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

Overprescribing of potentially harmful medication: an observational study in England's general practice

BACKGROUND

Overprescribing of potentially harmful medication in UK general practice has a complex association with socioeconomic deprivation.

AIM

To assess trends in general practice prescribing of five high-risk medications and their relationship with deprivation.

DESIGN & SETTING

An observational study was conducted using general practice data from three English regions with varied sociodemographic factors: West Yorkshire and Harrogate (WY), Black Country and West Birmingham (BC), and Surrey and East Sussex (SE).

METHOD

Practice-level prescribing data were obtained from 2016-2021 for five drug classes: opioids, hypnotics, gabapentinoids, non-steroidal anti-inflammatory drugs (NSAIDs), and antibacterials. Prescribing trends were demonstrated using a linear model.

RESULTS

Reduction in NSAID, opioid, hypnotic and antibacterial prescriptions, and the increase in gabapentinoid prescriptions, were significant at each financial year time period. Index of Multiple Deprivation (IMD) was positively associated with all drug classes except antibacterials, which showed a positive association when incorporating the interaction term between IMD and age.When adjusting for IMD and population, region was independently associated with prescribing rate. Compared with WY, IMD had a smaller association with prescribing in BC for NSAIDs (coefficient = -0.01578, P = 0.004) and antibacterials (coefficient = -0.02769, P = 0.007), whereas IMD had a greater association with prescribing in SE for NSAIDs (coefficient = 0.02443, P<0.001), opioids (coefficient = 0.08919, P<0.001), hypnotics (coefficient = 0.09038, P<0.001), gabapentinoids (coefficient = 0.1095, P<0.001), and antibacterials (coefficient = 0.01601, P = 0.19).

CONCLUSION

The association of socioeconomic deprivation with overprescribing of high-risk medication in general practice varies by region and drug type. Geographical location is associated with overprescribing, independent of socioeconomic status.

Data-Driven Identification of Potentially Successful Intervention Implementations Using 5 Years of Opioid Prescribing Data: Retrospective Database Study

BACKGROUND

We have previously demonstrated that opioid prescribing increased by 127% between 1998 and 2016. New policies aimed at tackling this increasing trend have been recommended by public health bodies, and there is some evidence that progress is being made.

OBJECTIVE

We sought to extend our previous work and develop a data-driven approach to identify general practices and clinical commissioning groups (CCGs) whose prescribing data suggest that interventions to reduce the prescribing of opioids may have been successfully implemented.

METHODS

We analyzed 5 years of prescribing data (December 2014 to November 2019) for 3 opioid prescribing measures-total opioid prescribing as oral morphine equivalent per 1000 registered population, the number of high-dose opioids prescribed per 1000 registered population, and the number of high-dose opioids as a percentage of total opioids prescribed. Using a data-driven approach, we applied a modified version of our change detection Python library to identify reductions in these measures over time, which may be consistent with the successful implementation of an intervention to reduce opioid prescribing. This analysis was carried out for general practices and CCGs, and organizations were ranked according to the change in prescribing rate.

RESULTS

We identified a reduction in total opioid prescribing in 94 (49.2%) out of 191 CCGs, with a median reduction of 15.1 (IQR 11.8-18.7; range 9.0-32.8) in total oral morphine equivalence per 1000 patients. We present data for the 3 CCGs and practices demonstrating the biggest reduction in opioid prescribing for each of the 3 opioid prescribing measures. We observed a 40% proportional drop (8.9% absolute reduction) in the regular prescribing of high-dose opioids (measured as a percentage of regular opioids) in the highest-ranked CCG (North Tyneside); a 99% drop in this same measure was found in several practices (44%-95% absolute reduction). Decile plots demonstrate that CCGs exhibiting large reductions in opioid prescribing do so via slow and gradual reductions over a long period of time (typically over a period of 2 years); in contrast, practices exhibiting large reductions do so rapidly over a much shorter period of time.

CONCLUSIONS

By applying 1 of our existing analysis tools to a national data set, we were able to identify rapid and maintained changes in opioid prescribing within practices and CCGs and rank organizations by the magnitude of reduction. Highly ranked organizations are candidates for further qualitative research into intervention design and implementation.

Barriers and facilitators to opioid deprescribing among Advanced Nurse Practitioners: A qualitative interview study

AIM

To explore the experiences primary care Advanced Nurse Practitioners have had in relation to deprescribing opioids in chronic non-malignant pain.

DESIGN

A qualitative interview study.

METHODS

Primary care Advanced Nurse Practitioners were recruited from across the Northern Ireland GP Federations. Data collection for this study took place between April and June 2022. In total, 10 semi-structured online interviews were conducted. Interviews were audio and visually recorded, transcribed verbatim and interpreted using a thematic analysis framework. The COREQ criteria were used to guide the reporting of this study.

RESULTS

The Advanced Nurse Practitioners experienced several challenges associated with opioid deprescribing and the implementation of current chronic pain guidelines. The main barriers identified were difficulties engaging patients in deprescribing discussions, a lack of availability of supportive therapies and poor access to secondary care services. The barriers identified directly impacted on their ability to deliver best practice which resulted in a sense of professional powerlessness.

CONCLUSION

The experiences of the Advanced Nurse Practitioners demonstrate that opioid deprescribing in patients with chronic pain is challenging, and implementation of current chronic pain guidelines is difficult.

IMPACT

This study contributes to existing literature on the topic of reducing opioid prescribing and as far as the authors are aware, is the first study to examine the experiences of primary care advanced nurse practitioners in this context. These findings will be of interest to other primary care practitioners, and prescribers involved in the management of chronic non-malignant pain.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Temporal trends and patterns in initial opioid prescriptions after hospital discharge following colectomy in England over 10 years

BACKGROUND

While opioid analgesics are often necessary for the management of acute postoperative pain, appropriate prescribing practices are crucial to avoid harm. The aim was to investigate the changes in the proportion of people receiving initial opioid prescriptions after hospital discharge following colectomy, and describe trends and patterns in prescription characteristics.

METHODS

This was a retrospective cohort study. Patients undergoing colectomy in England between 2010 and 2019 were included using electronic health record data from linked primary (Clinical Practice Research Datalink Aurum) and secondary (Hospital Episode Statistics) care. The proportion of patients having an initial opioid prescription issued in primary care within 90 days of hospital discharge was calculated. Prescription characteristics of opioid type and formulation were described.

RESULTS

Of 95 155 individuals undergoing colectomy, 15 503 (16.3%) received opioid prescriptions. There was a downward trend in the proportion of patients with no prior opioid exposure (opioid naive) who had a postdischarge opioid prescription (P <0.001), from 11.4% in 2010 to 6.7% in 2019 (-41.3%, P <0.001), whereas the proportions remained stable for those prescribed opioids prior to surgery, from 57.5% in 2010 to 58.3% in 2019 (P = 0.637). Codeine represented 44.5% of all prescriptions and prescribing increased by 14.5% between 2010 and 2019. Prescriptions for morphine and oxycodone rose significantly by 76.6% and 31.0% respectively, while tramadol prescribing dropped by 48.0%. The most commonly prescribed opioid formulations were immediate release (83.9%), followed by modified release (5.8%) and transdermal (3.2%). There was a modest decrease in the prescribing of immediate-release formulations from 86.0% in 2010 to 82.0% in 2019 (P <0.001).

CONCLUSION

Over the 10 years studied, there was a changing pattern of opioid prescribing following colectomy, with a decrease in the proportion of opioid-naive patients prescribed postdischarge opioids.

Investigating social deprivation and comorbid mental health diagnosis as predictors of treatment access among patients with an opioid use disorder using substance use services: a prospective cohort study

BACKGROUND

Opioid use is a major public health concern across the globe. Opioid use and subsequent access to care is often shaped by co-occurring issues faced by people using opioids, such as deprivation, mental ill-health, and other forms of substance use. We investigated the role of social deprivation and comorbid mental health diagnoses in predicting re-engagement with substance use services or contact with crisis and inpatient services for individuals with opioid use disorder in secondary mental health care in inner-city London.

METHODS

We conducted a prospective cohort study which followed individuals diagnosed with a first episode of opioid use disorder who accessed substance use services between September 2015 and May 2020 for up to 12 months, using anonymised electronic health records. We employed negative binominal regression and Cox proportional survival analyses to assess associations between exposures and outcomes.

RESULTS

Comorbid mental health diagnoses were associated with higher contact rates with crisis/inpatient services among people with opioid use disorder: incidence rate ratios (IRR) and 95% confidence intervals (CI) were 3.91 (1.74-9.14) for non-opioid substance use comorbidity, 8.92 (1.81-64.4) for a single comorbid mental health diagnosis, and 15.9 (5.89-47.5) for multiple comorbid mental health diagnoses. Social deprivation was not associated with contact rates with crisis/inpatient services within this sample. Similar patterns were found with time to first crisis/inpatient contact. Social deprivation and comorbid mental health diagnoses were not associated with re-engagement with substance use services.

CONCLUSION

Comorbid substance and mental health difficulties amongst people with an opioid use disorder led to earlier and more frequent contact with crisis/inpatient mental health services during the first 12 months of follow up. Given the common co-occurrence of mental health and substance use disorders among those who use opioids, a better understanding of their wider needs (such as social, financial and other non-medical concerns) will ensure they are supported in their treatment journeys.

