studies used one screening tool, and five studies used a range of neuropsychological assessments; assessing 14 cognitive domains. Most studies demonstrated no effect of opioid use on cognitive domains, whereas four studies showed mixed effects. In particular, attention, language, orientation, psychomotor function, and verbal working/delayed episodic memory were worsened. Changes to cognitive function were predominantly observed in studies with higher mean doses of opioids (120-190.7mg oral morphine equivalent daily dose).

CONCLUSION

Both improvements and impairments to cognition were observed in studies with higher mean opioid doses. In clinical practice, a brief screening tool assessing attention, language, orientation, psychomotor function, and verbal working/delayed episodic memory may be beneficial to detect worsening cognition in older adults with chronic pain using opioids.

The Surgeon's Role in the Opioid Crisis: A Narrative Review and Call to Action

Over the past two decades, there has been a sharp rise in the use of prescription opioids. In several countries, most notably the United States, opioid-related harm has been deemed a public health crisis. As surgeons are among the most prolific prescribers of opioids, growing attention is now being paid to the role that opioids play in surgical care. While opioids may sometimes be necessary to provide patients with adequate relief from acute pain after major surgery, the impact of opioids on the quality and safety of surgical care calls for greater scrutiny. This narrative review summarizes the available evidence on rates of persistent postsurgical opioid use and highlights the need to target known risk factors for persistent postoperative use before patients present for surgery. We draw attention to the mounting evidence that preoperative opioid exposure places patients at risk of persistent postoperative use, while also contributing to an increased risk of several other adverse clinical outcomes. By discussing the prevalence of excess opioid prescribing following surgery and highlighting significant variations in prescribing practices between countries, we note that there is a pressing need to optimize postoperative prescribing practices. Guided by the available evidence, we call for specific actions to be taken to address important research gaps and alleviate the harms associated with opioid use among surgical patients.

Acceptability of a primary care-based opioid and pain review service: a mixed-methods evaluation in England

BACKGROUND

Primary care opioid prescribing to treat chronic non-cancer pain (CNCP) has progressively increased despite a lack of evidence for long-term safety and effectiveness. Developing primary care interventions to reduce opioid dependence in patients with CNCP is a public health priority.

AIM

To report the acceptability of the South Gloucestershire pain and opioid review service for patients with CNCP, which aimed to help patients understand their relationship with prescribed opioids and support non-drug-based pain management strategies.

DESIGN AND SETTING

A mixed-methods evaluation was performed on the service, which was based in two GP practices in South Gloucestershire, England, and delivered by project workers.

METHOD

Descriptive data were collected on delivered-within-service and community-based interventions. Twenty-five semi-structured interviews (n = 18 patients, n = 7 service providers) explored experiences of the service.

RESULTS

The enrolment process, person-centred primary care-based delivery, and service content focused on psychological issues underlying CNCP were found to be acceptable to patients and service providers. Patients welcomed having time to discuss their pain, its management, and related psychological issues. Maintaining a long-term approach was desired as CNCP is a complex issue that takes time to address. GPs recommended that funding was needed to ensure they have dedicated time to support a similar service and to ensure that project workers received adequate clinical supervision.

CONCLUSION

This service model was acceptable and may be a useful means to manage patients with CNCP who develop opioid dependence after long-term use of opioids. A randomised controlled trial is needed to formally test the effectiveness of the service.

Oral antipsychotic prescribing and association with neighbourhood-level socioeconomic status: analysis of time trend of routine primary care data in England, 2011-2016

BACKGROUND

Increasing rates of antipsychotic prescribing have been reported previously, particularly for second-generation antipsychotics (SGAs), which are generally better tolerated than the older first-generation antipsychotics (FGAs). Prescribers, however, may exert bias, favouring prescriptions of novel drugs for patients of higher socioeconomic status (SES). We aimed to examine time trends in: (1) prescriptions of oral FGAs vs. SGAs and (2) associations between antipsychotic prescriptions and neighbourhood-level SES in England between 2011 and 2016.

METHODS

We used publicly available data for prescriptions made in primary care and linked general practices' postcodes with the Index of Multiple Deprivation (IMD) as a measure for neighbourhood-level SES. Absolute numbers of antipsychotic prescriptions were calculated. Linear regression analysis was used to examine the association of SGA vs. FGA prescription pattern with time and with SES.

RESULTS

A total of 27,486,000 oral antipsychotics were prescribed during the study period, mostly SGAs (n = 21,700,000; 78.9%). There was a significant increase in the ratio of SGA/FGA prescriptions over time (β = 0.376, 95% CI 0.277-0.464, P < 0.001). Individual FGAs were increasingly prescribed in areas of lower SES and the converse for SGAs except amisulpride. During the study period, a significantly larger proportion of total SGA prescriptions relative to total FGAs were made in areas of higher SES (β = 0.182, 95% CI 0.117-0.249, P < 0.001).

