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.

Historical Review: Opiate Addiction and Opioid Receptors

Substance use disorders (SUDs), defined as a collection of symptoms including tolerance and withdrawal, are chronic illnesses characterized by relapse and remission. In the United States, billions of dollars have been lost due to SUDs. In the past 30 years, effective medications and behavioral interventions have played a major role in preventing relapse and facilitating longer periods of abstinence. From the late 1990s to the present, the opioid epidemic or opioid crisis in the United States has raised public awareness of SUDs. Methadone, buprenorphine, and naloxone have proven their effectiveness in treating addicted individuals, and each of them has different effects on different opioid receptors. Methadone and buprenorphine target mu opioid receptors (MORs) in the brain to treat opioid dependence by reducing withdrawal and craving, whereas naloxone is an opioid antagonist used to treat opioid overdose. Mu, kappa, and delta are opioid receptor subtypes with common analgesic effects, and each also has unique effects and distribution in the brain. MORs in distinct brain regions, such as the nucleus accumbens and basolateral amygdala, trigger the euphoria and incentive properties of rewarding stimuli. Kappa opioid receptors can trigger anti-reward effects and produce dysphoric effects. Delta opioid receptors can induce anxiolytic effects. Though effective medications are available, relapse is still common due to neurobiological changes in brain pathways and tolerance of opioid receptors with repeated abuse of substances. In this article, I summarize the biological mechanisms of opioid dependence and opioid receptors and review previous articles about medications used to treat SUDs and their clinical effects.

Opiate Injection-Associated Skin, Soft Tissue, and Vascular Infections, England, UK, 1997-2016

In England, UK, hospital admissions caused by bacterial infections associated with opioid use have increased annually since 2012, after 9 years of decline, mirroring trends in overdose deaths. The increase occurred among persons of both sexes and in all age groups and suggests preventive measures need reviewing.

[The national anti-opium-smoking campaigns across the country in the Republican Period]

Anti-opium-smoking had been the key policy of successive central and local governments from the late Qing Dynasty to the Republican Period. Since the establishment of the Nanjing Provisional Government in January 1912, the Anti-opium-smoking campaign had culminated across the country. Under the support of the government, the "National Anti-Opium Association of China" and "Association of Chinese People Rejecting Opium" were established which made an important contribution to China's anti-opium-smoking campaign.Yunnan, Shaanxi, Heilongjiang, Zhejiang, Shanghai and other local governments also combined with local specific circumstances to make anti-opium-smaking policy for punishing severely the opium cultivation, trade and opium smoking, thus, the overrun of opium began to be brought under an overall control.

[The War on "Red Drugs": Anticommunism and Drug Policy in Republic of Korea, 1945-1960]

This paper investigates the discourses and policies on narcotics in Republic of Korea from 1945 to 1960. Since the Liberation the narcotic problem was regarded as the vestige of Japanese imperialism. which was expected to be cleaned up. The image of narcotic crimes as the legacy of the colonial past was turned into as the result of the Red Army's tactics to attack on the liberalist camp around the Korean war. The government of ROK represented the source of the illegal drugs as the Red army and the spy from North Korea. The anticommunist discourse about narcotics described the spies, who introduced the enormous amount of poppies into ROK and brought about the addicts, as the social evil. Through this discourse on poppies from North Korea, the government of ROK emphasized the immorality of the communists reinforcing the anticommunist regime, which was inevitable for the government of ROK to legitimize the division of Korea and the establishment of the government alone. This paper examines how the discourses and policies on narcotics in ROK was shaped and transformed from 1945 to 1960 focusing the relationship between the them and the political context such as anticommunism, Korean war, the division of Korea, and etc. This approach would be helpful to reveal the effect of the ROK's own political situation to the public health system involving the management for drugs.