Intersectionality as a theoretical framework for researching health inequities in chronic pain

Chronic pain is experienced unequally by different population groups; we outline examples from the pain literature of inequities related to gender, ethnicity, socioeconomic and migration status. Health inequities are systematic, avoidable and unfair differences in health outcomes between groups of people, with the fundamental 'causes of causes' recognised as unequal distribution of income, power and wealth. Intersectionality can add further theory to health inequities literature; collective social identities including class/socioeconomic status, race/ethnicity, gender, migration status, age, sexuality and disabled status intersect in multiple interconnected systems of power leading to differing experiences of privilege and oppression which can be understood as axes of health inequities. The process of knowledge creation in pain research is shaped by these interconnected systems of power, and may perpetuate inequities in pain care as it is largely based on majority white, middle class, Eurocentric populations. Intersectionality can inform research epistemology (ways of knowing), priorities, methodology and methods. We give examples from the literature where intersectionality has informed a justice oriented approach across different research methods and we offer suggestions for further development. The use of a reductionist frame can force unachievable objectivity on to complex health concepts, and we note increasing realisation in the field of the need to understand the individuals within their social world, and recognise the fluid and contextual nature of this.

Opioid prescription patterns in the province of Las Palmas, Canary Islands, Spain (2016-2020): differences between urban and rural areas

Introduction: The use of opioids has increased markedly in the past decades in European countries, especially for treatment of non-cancer pain including painful chronic musculoskeletal conditions. However, there are some notable differences in the relative levels of use between geographical areas and some distinct, context-specific patterns of weak and strong opioid use. The aim of this work is to describe real world trends in dosage forms and population exposure in the prescription opioid use on isolated geographically area: The Canary Islands of Gran Canaria, Lanzarote and Fuerteventura, Spain. For this, several factors such as living in a rural or urban area, population over 65 years of age, population density or socioeconomic status were analyzed. Methods: Data were extracted from the wholesalers who supply the community pharmacies at the population level. Prescription opioid use was measured as defined daily doses (DDD) per 1,000 inhabitants per day. A model based on covariance analysis with two nested fixed factors and one co-variable was used for contrast analysis at different level. Results: The overall DDD per 1000 inhabitants per day and year variation rate in Spain was very similar to that obtained for Gran Canaria and Fuerteventura (0.967 vs. 1.006), although the levels of dispensation were different (14.75 versus 18.24 for Gran Canaria and 12.7 for Fuerteventura, respectively). Lanzarote is completely different in all issues, where the opioid consumption rate remained stable during the study period, but with a decreasing tendency. The dispensation level of strong opioids varied between islands, from 56.41% for Fuerteventura vs. 17.61% for Gran Canaria, although these values remained stable. Tramadol with acetaminophen and Tramadol in monotherapy were the most consumed forms of the weak opioids, whereas Buprenorphine was the most used strong opioid followed by Fentanyl, although demand for it varied between islands, the transdermal formulations were the most frequent pharmaceutical preparation. Conclusion: The differences in prescription opioid use are most likely explained by the opioid prescribing practices in each island, whereas factors such urbanicity level, population age, population density and status socioeconomic does not help to explain the differences in prescription opioid use across rural and urban areas.

High-dose opioids for chronic non-cancer pain: an overview of Cochrane Reviews

BACKGROUND

This overview was originally published in 2017, and is being updated in 2022.  Chronic pain is typically described as pain on most days for at least three months. Chronic non-cancer pain (CNCP) is any chronic pain that is not due to a malignancy. Chronic non-cancer pain in adults is a common and complex clinical issue, for which opioids are prescribed by some physicians for pain management. There are concerns that the use of high doses of opioids for CNCP lacks evidence of effectiveness, and may increase the risk of adverse events.

OBJECTIVES

To describe the evidence from Cochrane Reviews and overviews regarding the efficacy and safety of high-dose opioids (defined as 200 mg morphine equivalent or more per day) for CNCP.

METHODS

We identified Cochrane Reviews and overviews by searching the Cochrane Database of Systematic Reviews in The Cochrane Library. The date of the last search was 21 July 2022. Two overview authors independently assessed the search results. We planned to analyse data on any opioid agent used at a high dose for two weeks or more for the treatment of CNCP in adults.

MAIN RESULTS

We did not identify any reviews or overviews that met the inclusion criteria. The excluded reviews largely reflected low doses or titrated doses, where all doses were analysed as a single group; we were unable to extract any data for high-dose use only.

AUTHORS' CONCLUSIONS

There is a critical lack of high-quality evidence, in the form of Cochrane Reviews, about how well high-dose opioids work for the management of CNCP in adults, and regarding the presence and severity of adverse events.  No evidence-based argument can be made on the use of high-dose opioids, i.e. 200 mg morphine equivalent or more daily, in clinical practice. Considering that high-dose opioids have been, and are still being used in clinical practice to treat CNCP, knowing about the efficacy and safety of these higher doses is imperative.

Digitally deployed, GP remote consultation video intervention that aims to reduce opioid prescribing in primary care: protocol for a mixed-methods evaluation

INTRODUCTION

Opioid prescribing rates are disproportionately high in the North of England. In addition to patients' complex health needs, clinician prescribing behaviour is also a key driver. Although strategies have been initiated to reduce opioid prescribing nationally, the COVID-19 pandemic has interrupted service provision and created challenges for the system and health professionals to tackle this complex issue. A pilot intervention using smartphone video messaging has been developed to remotely explain the rationale for opioid reduction and facilitate self-initiation of support. The aim of this study is to evaluate the potential benefits, risks and economic consequences of 'at scale' implementation.

METHODS AND ANALYSIS

This will be a mixed-methods study comprising a quasi-experimental non-randomised before-and-after study and qualitative interviews. The intervention arm will comprise 50 General Practitioner (GP) Practices using System 1 (a clinical computer system hosting the intervention) who will deliver the video to their patients via text message. The control arm will comprise 50 practices using EMIS (a different computer system) who will continue usual care. Monthly practice level prescribing and consultation data will be observed for 6 months postintervention. A general linear model will be used to estimate the association between the exposure and the main outcome (opioid prescribing; average daily quantity (ADQ)/1000 specific therapeutic group age-sex related prescribing unit). Semi-structured interviews will be undertaken remotely with purposively selected participants including patients who received the video, and health professionals involved in sending out the videos and providing additional support. Interviews will be audio recorded, transcribed and analysed thematically.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the NHS Health Research Authority Research Ethics Committee (22/PR/0296). Findings will be disseminated to the participating sites, participants, and commissioners, and in peer-reviewed journals and academic conferences.

TRIAL REGISTRATION NUMBER

NCT05276089.

Feasibility study of a Behavioural Intervention for Opioid Reduction (BIOR) for patients with chronic non-cancer pain in primary care: a protocol

INTRODUCTION

Around 30%-50% of adults suffer moderate to severe chronic pain not caused by cancer. Significant numbers are treated with opioids which over time may cease to be effective and produce side effects (eg, nausea, drowsiness and constipation). Stopping taking opioids abruptly can cause unpleasant withdrawal effects. Tapering in small steps is recommended, though some patients might struggle and need support, particularly if they have limited access to pain management alternatives. Awareness of the potential risks as well as benefits of tapering should be explored with patients.

METHODS AND ANALYSIS

A randomised controlled pilot feasibility study to investigate the effectiveness and feasibility of reducing high doses of opioids through a tapering protocol, education and support in primary care. Working with NHS Knowsley Place, we will identify patients taking 50 mg or above morphine equivalent dose of opioids per day to be randomly allocated to either the tapering group or tapering with support group. At an initial joint appointment with a pain consultant and General Practitioner (GP) GP tapering will be discussed and negotiated. Both groups will have their opioid reduced by 10% per week. The taper with support group will have access to additional support, including motivational counselling, realistic goal setting and a toolkit of resources to promote self-management. Some patients will successfully reduce their dose each week. For others, this may be more difficult, and the tapering reduction will be adjusted to 10% per fortnight. We assess opioid use, pain and quality of life in both groups at the start and end of the study to determine which intervention works best to support people with chronic pain who wish to stop taking opioids.

ETHICS AND DISSEMINATION

The Behavioural Intervention for Opioid Reduction feasibility study has been granted full approval by Liverpool Central Research Ethics Committee on 7 April 2022 (22/NW/0047). The current protocol version is V.1.1, date 6 July 2022. Results will be published in peer-reviewed journals and disseminated to patient stakeholders in a lay summary report available on the project website and in participating GP surgeries.

TRIAL REGISTRATION NUMBER

ISRCTN 30201337.

A comparison of opioid prescription trends in England and the United States from 2008 to 2020

BACKGROUND

The prescription opioid epidemic in the United States (US) is well documented, and recent measures have reduced prescribing rates in that country. Evidence suggests opioid prescriptions have been rising recently in other countries too.

OBJECTIVE

The current paper aimed to compare trends in opioid prescribing in England and the US.

METHODS

Trends in rates of prescriptions per 100 members of the population were calculated for England and the US using publicly available government data on prescriptions and population statistics.