CONCLUSION

Prescriptions of antipsychotics continue to rise overall, with SGAs taking preference especially in areas of higher SES. The pattern of antipsychotic prescription favouring people in areas of lower social deprivation carries implications on inequalities even among sub-groups of people with mental disorders.

Analysis of psychiatrists' prescription of opioid, benzodiazepine, and buprenorphine in Medicare Part D in the United States

INTRODUCTION

The opioid epidemic is a severe problem in the world, especially in the United States, where prescription opioid overdose accounts for a quarter of drug overdose deaths.

OBJECTIVE

To describe psychiatrists' prescription of opioid, benzodiazepine, and buprenorphine in the United States.

METHODS

We conducted a retrospective cross-sectional study of the 2016 Medicare Part D claims data and analyzed psychiatrists' prescriptions of: 1) opioids; 2) benzodiazepines, whose concurrent prescription with opioids can cause overdose death; 3) buprenorphine, a partial opioid agonist for treating opioid addiction; 4) and naltrexone microsphere, a once-monthly injectable opioid antagonist to prevent relapse to opioid dependence. Prescribers with 11 or more claims were included in the analysis.

RESULTS

In Medicare Part D in 2016, there were a total of 1,131,550 prescribers accounting for 1,480,972,766 total prescriptions and 78,145,305 opioid prescriptions, including 25,528 psychiatrists (2.6% of all prescribers) accounting for 44,684,504 total prescriptions (3.0% of all prescriptions) and 131,115 opioid prescriptions (0.2% of all opioid prescriptions). Psychiatrists accounted for 17.3% of benzodiazepine, 16.3% of buprenorphine, and 33.4% of naltrexone microsphere prescriptions. The opioid prescription rate of psychiatrists was much lower than that of all prescribers (0.3 vs 5.3%). The buprenorphine prescription rate of psychiatrists was much higher than that of all prescribers (2.3 vs. 0.1%). There was a substantial geographical variation across the United States.

CONCLUSIONS

The results show that, proportionally, psychiatrists have lower rates of opioid prescription and higher rates of benzodiazepine and buprenorphine prescription.

Strong opioids and non-cancer chronic pain in Catalonia. An analysis of the family physicians prescription patterns

OBJECTIVE

To identify family doctor prescription patterns for strong opioids for chronic, non-cancer-related pain.

MATERIALS AND METHODS

Design A descriptive study based on a self-administered email questionnaire.

LOCATION

All primary health care centres in Catalonia.

PARTICIPANTS

3,602 family doctors, all members of the Catalan Society of Family and Community Medicine.

INTERVENTIONS

Email survey of Catalan family doctors.

MAIN MEASUREMENTS

Demographic data, number of patients treated with potent opioids for chronic non-cancer pain, type of opioid used and indications, prescribing patterns and relationship with the Pain Management Unit.

RESULTS

A total of 551 answers were obtained from 3,602 questionnaires sent (response rate of 15.3%), in which 480 physicians (87%) prescribed strong opioids for musculoskeletal pain, 268 (48.6%) prescribed ultra-rapid fentanyl and 434 (78.7%) reduced benzodiazepines dosage when prescribing potent opioids. The most common adverse effects were constipation and nausea. The main problems related with opioid prescription were improper use (341, 71%) and patient and/or practitioner reluctance (87, 18.1%). The assessment of the relationship with Pain Management Units was 2±1 (on a 1 to 5 scale), with communication (271, 52.2%) and accessibility (141, 27.1%) being the areas most in need of improvement.

CONCLUSIONS

Opioid prescribing patterns generally follow clinical guidelines (e.g. reduction of benzodiazepine use or dose titration). However, there are some areas of improvement, such as sparse use of laxatives or use of ultra-rapid opioids for unapproved indications and in patients with no background opioid therapy. Family doctors perceive patient reluctance to adhere to the prescribed treatment, and call for specific training and better relationships with Pain Management Units.

Staff perceptions of prescription and over-the-counter drug dependence services in England: a qualitative study

BACKGROUND

Dependence to prescription and over-the-counter (OTC) drugs represents an increasing public health and clinical problem both in England and internationally. However, relatively little is known about those affected, particularly in relation to their management at drug dependence treatment centres. This study aimed to explore the views and experiences of health care professionals (HCPs) working in formal drug treatment services in relation to supporting clients with prescription and OTC drug dependence.

METHODS

An exploratory, qualitative design was used involving semi-structured telephone interviews. 15 staff were recruited using purposive sampling to represent a variety of different professional roles, funding (NHS, charity and local government) and geographical locations across England. Transcribed interviews were analysed using Braun and Clarke's six stage thematic analysis.