RESULTS

Rates of prescribing are converging. At the peak of the US epidemic in 2012, there were 81.3 prescriptions per 100 people, but this had fallen to 43.3 by 2020. Prescribing peaked in England in 2016 at 43.2 prescriptions per 100 people, but has fallen only slightly, so that in 2020 there were 40.9 prescriptions per 100 people.

CONCLUSION

The data indicate that levels of opioid prescribing in England are now similar to those in the US. They remain high in both countries, despite recent falls. This suggests the need for further measures to prevent over-prescribing and to support people who would benefit from withdrawing from these drugs.

Identifying Patterns of Clinical Interest in Clinicians' Treatment Preferences: Hypothesis-free Data Science Approach to Prioritizing Prescribing Outliers for Clinical Review

BACKGROUND

Data analysis is used to identify signals suggestive of variation in treatment choice or clinical outcome. Analyses to date have generally focused on a hypothesis-driven approach.

OBJECTIVE

This study aimed to develop a hypothesis-free approach to identify unusual prescribing behavior in primary care data. We aimed to apply this methodology to a national data set in a cross-sectional study to identify chemicals with significant variation in use across Clinical Commissioning Groups (CCGs) for further clinical review, thereby demonstrating proof of concept for prioritization approaches.

METHODS

Here we report a new data-driven approach to identify unusual prescribing behaviour in primary care data. This approach first applies a set of filtering steps to identify chemicals with prescribing rate distributions likely to contain outliers, then applies two ranking approaches to identify the most extreme outliers amongst those candidates. This methodology has been applied to three months of national prescribing data (June-August 2017).

RESULTS

Our methodology provides rankings for all chemicals by administrative region. We provide illustrative results for 2 antipsychotic drugs of particular clinical interest: promazine hydrochloride and pericyazine, which rank highly by outlier metrics. Specifically, our method identifies that, while promazine hydrochloride and pericyazine are barely used by most clinicians (with national prescribing rates of 11.1 and 6.2 per 1000 antipsychotic prescriptions, respectively), they make up a substantial proportion of antipsychotic prescribing in 2 small geographic regions in England during the study period (with maximum regional prescribing rates of 298.7 and 241.1 per 1000 antipsychotic prescriptions, respectively).

CONCLUSIONS

Our hypothesis-free approach is able to identify candidates for audit and review in clinical practice. To illustrate this, we provide 2 examples of 2 very unusual antipsychotics used disproportionately in 2 small geographic areas of England.

Long-term, high-dose opioid prescription for chronic non-cancer pain in primary care: an observational study

BACKGROUND

Opioid prescriptions for chronic pain have risen sharply over the last 25 years; harms associated with these drugs are related to dose and length of use.

AIM

The main aim of this study was to identify patients prescribed long-term, high-dose (LTHD) opioids in the community and to assess the prevalence of such use.

DESIGN & SETTING

An observational study of opioid prescribing in two demographically dissimilar GP practices in North Wales, UK.

METHOD

Details of opioid prescriptions were collected for 22 841 patients, of whom 1488 (6.5%) were being prescribed opioids on the census date. Exhaustive examination of the data identified all patients who were prescribed oral morphine equivalent doses of ≥120 mg/day for ≥1 year.

RESULTS

All these patients were being prescribed ≥120 mg/day, as a single drug, morphine, oxycodone, fentanyl, or buprenorphine, irrespective of opioid polypharmacy. Across both practices, 1.71/1000 patients were identified as LTHD users of opioid medication for chronic non-cancer pain (CNCP). Prevalence was similar in the two practices. Repetition of the process until January 2021 showed no change in the pattern.

CONCLUSION

This study offers confirmation that a significant group of patients are prescribed long-term opioid medication for chronic pain at doses that are unlikely to be effective in reducing pain, but are likely to have harmful consequences. The findings offer a simple, reliable, and practical method of data extraction to identify these patients individually from routinely collected prescribing data, which will help in monitoring and treating individuals and establishing the problem prevalence.

Lessons Learned in Implementing a Chronic Opioid Therapy Management System

OBJECTIVES

Opioid misuse has resulted in significant morbidity and mortality in the United States, and safer opioid use represents an important challenge in the primary care setting. This article describes a research collaborative of health service researchers, systems engineers, and clinicians seeking to improve processes for safer chronic opioid therapy management in an academic primary care center. We present implementation results and lessons learned along with an intervention toolkit that others may consider using within their organization.

METHODS

Using iterative improvement lifecycles and systems engineering principles, we developed a risk-based workflow model for patients on chronic opioids. Two key safe opioid use process metrics-percent of patients with recent opioid treatment agreements and urine drug tests-were identified, and processes to improve these measures were designed, tested, and implemented. Focus groups were conducted after the conclusion of implementation, with barriers and lessons learned identified via thematic analysis.

RESULTS

Initial surveys revealed a lack of knowledge regarding resources available to patients and prescribers in the primary care clinic. In addition, 18 clinicians (69%) reported largely "inheriting" (rather than initiating) their chronic opioid therapy patients. We tracked 68 patients over a 4-year period. Although process measures improved, full adherence was not achieved for the entire population. Barriers included team structure, the evolving opioid environment, and surveillance challenges, along with disruptions resulting from the 2019 novel coronavirus.

CONCLUSIONS

Safe primary care opioid prescribing requires ongoing monitoring and management in a complex environment. The application of a risk-based approach is possible but requires adaptability and redundancies to be reliable.

Patterns of prescribing in primary care leading to high-dose opioid regimens: a mixed-method study

BACKGROUND

There are concerns about continuing increases in the number of patients prescribed long-term opioids and the prescribing of 'strong' opioids for chronic pain. Little is known about patients who are prescribed these long-term, high-dose drugs.

AIM

To understand patterns of opioid prescribing that lead to long-term, high-dose use.

DESIGN & SETTING

A mixed-method study of the opioid prescription histories of patients using high doses in a North Wales GP practice.

METHOD

All patients on high-dose opioids during the census week were identified. Summary graphs of the prescription histories were prepared. Qualitative analysis was conducted individually by four researchers. A workshop was held to arrive at a consensus about common features and to inform further quantitative analysis.

RESULTS

A quarter of high-dose regimens were initiated outside the practice, either in a different primary care practice or in secondary care. The majority of the remaining patients showed a pattern of dose increases to high levels over a short period (median 3.5 months). None showed a pattern of gradual increases over a longer timescale. Most of the patients remained on high doses continuously once a daily dose of ≥120 mg oral morphine equivalent (OME) was reached.

CONCLUSION

These findings suggest that high-dose opioid regimens develop quickly in response to unknown clinical factors. An expected insidious upward drift in dose was not seen. The findings have implications for the prevention of potentially dangerous long-term, high-dose opioid prescribing. A dose of 60 mg OME or more is suggested as a useful 'red flag'.

A qualitative interview study of GPs' experiences of prescribing opioid medication for chronic pain

BACKGROUND

Prescribing of opioid medication has increased over the past 20 years. Most occurs in primary care for chronic pain. There is little evidence that these drugs are effective for this indication. There are concerns about the continuing prescribing of opioids, particularly in the long term and at high doses.

AIM

To explore GPs' experiences of prescribing opioids, problems encountered, and factors militating against good prescribing practice.

DESIGN & SETTING

Qualitative interviews with GPs who prescribe opioids in primary care in North East Wales.

METHOD

Semi-structured interviews with 20 GPs were transcribed and subjected to thematic analysis utilising the framework approach.

RESULTS

Participating GPs identified a range of problems associated with prescribed opioids. They were concerned about limited effectiveness of the drugs and what they perceived as addiction resulting from their use. They identified healthcare system factors that were obstacles to good prescribing practice such as lack of continuity of care, poor access to secondary care pain management support, and, most importantly, constant time pressure. They reported adverse effects on relationships with patients. Unrealistic expectations that pain could be eliminated resulted in pressure to prescribe stronger drugs and increased doses. It led to difficulties in establishing and maintaining trust and in persuading patients to agree to, and to carry out, dose reductions.

CONCLUSION

Themes emerging from this study suggest that GPs lack appropriate control of opioid prescribing. There is a need to develop methods to help patients and GPs to work together to manage chronic pain safely.

Regional variation in longitudinal trajectories of primary care opioids prescribing across Health Boards in Scotland: a population-based study

BACKGROUND

This study aims to describe the longitudinal trajectory of opioid prescribing at the practice level and assess associated factors, including Health Boards and socioeconomic status.

RESEARCH DESIGN AND METHODS

This drug utilization research used practice-level dispensing data from 2016 to 2018. Practice-level prescription opioids dispensed were quantified by the defined daily doses (DDDs) per 1000 registrants. Group-based trajectory models were used to identify groups of practices with similar trajectories based on the difference in monthly opioid utilization. Characteristics of registrants were associated with the trajectory by a conditional logistic regression and the prescription opioids dispensed by a random-effect regression model.

RESULTS

Of the 798 practices, 29.5% increased opioid prescription by an additional 100 DDDs/1000 registrants/month during 2017 and 2018. Practice in southwest Scotland tended to be categorized into the group with increasing opioid utilization. Deprived socioeconomic status was associated with increasing opioid utilization (odds ratio: 2.2; 95% confidence interval: 1.5, 3.2) or higher annual opioid utilization (coefficient: 358.2; 95% confidence interval: 327.6, 388.8).