RESULTS

Current services were considered to be inappropriate for the treatment of OTC and prescription drug dependence, which was perceived to be a significantly under-recognised issue affecting a range of individuals but particularly those taking opioid analgesics. Negativity around current treatment services involved concerns that these were more suited for illicit drug users and this was exacerbated by a lack of specific resources, funding and commissioning. There was a perceived variation in service provision in different areas and a further concern about the lack of formal treatment guidelines and care pathways. Participants felt there to be stigma for affected clients in both the diagnosis of OTC or prescription drug dependence and also attendance at drug treatment centres which adversely impacted service engagement. Suggested service improvements included commissioning new specific services in general practices and pain management clinics, developing national guidelines and care pathways to ensure equal access to treatment and increasing awareness amongst the public and HCPs.

CONCLUSIONS

This study reveals considerable negativity and concern about current treatment services for prescription and OTC drug dependence in England from the perspective of those working in such services. Policy and practice improvement are suggested to improve outcomes for this neglected group in relation to increasing funding, guidelines and awareness.

Medicines associated with dependence or withdrawal: a mixed-methods public health review and national database study in England

BACKGROUND

Antidepressants, opioids for non-cancer pain, gabapentinoids (gabapentin and pregabalin), benzodiazepines, and Z-drugs (zopiclone, zaleplon, and zolpidem) are commonly prescribed medicine classes associated with a risk of dependence or withdrawal. We aimed to review the evidence for these harms and estimate the prevalence of dispensed prescriptions, their geographical distribution, and duration of continuous receipt using all patient-linked prescription data in England.

METHODS

This was a mixed-methods public health review, comprising a rapid evidence assessment of articles (Jan 1, 2008, to Oct 3, 2018; with searches of MEDLINE, Embase, and PsycINFO, and the Cochrane and King's Fund libraries), an open call-for-evidence on patient experience and service evaluations, and a retrospective, patient-linked analysis of the National Health Service (NHS) Business Services Authority prescription database (April 1, 2015, to March 30, 2018) for all adults aged 18 years and over. Indirectly (sex and age) standardised rates (ISRs) were computed for all 195 NHS Clinical Commissioning Groups in England, containing 7821 general practices for the geographical analysis. We used publicly available mid-year (June 30) data on the resident adult population and investigated deprivation using the English Indices of Multiple Deprivation (IMD) quintiles (quintile 1 least deprived, quintile 5 most deprived), with each patient assigned to the IMD quintile score of their general practitioner's practice for each year. Statistical modelling (adjusted incident rate ratios [IRRs]) of the number of patients who had a prescription dispensed for each medicine class, and the number of patients in receipt of a prescription for at least 12 months, was done by sex, age group, and IMD quintile.

FINDINGS

77 articles on the five medicine classes were identified from the literature search and call-for-evidence. 17 randomised placebo-controlled trials (6729 participants) reported antidepressant-associated withdrawal symptoms. Almost all studies were rated of very low, low, or moderate quality. The focus of qualitative and other reports was on patients' experiences of long-term antidepressant use, and typically sudden onset, severe, and protracted withdrawal symptoms when medication was stopped. Between April 1, 2017, and March 31, 2018, 11·53 million individuals (26·3% of residents in England) had a prescription dispensed for at least one medicine class: antidepressants (7·26 million [16·6%]), opioids (5·61 million [12·8%]), gabapentinoids (1·46 million [3·3%]), benzodiazepines (1·35 million [3·1%]), and Z-drugs (0·99 million [2·3%]). For three of these medicine classes, more people had a prescription dispensed in areas of higher deprivation, with adjusted IRRs (referenced to quintile 1) ranging from 1·10 to 1·24 for antidepressants, 1·20 to 1·85 for opioids, and 1·21 to 1·85 for gabapentinoids across quintiles, and higher ISRs generally concentrated in the north and east of England. In contrast, the highest ISRs for benzodiazepines and Z-drugs were generally in the southwest, southeast, and east of England, with low ISRs in the north. Z-drugs were associated with increased deprivation, but only at the highest quintile (adjusted IRR 1·11 [95% CI 1·01-1·22]). For benzodiazepines, prescribing was reduced for people in quintiles 4 (0·90 [0·85-0·96]) and 5 (0·89 [0·82-0·97]). In March, 2018, for each of medicine class, about 50% of patients who had a prescription dispensed had done so continuously for at least 12 months, with the highest ISRs in the north and east. Long-term prescribing was associated with a gradient of increased deprivation.

INTERPRETATION

In 1 year over a quarter of the adult population in England had a prescription dispensed for antidepressants, opioids (for non-cancer pain), gabapentinoids, benzodiazepines, or Z-drugs. Long-term (>12 months) prescribing is common, despite being either not recommended by clinical guidelines or of doubtful efficacy in many cases. Enhanced national and local monitoring, better guidance for personalised care, and better doctor-patient decision making are needed.

FUNDING

Public Health England.

Prescribing trends of gabapentin, pregabalin, and oxycodone: a secondary analysis of primary care prescribing patterns in England

Background

The risk of iatrogenic harm from the use and misuse of prescription drugs such as gabapentin, pregabalin, and oxycodone is substantial. In recent years, deaths associated with these drugs in England have increased.