CONCLUSIONS

Increasing opioid utilization over time was related to deprived socioeconomic status associated with chronic pain conditions and inequality in pain services. Further strategies to balance inequality are needed, which needs further investigation.

Prescribing Pattern of Analgesics in Colombia. Are there Differences between Capital Cities and Municipalities? A Cross-Sectional Study

Background

Analgesics provide multiple clinical benefits but they are not without risks.

Objective

The aim of this study was to compare the outpatient prescribing pattern of analgesics between cities and municipalities in Colombia and to identify the variables associated with prescribing opioid analgesics.

Methods

This was a cross-sectional study that identified the prescription of analgesics for outpatient use from a population database of 8.5 million Colombians. A descriptive, bivariate, and multivariate analysis was performed.

Results

A total of 573,248 patients were identified who had received prescriptions for an analgesic. Mean age was 46.5 ± 23.6 years and 65.7% were females. The most commonly prescribed analgesics were non-opioid analgesics, antispasmodics, and opioid analgesics. The average milligram equivalent of morphine was higher in capital cities than in municipalities. Age ≥ 65 years (odds ratio [OR] 2.60, 95% confidence interval [CI] 2.54–2.67), male sex (OR 1.09, 95% CI 1.07–1.11), dispensing in cities (OR 2.25, 95% CI 2.20–2.30) and experiencing chronic pain (OR 13.25, 95% CI 10.89–16.14) were associated with an increased risk of receiving an opioid analgesic.

Conclusions

Differences were found in the prescription of analgesics between capital cities and municipalities. The use of opioids does not appear to be in line with the recommendations for clinical practice, and they were mainly prescribed for elderly males with chronic non-oncological pain and for residents of capital cities.

The impact of the COVID-19 pandemic lockdown measures on the prescribing trends and utilization of opioids in the English primary care setting: segmented-liner regression analysis

BACKGROUND

The COVID-19 lockdown has resulted in limited access to most of the conventional chronic pain management services. Subsequently, changes in opioids' utilization could be expected. This study assessed the impact of the first COVID-19 lockdown on opioid utilization using aggregated-level, community dispensing dataset covering the whole English population.

RESEARCH DESIGN AND METHODS

A segmented-linear regression analysis was applied to monthly dispensed opioid prescriptions from March 2019 to March 2021. Opioid utilization was measured using the number of opioids' items dispensed/1000 inhabitants and Defined Daily Dose (DDD)/1000 inhabitants/day during 12-months pre/post the lockdown in March 2020 stratified by strong and weak opioids.

RESULTS

For all opioids' classes, there were nonsignificant changes in the number of opioids' items dispensed/1000 inhabitants trend pre-lockdown, small increases in their level immediately post-lockdown, and a non-significant decline in the trend post-lockdown. Similarly, a non-significant reduction in the DDD/1000 inhabitant/day baseline trend pre-lockdown, nonsignificant immediate increases in the level post-lockdown, and declines in the trend post-lockdown for all opioids' classes were observed.

CONCLUSION

Unexpectedly, opioid utilization does not appear to have been significantly affected by the lockdown measures during the study period. However, patient-level data is needed to determine more accurate estimates of any changes in the opioid prescribing including incident prescribing/use.

Efficacy and safety of strong opioids for chronic noncancer pain and chronic low back pain: a systematic review and meta-analyses

ABSTRACT

In recent years, long-term prescribing and use of strong opioids for chronic noncancer pain (CNCP) has increased in high-income countries. Yet existing uncertainties, controversies, and differing recommendations make the rationale for prolonged opioid use in CNCP unclear. This systematic review and meta-analyses compared the efficacy, safety, and tolerability of strong opioids with placebo or nonopioid therapy in CNCP, with a special focus on chronic low back pain (CLBP). Systematic literature searches were performed in 4 electronic databases (MEDLINE, Web of Science, Cochrane Library, and CINAHL) in July 2019 and updated by regular alerts until December 2020. We included 16 placebo-controlled randomized controlled trials for CLBP and 5 studies (2 randomized controlled trials and 3 nonrandomized studies) of opioids vs nonopioids for CNCP in the quantitative and qualitative synthesis. Random effects pairwise meta-analyses were performed for efficacy, safety, and tolerability outcomes and subgroup analyses for treatment duration, study design, and opioid experience status. Very low to low certainty findings suggest that 4 to 15 weeks (short or intermediate term) opioid therapy in CLBP (compared with placebo) may cause clinically relevant reductions in pain but also more gastrointestinal and nervous system adverse events, with likely no effect on disability. By contrast, long-term opioid therapy (≥6 months) in CNCP may not be superior to nonopioids in improving pain or disability or pain-related function but seems to be associated with more adverse events, opioid abuse or dependence, and possibly an increase in all-cause mortality. Our findings also underline the importance and need for well-designed trials assessing long-term efficacy and safety of opioids for CNCP and CLBP.

Highlighting the hidden dangers of a 'weak' opioid: Deaths following use of dihydrocodeine in England (2001-2020)

BACKGROUND

Dihydrocodeine (DHC) is considered a 'weak' opioid, but there is evidence of its increasing misuse in overdose deaths. This research aims to analyse trends in DHC-related deaths in England relevant to source and dose of DHC, and decedent demographics.

METHODS

Cases from England reported to the National Programme on Substance Abuse Deaths (NPSAD) where DHC was identified at post-mortem and/or implicated in death between 2001 and 2020 were extracted for analysis.

RESULTS

2071 DHC-related deaths were identified. The greatest number of deaths involved illicitly obtained DHC and a significant increase in these deaths was recorded over time (r = 0.5, p = 0.03). However, there was a concurrent decline in the implication rate of DHC in causing death (r = -0.6, p < 0.01). Fatalities were primarily due to accidental overdose (64.8%) and misuse was highly prevalent in combination with additional central nervous system depressants (95.3%), namely illicit heroin/morphine and diazepam. In contrast, when DHC was obtained over-the-counter (OTC) suicide mortality accounted for almost half of the deaths (42.5%). Differences in polysubstance use were also identified, with less heroin/morphine and benzodiazepine co-detection, but increased OTC codeine co-detection.

CONCLUSIONS

DHC misuse in England is increasing. The pharmacological consideration of DHC as a 'weak' opioid may be misinterpreted by users, leading to accidental overdosing. There is an urgent need to understand increasing polypharmacy in overdose deaths. Additionally, suicides involving DHC is a potential cause for concern and a review of OTC opioid-paracetamol preparations is necessary to determine whether the benefits of these medications continue to outweigh the risks of intentional overdose.

Effectiveness of non-opioid interventions to reduce opioid withdrawal symptoms in patients with chronic pain: a systematic review

BACKGROUND

Dealing with the opioid crisis, medical doctors are keen to learn how to best treat opioid dependency in patients with chronic non-cancer pain. Opioid replacement therapy is commonly used, but success rates vary widely. Since many patients still experience severe withdrawal symptoms, additional interventions are necessary.

OBJECTIVE

To review the effectiveness of interventions in the treatment of withdrawal symptoms during opioid tapering or acute withdrawal in patients with long-term non-cancer pain.

METHODS

A systematic review was conducted in Embase.com, MEDLINE, Web of Science, PsycINFO, and Cochrane CENTRAL register of trials. Studies eligible for inclusion were (non-)randomized controlled trials in adults with long-term opioid prescriptions for non-cancer pain. Included trials had to compare a non-opioid intervention to placebo, usual care, no treatment, or non-opioid drug and had to report on withdrawal symptoms as an outcome. Study quality was assessed with the 2.0 Cochrane risk of bias (RoB) tool. Evidence quality was rated following the GRADE approach.

RESULTS

One trial (n = 21, some concerns regarding RoB) compared Varenicline to placebo. There was no statistically significant between-group reduction of withdrawal symptoms (moderate-quality evidence).

CONCLUSIONS

Evidence from clinical trials on interventions reducing withdrawal symptoms is scarce. Based on one trial with a small sample size, no firm conclusion can be drawn. Meanwhile, doctors are in dire need for therapeutic options to tackle withdrawal symptoms while tapering patients with prescription opioid dependence. We hope this review draws attention to this unfortunate research gap so that future research can provide doctors with answers.

An overview of the use and misuse/abuse of opioid analgesics in different world regions and future perspectives

Opioids are an important therapeutic option for severe resistant chronic pain but, in the absence of proper oversight, their use has risks. The level of prescription opioid misuse/abuse differs among countries, due to differences in healthcare systems and pain management approaches. However, evaluating the true dimension of prescription opioid misuse/abuse is complicated by statistical reporting which often does not differentiate between prescription and illicit opioid use, or between prescription opioid use by patients and nonpatients, highlighting a need for greater uniformity. Parallel efforts to educate patients and the general public about opioid risks, facilitate appropriate analgesic prescribing and identify alternative formulations or options to use instead of or with opioids, may contribute to optimizing prescription opioid use for pain management.

Opioid use trends in Spain: the case of the island of La Gomera (2016-2019)

This study is an evaluation of prescription opioid use on the island of La Gomera, a mainly rural area, during the period 2016-2019 at various levels. Data were extracted from the wholesalers who supply the community pharmacies at the population level. Prescription opioid use was measured as defined daily doses per 1,000 inhabitants/day (DID) and by the number of units sold per 1,000 inhabitants and year (units sold). This provided an island total of La Gomera's overall prescription of opioids and its rate of change, as well as differences in prescribing at the municipal and health area level. Tramadol with acetaminophen and tramadol in monotherapy were the most consumed by "units sold" parameter, which accounted for 69.48% and 18.59% of the total. The situation was similar for DID, although with lower percentages, but a significant increase was observed in the use of fentanyl and buprenorphine, around 15% in each case. The balance between the uses of weak or strong opioids was different in La Gomera compared to that of Spain as a whole. In Spain, almost 70% of the prescriptions were for weak opioids compared to 58.67% in La Gomera. Fentanyl was the most used strong opioid (16.10%) followed by tapentadol and buprenorphine, around 5% each, whereas in La Gomera, buprenorphine was the most consumed (15.75%) followed by fentanyl (14.87%) and tapentadol (5.82%). These differences in prescription opioid use are most likely explained by prescriber characteristics, whereas the population age, socioeconomic status, or living in rural/urban area are not decisive determinants.

Opioid Prescription Following Wrist and Ankle Fracture Fixation in Scotland—Tradition Prevails

The American ‘opioid crisis’ is rapidly spreading internationally. Perioperative opioid use increases the risk of long-term opioid use. We review opioid use following wrist and ankle fracture fixation across Scotland, establishing prescribing patterns and associations with patient, injury, or perioperative factors. Six Scottish orthopedic units contributed. A total of 598 patients were included. Patient demographics were similar across all sites. There was variation in anesthetic practice, length of stay, and AO fracture type (p < 0.01). For wrist fractures, 85.6% of patients received a discharge opioid prescription; 5.0% contained a strong opioid. There was no significant variation across the six units in prescribing practice. For ankle fractures, 82.7% of patients received a discharge opioid prescription; 17% contained a strong opioid. Dundee and Edinburgh used more strong opioids; Inverness and Paisley gave the least opioids overall (p < 0.01). Younger patient age, location, and length of stay were independent predictors of increased prescription on binary regression. Despite variability in perioperative practices, discharge opioid analgesic prescription remains overwhelmingly consistent. We believe that the biggest influence lies with the prescriber-institutional ‘standard practice’. Education of these prescribing clinicians regarding the risk profile of opioids is key to reducing their use following surgery, thus lowering long-term opioid dependence.

Determinants of long-term opioid prescribing in an urban population- a cross sectional study

BACKGROUND

Opioid prescribing has more than doubled in the UK between 1998 and 2016. Potential adverse health implications include dependency, falls and increased health expenditure.

AIM

To describe the predictors of long-term opioid prescribing (LTOP), (≥3 opioid prescriptions in a 90-day period).

DESIGN AND SETTING

A retrospective cross-sectional study in 41 General Practices in South London.

METHOD

Multi-level multivariable logistic regression to investigate the determinants of LTOP.

RESULTS

2,679 (0.8%) out of 320,639 registered patients ≥18 years were identified as having LTOP. Patients Were most likely to have LTOP, if: they had ≥5 long term conditions (LTCs) (adjusted odds ratio [AOR] 36.5, 95% confidence interval [CI] 30.4-43.8) or 2-4 LTCs (AOR 13.8, CI 11.9-16.1), in comparison to no LTCs, ≥75 years compared to 18-24 years (AOR 12.31, CI 7.1-21.5), smokers compared to non-smokers (AOR 2.2, CI 2.0-2.5), females compared to males (AOR 1.9, CI 1.7-2.0) and in the most deprived deprivation quintile (AOR 1.6, CI 1.4-1.8) compared to the least deprived. In a separate model examining individual long-term conditions (LTCs), the strongest associations for LTOP were noted for sickle cell disease (SCD) (AOR 18.4, CI 12.8-26.4), osteoarthritis (AOR 3.0, CI 2.8-3.3), rheumatoid arthritis (AOR 2.8, CI 2.2-3.4), depression (AOR 2.6, CI 2.3-2.8) and multiple sclerosis (OR 2.5, CI 1.4-4.4).

CONCLUSION

LTOP was significantly higher in those aged ≥75 years, with multi-morbidity or specific LTCs: sickle cell disease, osteoarthritis, rheumatoid arthritis, depression, and multiple sclerosis. These characteristics may enable the design of targeted interventions to reduce LTOP.

Healthcare resource utilisation and cost analysis associated with opioid analgesic use for non-cancer pain: A case-control, retrospective study between 2005 and 2015

Objective

To examine differences in healthcare utilisation and costs associated with opioid prescriptions for non-cancer pain issued in primary care.

Method

A longitudinal, case-control study retrospectively examined Welsh healthcare data for the period 1 January 2005–31 December 2015. Data were extracted from the Secure Anonymised Information Linkage (SAIL) databank. Subjects, aged 18 years and over, were included if their primary care record contained at least one of six overarching pain diagnoses during the study period. Subjects were excluded if their record also contained a cancer diagnosis in that time or the year prior to the study period. Case subjects also received at least one prescription for an opioid analgesic. Controls were matched by gender, age, pain-diagnosis and socioeconomic deprivation. Healthcare use included primary care visits, emergency department (ED) and outpatient (OPD) attendances, inpatient (IP) admissions and length of stay. Cost analysis for healthcare utilisation used nationally derived unit costs for 2015. Differences between case and control subjects for resource use and costs were analysed and further stratified by gender, prescribing persistence (PP) and deprivation.

Results

Data from 3,286,215 individuals were examined with 657,243 receiving opioids. Case subjects averaged 5 times more primary care visits, 2.8 times more OPD attendances, 3 times more ED visits and twice as many IN admissions as controls. Prescription persistence over 6 months and greater deprivation were associated with significantly greater utilisation of healthcare resources. Opioid prescribing was associated with 69% greater average healthcare costs than in control subjects. National Health Service (NHS) healthcare service costs for people with common, pain-associated diagnoses, receiving opioid analgesics were estimated to be £0.9billion per year between 2005 and 2015.

Conclusion

Receipt of opioid prescriptions was associated with significantly greater healthcare utilisation and accompanying costs in all sectors. Extended prescribing durations are particularly important to address and should be considered at the point of initiation.

"The lesser of two evils": a framework analysis of consumers' perspectives on opioid deprescribing and the development of opioid deprescribing guidelines

ABSTRACT

Deprescribing opioids has been identified as an intervention to mitigate opioid harm; however, it is often challenging to implement interventions and communicate deprescribing decisions to consumers. The development of opioid deprescribing guidelines may provide guidance and support on when and how to reduce or cease opioids in routine care. This study aimed to explore the perspectives of opioid consumers on opioid deprescribing and determine factors to be considered in the development of opioid deprescribing guidelines. A purposive sample of 20 consumers using opioids for pain was recruited. Semistructured interviews were conducted, audio recorded, and transcribed verbatim. Inductive thematic analysis was undertaken, followed by a framework analysis informed by Bandura's Social Cognitive Theory. Behavioral, cognitive, and environmental factors influence consumers' attitudes and actions regarding opioid deprescribing. Significant barriers to opioid deprescribing were identified, including fears of pain and withdrawal effects, opioid-related stigma, and perceived inadequacies of the healthcare system. Improved communication between healthcare professionals and consumers regarding expectations of deprescribing and goals of care, as well as the provision of greater opportunities for consumer engagement in decision making were identified as avenues to improve the success of opioid deprescribing. For opioid deprescribing guidelines to be effective and achieve the intended goal of optimizing opioid use, consumers need to feel empowered to engage in opioid reduction or cessation. The findings of this study may facilitate a patient-centred approach for practitioners and guideline developers in creating recommendations and interventions to enable opioid deprescribing through targeting behavioral change.

Opioid abuse and austerity: Evidence on health service use and mortality in England

Opioid abuse has become a public health concern among many developed countries, with policymakers searching for strategies to mitigate adverse effects on population health and the wider economy. The United Kingdom has seen dramatic increases in opioid-related mortality following the financial crises in 2008. We examine the impact of spending cuts resulting from government prescribed austerity measures on opioid-related hospitalisations and mortality, thereby expanding on existing evidence suggesting a countercyclical relationship with macroeconomic performance. We take advantage of the variation in spending cuts passed down from central government to local authorities since 2010, with reductions in budgets of up to fifty percent in some areas resulting in the rescaling of vital public services. Longitudinal panel data methods are used to analyse a comprehensive, linked dataset that combines information from spending records, official death registry data and large administrative health care data for 152 local authorities (i.e., unitary authorities and county councils) in England between April 2010 and March 2017. A total of 280,827 people experienced a hospital admission in the English National Health Service because of an opioid overdose and 14,700 people died from opioids across the study period. Local authorities that experienced largest spending cuts also saw largest increases in opioid abuse. Interactions between changes in unemployment and spending items for welfare programmes show evidence about the importance for governments to protect populations from social-risk effects at times of deteriorating macroeconomic performance. Our study carries important lessons for countries aiming to address high rates of opioid abuse, including the United States, Canada and Sweden.

Opioids and Gabapentinoids Utilisation and Their Related-Mortality Trends in the United Kingdom Primary Care Setting, 2010-2019: A Cross-National, Population-Based Comparison Study

Background: There is growing concern over the increasing utilisation trends of opioids and gabapentinoids across but there is lack of data assessing and comparing the utilisation trends across the four United Kingdom countries. We assessed/compared opioids and gabapentinoids utilisation trends across the four United Kingdom countries then evaluated the correlation between their utilisation with related mortality.