Aim

To characterise general practice prescribing trends for gabapentin, pregabalin, and oxycodone — termed dependence forming medicines (DFM) — in England and describe potential drivers of unwarranted variation (that is, very high prescribing).

Design & setting

This study is a retrospective secondary analysis of open source, publicly available government data from various sources pertaining to primary care demographics and prescriptions.

Method

This study used 5 consecutive years (April 2013–March 2018) of aggregate data to investigate longitudinal trends of prescribing and variation in prescribing trends at practice and clinical commissioning group (CCG) level.

Results

Annual prescriptions of gabapentin, pregabalin, and oxycodone increased each year over the period. Variation in prescribing trends was associated with GP practice deprivation quintile, where the most deprived GP practices prescribed 313% (P<0.001) and 238% (P<0.001) greater volumes of gabapentin and pregabalin per person respectively, than practices in the least deprived quintile. The highest prescribing CCGs of each of these drugs were predominantly in northern and eastern regions of England.

Conclusion

Substantial increases in gabapentin, pregabalin, and oxycodone prescriptions are concerning and will increase iatrogenic harm from drug-related morbidity and mortality. More research is needed to understand the large variation in prescribing between general practices, and to develop and implement interventions to reduce unwarranted variation and increase the appropriateness of prescribing of these drugs.

Trends in gabapentinoid prescribing in patients with osteoarthritis: a United Kingdom national cohort study in primary care

OBJECTIVE

To investigate trends in gabapentinoid prescribing in patients with osteoarthritis (OA).

METHODS

Patients aged 40 years and over with a new OA diagnosis recorded between 1995 and 2015 were identified in the Clinical Practice Research Datalink (CPRD) and followed to first prescription of gabapentin or pregabalin, or other censoring event. We estimated the crude and age-standardised annual incidence rates of gabapentinoid prescribing, stratified by patient age, sex, geographical region, and time since OA diagnosis, and the proportion of prescriptions attributable to OA, or to other conditions representing licensed and unlicensed indications for a gabapentinoid prescription.

RESULTS

Of 383,680 newly diagnosed OA cases, 35,031 were prescribed at least one gabapentinoid. Irrespective of indication, the annual age-standardised incidence rate of first gabapentinoid prescriptions rose from 1.6 [95% confidence interval (CI): 1.3, 2.0] per 1000 person-years in 2000, to 27.6 (26.7, 28.4) in 2015, a trend seen across all ages and not explained by length of follow-up. Rates were higher among women, younger patients, and in Northern Ireland, Scotland and the North of England. Approximately 9% of first prescriptions could be attributed to OA, a further 13% to comorbid licensed or unlicensed indications.

CONCLUSION

Gabapentinoid prescribing in patients with OA increased dramatically between 1995 and 2015. In most cases, diagnostic codes for licensed or unlicensed indications were absent. Gabapentinoid prescribing may be attributable to OA in a significant proportion but evidence for their effectiveness in OA is lacking. Further research to investigate clinical decision making around prescribing these expensive and potentially harmful medicines is recommended.

The opioid epidemic: helping rheumatologists prevent a crisis

An endemic increase in the number of deaths attributable to prescribed opioids is found in all developed countries. In 2016 in the USA, more than 46 people died each day from overdoses involving prescription opioids. European data show that the number of patients receiving strong opioids is increasing. In addition, there is an upsurge in hospitalisations for opioid intoxication, opioid abuse and deaths in some European countries. This class of analgesic is increasingly used in many rheumatological pathologies. Cohort studies, in various chronic non-cancer pain (CNCP) (osteoarthritis, chronic low back pain, rheumatoid arthritis, etc), show that between 2% and 8% of patients are treated with strong opioids. In order to help rheumatologists prescribe strong opioids under optimal conditions and to prevent the risk of death, abuse and misuse, recommendations have recently been published (in France in 2016, the recommendations of the French Society of Study and Treatment of Pain, in 2017, the European recommendations of the European Federation of IASP Chapters and the American Society of International Pain Physicians). They agree on the same general principles: opioids may be of interest in situations of CNCP, but their prescription must follow essential rules. It is necessary to make an accurate assessment of the pain and its origin, to formulate therapeutic objectives (pain, function and/or quality of life), to evaluate beforehand the risk of abuse and to get a specialised opinion beyond a certain dose or duration of prescription.

An examination of opioid prescription for Medicare Part D patients among family practice prescribers

BACKGROUND

In the USA, opioid overdose accounted for more than 60% of drug overdose deaths in 2015. Of these deaths, 40% were due to use of prescription opioids.

OBJECTIVES

The aims of the study were to (i) study family medicine physician opioid-prescribing rate and duration of prescription, (ii) study the distribution of prescription by medication potency, (iii) study opioid-prescribing trends in health care shortage areas and (iv) study the association between extreme high prescribing rates and medical board discipline.

METHODS

This is a retrospective cross-sectional study of the 2015 Medicare Part D claim data.