Methods: This repeated cross-national study used Prescription Cost Analysis (PCA) datasets (2010–2019). Opioids and gabapentinoids utilisation were measured using number of items dispensed/1,000 inhabitants and defined daily doses (DDDs)/1,000 inhabitant/day. Number of Opioids and gabapentinoids-related mortality were extracted from the United Kingdom Office for National Statistics (2010–2018). Data were analysed using descriptive statistics including linear trend analysis; correlation between the Opioids and gabapentinoids utilisation and their related mortality using Pearson correlation coefficient.

Results: The results illustrated an overall significant increasing trend in the utilisation of opioids (12.5–14%) and gabapentinoids (205–207%) with substantial variations among the four United Kingdom countries. For opioids, Scotland had the highest level of number of items dispensed/1,000 inhabitant (156.6% higher compared to the lowest level in England), whereas in terms of DDD/1,000 inhabitant/day, NI had the highest level. Utilisation trends increased significantly across the four countries ranging from 7.7% in Scotland to 20.5% in NI (p < 0.001). Similarly, for gabapentinoids, there were significant increasing trends ranging from 126.5 to 114.9% in NI to 285.8–299.6% in Wales (p < 0.001) for number of items/1,000 inhabitants and DDD/1,000 inhabitant/day, respectively. Although the utilisation trends levelled off after 2016, this was not translated into comparable reduction in opioids and gabapentinoids-related mortality as the latter continued to increase with the highest level in Scotland (3.5 times more deaths in 2018 compared to England- 280.1 vs. 79.3 deaths/million inhabitants). There were significant moderate-strong positive correlations between opioids and gabapentinoids utilisation trends and their related mortality.

Conclusion: The utilisation trends of opioids and gabapentinoids have increased significantly with substantial variations among the four United Kingdom countries. This coincided with significant increase in their related mortality. Our findings support the call for immediate actions including radical changes in official United Kingdom policies on drug use and effective strategies to promote best clinical practice in opioids and gabapentinoids prescribing.

Prescription opioid use and employment: A nationwide Finnish register study

BACKGROUND

The secular decline in labor market participation and the concurrent increase in opioid use in many developed countries have sparked a policy debate on the possible connection between these two trends. We examined whether the use of prescription opioids was connected to labor market outcomes relating to participation, employment and unemployment among the Finnish population.

METHODS

The working-age population (aged 19-64 years) living in Finland during the period 1995-2016 was used in the analyses (consisting of 67 903 701 person-year observations). Lagged values of prescription opioid use per capita were used as the exposure. Instrumental variables (IV) estimation method was used to identify causal effects, where opioid use per capita for the elderly (65-95-year-old) was used as an instrument for the opioid use per capita for the working-age population of the same gender, education and region.

RESULTS

Increased opioid use led to worse labor market outcomes in the long run, with the effect size of 16 % and 20 %, compared to the standard deviation of the employment and participation rates. On the contrary, in the short run, increased opioid use had positive employment effects.

CONCLUSIONS

Policymakers should take the contradictory short- and long-term effects into account while considering regulation and monitoring of opioid use. Regulating and monitoring long-term prescription opioids is crucial for reducing their negative labor market consequences.

General practice responses to opioid prescribing feedback: a qualitative process evaluation

BACKGROUND

The rise in opioid prescribing in primary care represents a significant public health challenge, associated with increased psychosocial problems, hospitalisations, and mortality. An evidence-based bimonthly feedback intervention to reduce opioid prescribing was developed and implemented, targeting 316 general practices in West Yorkshire over 1 year.

AIM

To understand how general practice staff received and responded to the feedback intervention.

DESIGN AND SETTING

Qualitative process evaluation involving semi-structured interviews, guided by Normalisation Process Theory (NPT), of primary care healthcare professionals targeted by feedback.

METHOD

Participants were purposively recruited according to baseline opioid prescribing levels and degree of change following feedback. Interview data were coded to NPT constructs, and thematically analysed.

RESULTS

Interviews were conducted with 21 staff from 20 practices. Reducing opioid prescribing was recognised as a priority. While high achievers had clear structures for quality improvement, feedback encouraged some less structured practices to embed changes. The non-prescriptive nature of the feedback reports allowed practices to develop strategies consistent with their own ways of working and existing resources. Practice concerns were allayed by the credibility of the reports and positive experiences of reducing opioid prescribing. The scale, frequency, and duration of feedback may have ensured a good overall level of practice population reach.

CONCLUSION

The intervention engaged general practice staff in change by targeting an issue of emerging concern, and allowing adaption to different ways of working. Practice efforts to reduce opioid prescribing were reinforced by regular feedback, credible comparative data showing progress, and shared experiences of patient benefit.

The effects of an evidence- and theory-informed feedback intervention on opioid prescribing for non-cancer pain in primary care: A controlled interrupted time series analysis

BACKGROUND

The rise in opioid prescribing in primary care represents a significant international public health challenge, associated with increased psychosocial problems, hospitalisations, and mortality. We evaluated the effects of a comparative feedback intervention with persuasive messaging and action planning on opioid prescribing in primary care.

METHODS AND FINDINGS

A quasi-experimental controlled interrupted time series analysis used anonymised, aggregated practice data from electronic health records and prescribing data from publicly available sources. The study included 316 intervention and 130 control primary care practices in the Yorkshire and Humber region, UK, serving 2.2 million and 1 million residents, respectively. We observed the number of adult patients prescribed opioid medication by practice between July 2013 and December 2017. We excluded adults with coded cancer or drug dependency. The intervention, the Campaign to Reduce Opioid Prescribing (CROP), entailed bimonthly, comparative, and practice-individualised feedback reports to practices, with persuasive messaging and suggested actions over 1 year. Outcomes comprised the number of adults per 1,000 adults per month prescribed any opioid (main outcome), prescribed strong opioids, prescribed opioids in high-risk groups, prescribed other analgesics, and referred to musculoskeletal services. The number of adults prescribed any opioid rose pre-intervention in both intervention and control practices, by 0.18 (95% CI 0.11, 0.25) and 0.36 (95% CI 0.27, 0.46) per 1,000 adults per month, respectively. During the intervention period, prescribing per 1,000 adults fell in intervention practices (change -0.11; 95% CI -0.30, -0.08) and continued rising in control practices (change 0.54; 95% CI 0.29, 0.78), with a difference of -0.65 per 1,000 patients (95% CI -0.96, -0.34), corresponding to 15,000 fewer patients prescribed opioids. These trends continued post-intervention, although at slower rates. Prescribing of strong opioids, total opioid prescriptions, and prescribing in high-risk patient groups also generally fell. Prescribing of other analgesics fell whilst musculoskeletal referrals did not rise. Effects were attenuated after feedback ceased. Study limitations include being limited to 1 region in the UK, possible coding errors in routine data, being unable to fully account for concurrent interventions, and uncertainties over how general practices actually used the feedback reports and whether reductions in prescribing were always clinically appropriate.

CONCLUSIONS

Repeated comparative feedback offers a promising and relatively efficient population-level approach to reduce opioid prescribing in primary care, including prescribing of strong opioids and prescribing in high-risk patient groups. Such feedback may also prompt clinicians to reconsider prescribing other medicines associated with chronic pain, without causing a rise in referrals to musculoskeletal clinics. Feedback may need to be sustained for maximum effect.

Physiologically-based Pharmacokinetic Modeling to Assess the Impact of CYP2D6-Mediated Drug-Drug Interactions on Tramadol and O-Desmethyltramadol Exposures via Allosteric and Competitive Inhibition

Tramadol is an opioid medication used to treat moderately severe pain. Cytochrome P450 (CYP) 2D6 inhibition could be important for tramadol, as it decreases the formation of its pharmacologically active metabolite, O‐desmethyltramadol, potentially resulting in increased opioid use and misuse. The objective of this study was to evaluate the impact of allosteric and competitive CYP2D6 inhibition on tramadol and O‐desmethyltramadol pharmacokinetics using quinidine and metoprolol as prototypical perpetrator drugs. A physiologically based pharmacokinetic model for tramadol and O‐desmethyltramadol was developed and verified in PK‐Sim version 8 and linked to respective models of quinidine and metoprolol to evaluate the impact of allosteric and competitive CYP2D6 inhibition on tramadol and O‐desmethyltramadol exposure. Our results show that there is a differentiated impact of CYP2D6 inhibitors on tramadol and O‐desmethyltramadol based on their mechanisms of inhibition. Following allosteric inhibition by a single dose of quinidine, the exposure of both tramadol (51% increase) and O‐desmethyltramadol (52% decrease) was predicted to be significantly altered after concomitant administration of a single dose of tramadol. Following multiple‐dose administration of tramadol and a single‐dose or multiple‐dose administration of quinidine, the inhibitory effect of quinidine was predicted to be long (≈42 hours) and to alter exposure of tramadol and O‐desmethyltramadol by up to 60%, suggesting that coadministration of quinidine and tramadol should be avoided clinically. In comparison, there is no predicted significant impact of metoprolol on tramadol and O‐desmethyltramadol exposure. In fact, tramadol is predicted to act as a CYP2D6 perpetrator and increase metoprolol exposure, which may necessitate the need for dose separation.