RESULTS

Family practitioners have opioid prescription rates (5.6%) similar to medical subspecialists (6.0%), but lower than pain specialists (53.2%) and surgical specialists (36.6%). Family practitioners have an average opioid prescription duration (21.5 days) similar to medical subspecialists (23.1 days) and pain specialists (27.1 days), but longer than surgical specialists (8.9 days). Family practitioners tend to prescribe lower potency opioids. Family practitioners in rural health care shortage areas have a higher opioid prescription rate than other family practitioners (6.5% versus 5.6%). Among the 52 family practitioners who prescribed opioids as frequently as pain specialists, 26 of the 52 (50%) were certified in pain management or worked with a partner certified in pain management. Of the other 26 family practitioners, 3 (12%) had medical board disciplinary actions regarding opioid prescription.

CONCLUSIONS

While monitoring extreme prescribers is important and needs to be continued, the next step in policies to reduce prescription opioids will require systemic change, especially providing support for family practitioners in rural health care shortage areas.

Chronic Opioid Prescribing in Primary Care: Factors and Perspectives

BACKGROUND

Primary care clinicians write 45% of all opioid prescriptions in the United States, but little is known about the characteristics of patients who receive them and the clinicians who prescribe opioids in primary care settings. Our study aimed to describe the patient and clinician characteristics and clinicians' perspectives of chronic opioid prescribing in primary care.

METHODS

Using a mixed methods approach, we completed an analysis of 2016 electronic health records from 21 primary care practices to identify patients who had received chronic opioids, which we defined as in receipt of an opioid prescription for at least 3 consecutive months. We compared those receiving chronic opioids with those not in terms of their demographics, prescribing clinician characteristics, and risk factors for opioid-related harms, as identified by the Centers for Disease Control and Prevention Guideline on Opioid Prescribing for Chronic Pain. We then interviewed 16 primary care clinicians about their perspectives on chronic opioid prescribing.

RESULTS

Of 84,029 patients, 1.1% (902/84,929) received chronic opioid prescriptions. Characteristics associated with being prescribed chronic opioids include being female, being of black or African American race, and having risks for opioid-related harms, such as mental health diagnoses, substance use disorder, and concurrent benzodiazepine use. Clinicians report multiple difficulties in weaning patients from chronic opioids, including medical contraindications of nonopioid alternatives and difficulty justifying weaning by stable long-term patients.

CONCLUSION

Although patients prescribed opioids in primary care have higher risks of opioid-related harms, clinicians report multiple barriers in deprescribing chronic opioids. Future studies should examine strategies to mitigate these harms and engage patients in shared decision making about their chronic opioid use.

Codeine Addiction and Internet Forum Use and Support: Qualitative Netnographic Study

BACKGROUND

The use of codeine as an analgesic is well-recognized, but there are increasing concerns that for some individuals continued use may lead to misuse, dependence, and fatalities. Research suggests that those affected may represent a hard-to-reach group who do not engage with formal treatment services.

OBJECTIVE

This study sought to explore the experiences of people with self-reported addiction to codeine and, specifically, how a social media forum is used to communicate with others about this issue.

METHODS

Using a qualitative netnographic methodology, the social media forum Mumsnet was used, with permission, and searches were undertaken in 2016 of any posts that related to codeine and addiction. A total of 95 relevant posts were identified; a purposive sample of 25 posts was selected to undertake subsequent six-stage thematic analysis and development of emerging themes. These 25 posts were posted between 2003 and 2016 and comprised 757 individual posts.

RESULTS

Individuals created posts to actively request help in relation to usually their own, but occasionally their partner's or relative's, problems relating to codeine use and self-reported "addiction." Varying levels of detail were provided in narratives of problematic codeine use. There were both positive and negative descriptions of side effects emerging, problems experiencing withdrawal, and failed attempts to discontinue codeine use. Mainly positive and supportive responses to posts were identified from those with either self-reported health profession experience or lay respondents, who often drew on their own experiences of similar problems. Treatment advice emerged in two main ways, either as signposting to formal health services or to informal approaches and often anecdotal advice about how to taper or use cold turkey techniques. Some posts were more critical of the original poster, and arguments and challenges to advice were not uncommon. Shame and stigma were often associated with users' posts and, while there was a desire to receive support and treatment advice in this forum, users often wanted to keep their codeine use hidden in other aspects of their lives. Distinctly different views emerged as to whether responsibility lay with prescribers or patients. Some users expressed anger toward doctors and their prescribing practices.

CONCLUSIONS

This study provides a unique insight into how a public internet forum is used by individuals to confirm and seek support about problematic codeine use and of the ways others respond. The pseudonymous use of internet forums for such information and variation in treatment options suggested by often lay respondents suggest that increased formal support and awareness about codeine addiction are needed. There may be opportunities for providing further support directly on such online forums. Improvements in prescribing codeine and in the over-the-counter supply of codeine are required to prevent problematic use from occurring.