Quantifying prescribed high dose opioids in the community and risk of overdose

Background

Opioid prescribing for a range of health issues is increasing globally. The risk of fatal and non-fatal overdose is increased among people prescribed strong opioids: in high doses in the context of polypharmacy (the use of multiple medications at the same time), especially with other sedatives; and among people with multiple morbidities including cardiorespiratory, hepatic and renal conditions. This study described and quantified the prescribing of strong opioids, comorbidities and other overdose risk factors among those prescribed strong opioids, and factors associated with high/very high opioid dosage in a regional health authority in Scotland as part of a wider service improvement exercise.

Methods

Participating practices ran searches to identify patients prescribed strong opioids and their characteristics, polypharmacy, and other overdose risk factors. Data were anonymised before being analysed at practice and patient-level. Morphine Equivalent Doses were calculated for patients based on drug/dose information and classed as Low/Medium/High/Very High. Descriptive statistics were generated on the strong opioid patient population and overdose risk factors. The relationship between the prescribing of strong opioids and practice/patient-level factors was investigated using linear and logistic regression models.

Results

Eighty-five percent (46/54) of GP practices participated. 12.4% (42,382/341,240) of individuals in participating practices were prescribed opioids and, of these, one third (14,079/42,382) were prescribed strong opioids. The most common comorbidities and overdose risk factors among strong opioid recipients were pain (67.2%), cardiovascular disease (43.2%), and mental health problems (39.3%). There was a positive significant relationship between level of social deprivation among practice caseload and level of strong opioid prescribing (p < 0.001). People prescribed strong opioids tended to be older (mean 59.7 years) and female (8638, 61.4%) and, among a subset of patients, age, gender and opioid drug class were significantly associated with prescribing of High/Very High doses.

Conclusions

Our findings have identified a large population at potential risk of prescription opioid overdose. There is a need to explore pragmatic models of tailored interventions which may reduce the risk of overdose within this group and clinical practice may need to be tightened to minimise overdose risk for individuals prescribed high dose opioids.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11162-4.

Trends in strong opioid prescribing in Ireland: A repeated cross-sectional analysis of a national pharmacy claims database between 2010 and 2019

PURPOSE

Significant increases in opioid utilisation have been reported in many countries in recent decades. This study investigated strong opioid prescribing in Irish General Medical Services (GMS) patients over a 10-year period.

METHODS

A retrospective repeated cross-sectional analysis of a national pharmacy claims database between January 2010 and December 2019 was conducted. Strong opioid prescribing in GMS patients was evaluated, including by route of administration, age (16-64 years and ≥65 years) and gender. Measures of consumption included prescribing prevalence and defined daily dose (DDD)/1000 population/day. Prevalence ratios (PRs) with 95% confidence intervals (CIs), and percentage and absolute changes were determined.

RESULTS

Strong opioid prescribing prevalence increased from 14.43% in 2010 to 16.28% in 2019, with the greatest increase in the ≥65 years age group. Tramadol was the most frequently prescribed product, constituting 63.9% of total strong opioid prescribing. The prescribing prevalence of oxycodone increased from 0.95% in 2010 to 2.68% in 2019 (PR 2.81, 95% CI 2.76, 2.87), with steep increases in oxycodone-naloxone since it became available (PR 5.23, 95% CI 4.98, 5.50). The prescribing prevalence of tapentadol increased from 0.18% to 1.58% between 2012 (first complete year available for reimbursement) and 2019 (PR 8.79, 95% CI 8.43, 9.16). Strong opioid prescribing was highest in females aged ≥65 years.

CONCLUSIONS

This study found an overall increase in strong opioid prescribing in Ireland between 2010 and 2019, particularly in older adults. Tramadol was the most frequently prescribed product, with oxycodone and tapentadol prescribing increasing markedly over the study period.

Trends in long-term opioid prescriptions for musculoskeletal conditions in Australian general practice: a national longitudinal study using MedicineInsight, 2012-2018

OBJECTIVE

Describe trends and patterns in long-term opioid prescriptions among adults with musculoskeletal conditions (MSK).

DESIGN

Interrupted time-series analysis based on an open cohort study.

SETTING

A representative sample of 402 Australian general practices contributing data to the MedicineInsight database.

PARTICIPANTS

811 174 patients aged 18+ years with an MSK diagnosis and three or more consultations in any two consecutive years between 2012 and 2018. Males represented 44.5% of the sample, 28.4% were 65+ years and 1.9% were Aboriginal or Torres Strait Islanders.

PRIMARY AND SECONDARY OUTCOME MEASURES

Annual prevalence and cumulative incidence (%) of long-term opioid prescribing (3+ prescriptions in 90 days) among patients with an MSK. Average duration of these episodes in each year between 2012 and 2018.

RESULTS

The prevalence of long-term opioid prescribing increased from 5.5% (95% CI 5.2 to 5.8) in 2012 to 9.1% (95% CI 8.8 to 9.7) in 2018 (annual change OR 1.09, 95% CI 1.08 to 1.09), but a slightly lower incidence was observed in 2018 (3.0% vs 3.6%-3.8% in other years; annual change OR 0.99, 95% CI 0.98 to 0.99). The incidence was between 37% and 52% higher among practices located in rural Australia or lower socioeconomic areas. Individual risk factors included increasing age (3.4 times higher among those aged 80+ years than the 18-34 years group in 2012, increasing to 4.8 times higher in 2018), identifying as Aboriginal or Torres Strait Islander (1.7-1.9 higher incidence than their peers), or living in disadvantaged areas (36%-57% more likely than among those living in wealthiest areas). Long-term opioid prescriptions lasted in average 287-301 days between 2012 and 2016, reducing to 229 days in 2017 and 140 days in 2018. A longer duration was observed in practices from more disadvantaged areas and females in all years, except in 2018.

CONCLUSIONS

The continued rise in the prevalence of long-term opioid prescribing is of concern, despite a recent reduction in the incidence and duration of opioid management.

Challenges in the management of pain in hospital patients with opioid use disorder

This article explores the challenges and barriers to the effective nursing management of pain in patients with a history of opioid use disorder. It also identifies recommendations for improving patient care and possible areas for further research. The author examined the relevant literature, which revealed that patients with opioid use disorder may experience stigmatisation by nurses; such negative attitudes are often in conflict with nurses' professional and ethical duties. This issue is compounded by a lack of knowledge and understanding of dependence, addiction and withdrawal. It was also identified that patients often recognise the effects of stigma and this can cause resentment, frustration and anxiety, in some cases leading to aggressive or disruptive behaviours that reinforce negative stereotypes of people who use opioids. A breakdown in the nurse-patient relationship can result in suboptimal pain management in this often-marginalised patient group. Therefore, effective pain management relies on a nurse-patient relationship that minimises anxiety, as well as multidisciplinary team collaboration.

Determinants of prescription opioid use: population-based evidence from Finland

BACKGROUND AND AIMS

Previous studies have shown that prescription opioid use is more common in socio-economically disadvantaged communities in the United States. This study examined the area and individual-level determinants of prescription opioid use in Finland during the period 1995-2016.

DESIGN

Logistic regression analysis using nation-wide data on filled opioid-related prescriptions dispensed at Finnish pharmacies and covered by National Health Insurance. Opioid consumption was linked, using personal identification codes, to population-based data maintained by Statistics Finland, which records individual background and area-level characteristics.

SETTING AND PARTICIPANTS

Working-age population aged between 15 and 64 years in Finland during the periods 1995-2007 (n = 4 315 409) and 2009-16 (n = 4 116 992).

MEASUREMENTS

Annual prescription opioid use was measured using defined daily doses (DDD) and whether people used opioids during a year.

FINDINGS

Prescription opioid use increased in Finland from 1995 to 2016 (from less than 1 to 7%), but the increase was explained by the change in the treatment of codeine-based opioids in National Health Insurance. The area-level unemployment rate was positively correlated with the share of opioid users at the municipal level (r = 0.36; P < 0.001). In comparison with being employed, being outside the labour force was associated with increased opioid use in 1995-2007 [odds ratio (OR) = 2.22, 95% confidence interval (CI) = 2.10-2.36] and non-codeine opioid use in 2009-16 (OR = 2.16, 95% CI = 2.06-2.27), but not with codeine opioid use in 2009-16.

CONCLUSIONS

Prescription opioid use in Finland appears to be more common among low socio-economic status people, similar to the United States and the United Kingdom.

Association of socioeconomic deprivation with opioid prescribing in primary care in England: a spatial analysis

BACKGROUND

The increasing trends in opioid prescribing and opioid-related deaths in England are concerning. A greater understanding of the association of deprivation with opioid prescribing is needed to guide policy responses and interventions.

METHODS

The 2018/2019 English national primary care prescribing data were analysed spatially. Prescribing of opioids in general practice was quantified by defined daily doses (DDD) and attributed to 32 844 lower layer super output areas (LSOAs), the geographical units representing ~1500 people. Linear regression was used to model the effect of socioeconomic deprivation (quintiles) on opioid prescribing while accounting for population demographics and the prevalence of specific health conditions. Adjusted DDD estimates were compared at each deprivation level within higher organisational areas (Clinical Commissioning Groups, CCGs).