An integrated safety analysis of combined acetaminophen and ibuprofen (Maxigesic /Combogesic®) in adults

INTRODUCTION

Acetaminophen (APAP) and ibuprofen (IBP) are two analgesic compounds with a long history of use. Both are considered safe at recommended over-the-counter daily doses. Chronic use, high doses, or concomitant medication can produce safety risks for both drugs. APAP is associated with increased risk of hepatic injury, while IBP can produce gastric bleeding and thromboembolic events. Using a combination of APAP and IBP provides superior analgesia without transgressing daily dose limits of each individual drug.

METHODS

The present study aimed to determine if treatment with a fixed-dose combination (FDC) containing APAP and IBP results in any unexpected adverse events (AEs) and/or changes in the safety profiles of its two ingredients compared to monotherapy. The analysis will examine clinical safety data obtained from either single dose trials, multiple dose trials, a long-term exposure trial, and post-marketing surveillance data of APAP/IBP FDC tablets (Maxigesic®/Combogesic®, AFT Pharmaceuticals Ltd). The largest dataset was obtained by pooling the four randomized-controlled, multiple-dose clinical studies with either APAP 325 mg + IBP 97.5 mg (FDC 325/97.5, three tablets per dose) or APAP 500 mg + IBP 150 mg (FDC 500/150, two tablets per dose). At maximum doses, the two FDCs are bioequivalent, permitting the pooling of data for the analysis of safety.

RESULTS

A safety population of 922 patients who received full doses of either FDC, APAP alone, IBP alone, or placebo was compiled from the four studies. A total of 521 AEs were experienced with the incidence of FDC AEs similar to or below either monotherapy group or placebo. The FDC did not alter the incidence and percentage of the most common AEs, including gastrointestinal events and postoperative bleeding.

CONCLUSION

Overall, the FDC is well tolerated and has a strong safety profile at single and multiple doses with improved efficacy over monotherapy.

Opioid prescribing trends and geographical variation in England, 1998-2018: a retrospective database study

BACKGROUND

There is a call for greater monitoring of opioid prescribing in the UK, particularly of strong opioids in chronic pain, for which there is little evidence of clinical benefit. We aimed to comprehensively assess trends and variation in opioid prescribing in primary care in England, from 1998 to 2018, and to assess factors associated with high-dose opioid prescribing behaviour in general practices.

METHODS

We did a retrospective database study using open data sources on prescribing for all general practices in England. For all standard opioids we calculated the number of items prescribed, costs, and oral morphine equivalency to account for variation in strength. We assessed long-term prescribing trends from 1998 to 2017, patterns of geographical variation for 2018, and investigated practice factors associated with higher opioid prescribing. We also analysed prescriptions for long-acting opioids at high doses.

FINDINGS

Between 1998 and 2016, opioid prescriptions increased by 34% in England (from 568 per 1000 patients to 761 per 1000). After correcting for total oral morphine equivalency, the increase was 127% (from 190 000 mg to 431 000 mg per 1000 population). There was a decline in prescriptions from 2016 to 2017. If every practice prescribed high-dose opioids at the lowest decile rate, 543 000 fewer high-dose prescriptions could have been issued over a period of 6 months. Larger practice list size, ruralness, and deprivation were associated with greater high-dose prescribing rates. The clinical commissioning group to which a practice belongs accounted for 11·7% of the variation in high-dose prescribing. We have developed a publicly available interactive online tool, OpenPrescribing.net, which displays all primary care opioid prescribing data in England down to the individual practice level.

INTERPRETATION

Failing to account for opioid strength would substantially underestimate the true increase in opioid prescribing in the National Health Service (NHS) in England. Our findings support calls for greater action to promote best practice in chronic pain prescribing and to reduce geographical variation. This study provides a model for routine monitoring of opioid prescribing to aid targeting of interventions to reduce high-dose prescribing.

FUNDING

National Institute for Health Research (NIHR) School of Primary Care Research, NIHR Biomedical Research Centre Oxford, NHS England.

Assessing the 2004-2018 Fentanyl Misusing Issues Reported to an International Range of Adverse Reporting Systems