RESULTS

In total, 624 411 164 DDDs of opioids were prescribed. LSOA-level prescribing varied between 1.7 and 121.04 DDD/1000 population/day. Prescribing in the most deprived areas in the North of England was 1.2 times higher than the national average for areas with similar deprivation levels and 3.3 times higher than the most deprived areas in London. Prescribing in the most deprived areas was on average 9.70 DDD/1000 people/day (95% CI 9.41 to 10.00) higher than the least deprived areas. Deprivation-driven disparities varied between individual CCGs. In the most unequal CCG, prescribing in the most deprived areas was twice that in the least deprived areas.

CONCLUSION

Opioid prescribing varied substantially across England and deprivation was strongly associated with prescribing. This paper provides evidence for guiding policy interventions and allocation of resources to areas with the highest levels of opioid prescribing.

Associations between socioeconomic deprivation and pharmaceutical prescribing in primary care in England

BACKGROUND

Socioeconomic deprivation is associated with health inequality. Previous studies have described associations between primary care prescribing rates and deprivation for individual drugs or drug classes. We explore the correlation between socioeconomic deprivation and the rate of prescribing of individual pharmaceutical drugs, and drug classes, in primary care in England, to identify prescribing inequalities that would require further investigation.

METHODS

In this cross-sectional study, national primary care prescribing data, by primary care practice, were retrieved for the calendar year 2019 in England. Socioeconomic deprivation was quantified using the Index of Multiple Deprivation (IMD) score. Correlations were calculated using Spearman's rank correlation coefficient (ρ), adjusting for practice list size and demographics, with a Bonferroni-corrected p value threshold of 5×10^-5.

RESULTS

We included 1.05 billion prescription items dispensed from 6896 England practices. 142/206 (69%) drug classes and 505/774 (65%) drugs were significantly correlated with IMD score (p<5×10^-5). Of the 774 included drugs, 31 (4%) were moderately positively associated with IMD score (ρ>0.4). Only one was moderately negatively correlated with IMD score (ρ<-0.4), suggesting higher prescribing rates in more affluent areas. The drug classes most strongly associated with IMD score included opioid and non-opioid analgesics, antipsychotics and reflux medications. Drug classes most strongly associated with affluence included epinephrine, combined oral contraceptives and hormone replacement therapy.

CONCLUSION

We identify novel associations of prescribing with deprivation. Further work is required to identify the underlying reasons for these associations so that appropriate interventions can be formulated to address drivers of inequality.

Current status of opioid epidemic in the United Kingdom and strategies for treatment optimisation in chronic pain

The increase in opioid prescriptions in the United States has been accompanied by an increase in misuse as well as overdose and toxicity related morbidity and mortality. However, the extent of the increased opioid use, including misuse in the United Kingdom, currently remains less debated. Recent studies in the United Kingdom have shown a rise in opioid use and attributed deaths, particularly in areas with higher deprivation. There are also large variations amongst the devolved nations; Scotland has the highest drug-related deaths and year-on-year increase within Europe. Better clinical guidelines that can enable person-centred management of chronic pain, medicines optimisation, and early diagnosis and treatment of opioid use disorder are crucial to addressing opioid-related morbidity and mortality in the United Kingdom.

Examining opioid prescribing trends for non-cancer pain using an estimated oral morphine equivalence measure: a retrospective cohort study between 2005 and 2015

Background

Over the past 20 years prescription of opioid medicines has markedly increased in the UK, despite a lack of supporting evidence for use in commonly occurring, painful conditions. Prescribing is often monitored by counting numbers of prescriptions dispensed, but this may not provide an accurate picture of clinical practice.

Aim

To use an estimated oral morphine equivalent (OMEQ_e) dose to describe trends in opioid prescribing in non-cancer pain, and explore if opioid burden differed by deprivation status.

Design & setting

A retrospective cohort study using cross-sectional and longitudinal trend analyses of opioid prescribing data from Welsh Primary Care General Practices (PCGP) took place. Data were used from the Secure Anonymised Information Linkage (SAIL) databank.

Method

An OMEQ_e measure was developed and used to describe trends in opioid burden over the study period. OMEQ_e burden was stratified by eight drug groups, which was based on usage and deprivation.

Results

An estimated 643 436 843 milligrams (mg) OMEQ_e was issued during the study. Annual number of prescriptions increased 44% between 2005 and 2015, while total daily OMEQ_e per 1000 population increased by 95%. The most deprived areas of Wales had 100 711 696 mg more OMEQ_e prescribed than the least deprived over the study period.

Conclusion

Over the study period, OMEQ_e burden nearly doubled, with disproportionate OMEQ_e prescribed in the most deprived communities. Using OMEQ_e provides an alternative measure of prescribing and allows easier comparison of the contribution different drugs make to the overall opioid burden.

An evaluation of online discussion relating to nonmedical use of prescription opioids within the UK

AIM

To identify and describe the nature of online discussion relating to prescription opioids within the UK.

METHODS

We performed analysis of posts originating in the UK related to buprenorphine, hydrocodone, oxycodone and tramadol using Social Studio, a web-monitoring platform. The study included posts published between January 2014 and December 2016. The data were cleaned to produce a final dataset consisting only of substantive mentions, which were then categorised by defined themes.

RESULTS

The final dataset included a total of 17 361 substantive mentions (2936 buprenorphine, 2894 hydrocodone, 3826 oxycodone and 7705 tramadol). The most common theme for all 4 drugs was sharing experience or opinion comprising over 90% of mentions for each drug, while discussion related to polysubstance use was present in >1/4 of mentions across drug substances. Mentions related to diversion were more common for hydrocodone and oxycodone (8.1% [6.3-10.1 95% confidence interval] and 7.8% [6.5-9.2], respectively) than buprenorphine or tramadol (4.1 and 3.9% [3.5-4.3], respectively).

CONCLUSION

This investigation shows that there is substantial online discussion relating to a variety of nonmedical use (NMU) behaviours of prescription opioids within the UK, including for hydrocodone, which is not medically available. Web monitoring provides useful data and merits future investigation; this could include expansion to other categories of drugs and a more in-depth analysis of motivations behind NMU, both of which could add timely evidence regarding the current situation in the UK and help inform public health interventions for NMU of prescription drugs.

The associations between loneliness, social exclusion and pain in the general population: A N=502,528 cross-sectional UK Biobank study

Chronic pain presents a huge burden for individuals and society and evidence suggests intrinsic links with loneliness, social exclusion and sleep. Research examining how these factors interact is warranted. We aimed to explore the relationships between social exclusion, loneliness, acute and chronic pain, and the influence of poor sleep, in the general UK population. A cross-sectional analysis of UKBiobank participants with baseline data for acute and chronic pain, loneliness and sleep. Principal components analysis (PCA) used data relating to social isolation and deprivation to establish a composite measure of social exclusion. Binary logistic regression analyses were performed. 502,528 UKBiobank participants (mean age = 56.6years, 54.4%female, 94.6%white) were included in the analysis. PCA suggested three social exclusion factors "social participation", "individual deprivation" and "area deprivation". Loneliness significantly predicted acute (OR:1.887; 95%CI1.857-1.917) and chronic pain (OR:1.843; 95%CI1.816-1.870). Each social exclusion factor alone and in combination significantly predicted pain with largest effects for individuals scoring high on all social exclusion factors, for acute (OR:2.087; 95%CI2.026-2.150) and chronic (OR:2.314; 95%CI2.249-2.380) pain. Coefficients remained statistically significant when models were adjusted for demographics and sleep. Social exclusion (as a multifaceted construct) and loneliness are associated with an increased prevalence of acute and chronic pain. Poor sleep has a potential mediating effect on these associations. Exploration of the incidence of pain in loneliness and social exclusion in the general population is warranted. From a public health perspective these findings could be used to design social interventions to prevent or manage pain and mitigate social exclusion.

The link between unemployment and opioid prescribing. An instrumental variable approach using evidence from England

BACKGROUND

Unemployment has been associated with chronic pain, which is often treated with prescription opioids. Opioid mortality has been included in the so-called category of 'deaths of despair' due to the role of lack of opportunity. While previous studies have found an association between unemployment and opioids, the relationship is endogenous and examining any effect is challenging.

OBJECTIVE

The objective of this paper is to study the association between unemployment and opioid prescribing in England.

DATA AND METHODS

We used data from the GP prescribing database in England for the period 2011-2017 and followed ordinary least squares (OLS) and Instrumental Variable econometric approaches, controlling for other confounders. We used the number of foreign direct investment projects and the number of registered companies as instruments for unemployment, taking population size into account.

RESULTS

The OLS model suggests that an increase in the unemployment rate by 1 percentage point is associated with 0.017 additional opioid defined daily doses per capita-a 0.9% increase compared with the mean of 1.745. According to the instrumental variable model, an increase in unemployment by 1 percentage point leads to an increase in the number of opioid doses prescribed per capita by between 0.315 and 0.437, which constitutes a 18-25% increase compared with the mean of 1.745.

CONCLUSIONS

Unemployment appears to have an impact on opioid prescribing volume in England. This reveals yet another negative effect of unemployment on health. Relevant labour market policies may play a protective role with regards to opioid use.

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.