Objective: A recent, global, increase in the use of opioids including the prescribing, highly potent, fentanyl has been recorded. Due its current popularity and the potential lethal consequences of its intake, we aimed here at analyzing the fentanyl misuse, abuse, dependence and withdrawal-related adverse drug reactions (ADRs) identified within the European Medicines Agency (EMA), the United Kingdom Yellow Card Scheme (YCS), and the United States Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) databases. Methods: Descriptive analysis of both ADRs and related cases. Results: The analysis of fentanyl-related misuse, abuse, dependence and withdrawal cases reported during years 2004-2018 to the EMA, the YCS, and the FAERS showed increasing levels overtime, specifically, EMA-related data presented two peaks (e.g., in 2008 and 2015), whilst the FAERS dataset was characterized by a dramatic increase of the ADRs collected over the last 18 months, and particularly from 2016. Some 127,313 ADRs (referring to n = 6,161 patients/single cases) related to fentanyl's misuse/abuse/dependence/withdrawal issues were reported to EMA, with 14,287 being judged by the reporter as "suspect." The most represented ADRs were: "drug dependence "(76.87%), "intentional product misuse" (13.06%), and "drug abuse" (7.45%). Most cases involved adult males and the concomitant use of other prescribing/illicit drugs. A range of idiosyncratic (i.e., ingestion/injection of transdermal patches' fentanyl) and very high-dosage intake cases were here identified. Significant numbers of cases required either a prolonged hospitalization (192/559 = 34.35%) or resulted in death (185/559 = 33.09%). Within the same time frame, YCS collected some 3,566 misuse/abuse/dependence/withdrawal ADRs, corresponding to 1,165 single patients/cases, with those most frequently reported being "withdrawal," "intentional product misuse," and "overdose" ADRs. Finally, FAERS identified a total of 19,145 misuse/abuse/dependence/withdrawal-related cases, being "overdose," withdrawal, and "drug use disorder/drug abuse/drug diversion" the most represented ADRs (respectively, 43.11, 20.80, and 20.29%). Conclusion: Fentanyl abuse may be considered a public health issue with significant implications for clinical practice. Spontaneous pharmacovigilance reporting systems should be considered for mapping new trends of drug abuse.

A typology of prescription drug monitoring programs: a latent transition analysis of the evolution of programs from 1999 to 2016

BACKGROUND AND AIMS

Prescription drug monitoring programs (PDMP), defined as state-level databases used in the United States that collect prescribing information when controlled substances are dispensed, have varied substantially between states and over time. Little is known about the combinations of PDMP features that, collectively, may produce the greatest impact on prescribing and overdose. We aimed to (1) identify the types of PDMP models that have developed from 1999 to 2016, (2) estimate whether states have transitioned across PDMP models over time and (3) examine whether states have adopted different types of PDMP models in response to the burden of opioid overdose.

METHODS

A latent transition analysis of PDMP models based on an adaptation of nine PDMP characteristics classified by prescription opioid policy experts as potentially important determinants of prescribing practices and prescription opioid overdose events.

RESULTS

We divided the time-period into three intervals (1999-2004, 2005-09, 2010-16), and found three distinct PDMP classes in each interval. The classes in the first and second interval can be characterized as 'no/weak', 'proactive' and 'reactive' types of PDMPs, and in the third interval as 'weak', 'cooperative' and 'proactive'. The meaning of these classes changed over time: until 2009, states in the 'no/weak' class had no active PDMP, whereas states in the 'proactive' class were more likely to proactively provide unsolicited information to PDMP users, provide open access to law enforcement, and require more frequent data reporting than states in the 'reactive' class. In 2010-16, the 'weak' class resembled the 'reactive' class in previous intervals. States in the 'cooperative' class in 2010-16 were less likely than states in the 'proactive' class to provide unsolicited reports proactively or to provide open access to law enforcement; however, they were more likely than those in the 'proactive' class to share PDMP data with other states and to report more federal drug schedules.

CONCLUSIONS

Since 1999, US states have tended to transition to more robust classes of prescription drug monitoring programs. Opioid overdose deaths in prior years predicted the state's prescription drug monitoring program class but did not predict transitions between prescription drug monitoring program classes over time.

Safe and effective management of analgesics in patients presenting to hospital with acute illness

Chronic pain affects a significant percentage of the population and is defined as pain that lasts beyond the point of healing. People presenting to hospital with acute illness may have underlying chronic pain that can be exacerbated by their presenting condition, even if this chronic pain is not the reason for their admission. While people may tolerate their usual medicine regimen under normal circumstances, small changes in their physical health can rapidly cause issues with their medication such as increased side effects. This article considers how nurses can improve the safety of people experiencing pain who have been admitted to hospital, and outlines when changes in their health might have implications for their prescribed analgesics.

'If you can't see a dilemma in this situation you should probably regard it as a warning': a metasynthesis and theoretical modelling of general practitioners' opioid prescription experiences in primary care

Introduction

The prescribing of opioids has increased internationally in developed countries in recent decades within primary and secondary care. The majority of patients with chronic non-malignant pain (CNMP) are managed by their general practitioner (GP). Recent qualitative studies have examined the issue of opioid prescribing for CNMP from a GP viewpoint. The aim of this study is to identify and synthesise the qualitative literature describing the factors influencing the nature and extent of opioid prescribing by GPs for patients with CNMP in primary care.

Methods

MEDLINE, Embase, PsycINFO, Cochrane Database, International Pharmaceutical Abstracts, Database of Abstracts of Reviews of Effects, CINAHL and Web of Science were systematically searched from January 1986 to February 2018. The full text of included articles was reviewed using the Critical Appraisal Skills Programme (CASP) tool for qualitative research. The papers were coded by two researchers and themes organised using Thematic Network Analysis. Themes were constructed in a hierarchical manner, basic themes informed organising themes which informed global themes. A theoretical model was derived using global themes to explain the interplay between factors influencing opioid prescribing decisions.

Results

From 7020 records, 21 full text papers were assessed, and 13 studies included in the synthesis; 9 were from the United States, 3 from the United Kingdom and 1 from Canada. Four global themes emerged: suspicion, risk, agreement and encompassing systems level factors. These global themes are inter-related and capture the complex decision-making processes underlying opioid prescribing whereby the physician both consciously and unconsciously quantifies the risk-benefit relationship associated with initiating or continuing an opioid prescription.

Conclusion

Recognising the inherent complexity of opioid prescribing and the limitations of healthcare systems is crucial to developing opioid stewardship strategies to combat the rise in opioid prescription morbidity and mortality.

Examining patterns in opioid prescribing for non-cancer-related pain in Wales: preliminary data from a retrospective cross-sectional study using large datasets

Objectives

To examine trends in strong opioid prescribing in a primary care population in Wales and identify if factors such as age, deprivation and recorded diagnosis of depression or anxiety may have influenced any changes noted.

Design

Trend, cross-sectional and longitudinal analyses of routine data from the Primary Care General Practice database and accessed via the Secure Anonymised Information Linkage (SAIL) databank.

Setting

A total of 345 Primary Care practices in Wales.

Participants

Anonymised records of 1,223,503 people aged 18 or over, receiving at least one opioid prescription between 1 January 2005 and 31 December 2015 were analysed. People with a cancer diagnosis (10.1%) were excluded from the detailed analysis.

Results

During the study period, 26,180,200 opioid prescriptions were issued to 1,223,503 individuals (55.9% female, 89.9% non-cancer diagnoses). The greatest increase in annual prescribing was in the 18-24 age group (10,470%), from 0.08 to 8.3 prescriptions/1000 population, although the 85+ age group had the highest prescribing rates across the study period (from 149.9 to 288.5 prescriptions/1000 population). The number of people with recorded diagnoses of depression or anxiety and prescribed strong opioids increased from 1.2 to 5.1 people/1000 population (328%). The increase was 366.9% in areas of highest deprivation compared to 310.3 in the least. Areas of greatest deprivation had more than twice the rate of strong opioid prescribing than the least deprived areas of Wales.

Conclusion

The study highlights a large increase in strong opioid prescribing for non-cancer pain, in Wales between 2005 and 2015. Population groups of interest include the youngest and oldest adult age groups and people with depression or anxiety particularly if living in the most deprived communities. Based on this evidence, development of a Welsh national guidance on safe and rational prescribing of opioids in chronic pain would be advisable to prevent further escalation of these medicines.

Summary points

This is the first large-scale, observational study of opioid prescribing in Wales.Over 1 million individual, anonymised medical records have been searched in order to develop the study cohort, thus reducing recall bias.Diagnosis and intervention coding in the Primary Care General Practice database is limited at input and may lead to under-reporting of diagnoses.There are limitations to the data available through the Secure Anonymised Information Linkage databank because anonymously linked dispensing data (what people collect from the pharmacy) are not currently available. Consequently, the results presented here could be seen as an 'intention to treat' and may under- or overestimate what people in Wales actually consume.

The Pain Divide: a cross-sectional analysis of chronic pain prevalence, pain intensity and opioid utilisation in England

OBJECTIVES

Our central research question was, in England, are geographical inequalities in opioid use driven by health need (pain)? To answer this question, our study examined: (1) if there are regional inequalities in rates of chronic pain prevalence, pain intensity and opioid utilisation in England; (2) if opioid use and chronic pain are associated after adjusting for individual-level and area-level confounders.

DESIGN

Cross-sectional study design using data from the Health Survey for England 2011.

SETTING

England.

PRIMARY AND SECONDARY OUTCOME MEASURES

Chronic pain prevalence, pain intensity and opioid utilisation.

PARTICIPANTS

Participant data relating to chronic pain prevalence, pain intensity and opioid usage data were obtained at local authority level from the Health Survey for England 2011; in total, 5711 respondents were included in our analysis.

METHODS

Regional and local authority data were mapped, and a generalised linear model was then used to explore the relationships between the data. The model was adjusted to account for area-level and individual-level variables.

RESULTS

There were geographical variations in chronic pain prevalence, pain intensity and opioid utilisation across the English regions-with evidence of a 'pain divide' between the North and the South, whereby people in the North of England more likely to have 'severely limiting' or 'moderately limiting' chronic pain. The intensity of chronic pain was significantly and positively associated with the use of opioid analgesics.

CONCLUSIONS

There are geographical differences in chronic pain prevalence, pain intensity and opioid utilisation across England-with evidence of a 'pain divide'. Given the public health concerns associated with the long-term use of opioid analgesics-and their questionable activity in the management of chronic pain-more guidance is needed to support prescribers in the management of chronic pain, so the initiation of opioids can be avoided.