Hong Kong Junk: Plague and the Economy of Chinese Things

Histories of the Third Plague Pandemic, which diffused globally from China in the 1890s, have tended to focus on colonial efforts to regulate the movement of infected populations, on the state's draconian public health measures, and on the development of novel bacteriological theories of disease causation. In contrast, this article focuses on the plague epidemic in Hong Kong and examines colonial preoccupations with Chinese "things" as sources of likely contagion. In the 1890s, laboratory science invested plague with a new identity as an object to be collected, cultivated, and depicted in journals. At the same time, in the increasingly vociferous anti-opium discourse, opium was conceived as a contagious Chinese commodity: a plague. The article argues that rethinking responses to the plague through the history of material culture can further our understanding of the political consequences of disease's entanglement with economic and racial categories, while demonstrating the extent to which colonial agents "thought through things."

Opioid substitution treatment in New Zealand: a 40 year perspective

We provide an overview of the history and philosophy of the treatment for opioid dependence, which has been dominated by methadone substitution treatment for the past 40 years in New Zealand. Although changes in approach have occurred over this time, influenced by various sociopolitical events and changing ideologies, opioid substitution treatment has still "not come of age". It remains undermined by stigma and risk concerns associated with methadone and has struggled to be accessible and attractive to illicit opioid drug users, comprehensive and integrated into mainstream health care. However, the introduction in 2012 of Pharmac-subsidised buprenorphine combined with naloxone (Suboxone) in the context of an emerging trend towards a broader recovery and well-being orientation could signal a new era in treatment. The availability of buprenorphine-naloxone may also facilitate a further shift in treatment from primarily siloed specialist addiction services to integrated primary care services. This shift will help reduce stigma, promote patient self-management and community integration and align opioid substitution treatment with treatment for other chronic health conditions such as diabetes and asthma.

[Opium alcaloids in toxicological medico-legal practice of Department of Forensic Medicine, Jagiellonian University Medical College]

Most likely, opium was the first narcotic substance discovered at the dawn of mankind. Contemporary drug abuse predominantly poses a social and clinical problem and encompasses among other aspects emergency procedures in cases of intoxication and treatment of addictions. On the other hand, this is also a problem of the judicial system, which implements the rule of apt punishment in criminal cases (rapes, robberies, drivers, production and trade in narcotic substances) and of the necessity of monitoring drug-associates deaths. In all drug-associated cases, investigative capabilities have increased with the introduction of extremely sensitive and specific analytical methods (GC-MS, LC/MS, HPLC/DAD) allowing for detection and identification of multi-component mixtures of xenobiotics found at low concentration levels in complex biological matrices. The history of the Krakow Department of Forensic Medicine dates back to the year 1877, since archival materials have been kept since that time. Isolated deaths resulting from morphine poisoning, mostly involving individuals employed in the health care sector, constituted the subject of medico-legal expert opinions starting at the beginning of the 20th century, but only the eighties did bring the need for multidirectional toxicological examinations of opiates and their metabolites in diversified biological and non-biological materials. The present report, in addition to the historical background of opiate addiction, discusses selected problems derived from published by Department reports on opiates, including cases of fatal intoxication, hair analysis of drug addicts in its various aspects, interactions in cases of poisoning and others.

[On the history of opium]

Most likely, opium was the first narcotic substance discovered at the dawn of humankind. The history of drug addiction is immensely rich and allows for tracing the long way humankind had to travel to reach the contemporary level of consciousness with respect to narcotic substances. A retrospective view of drug addiction that takes into consideration the historical context, while extending our knowledge, also allows for a better understanding of today's problems. The report presents elements of a retrospective view of problems associated with addiction to opium, morphine and heroin over the centuries, what is a subject of scientific interest in contemporary toxicology.

Degeneration and the origins of Mexico's war on drugs

In the early twentieth century, the concept of “degeneration” helped to turn “drugs” into a problem of national importance in Mexico. By invoking this concept, Mexico's sanitary authorities secured provisions in the Constitution of 1917 which specifically authorized a newly constituted Department of Public Sanitation to lead a nation-wide campaign against drug abuse. That Department then inaugurated Mexico's modern war on drugs when, in 1920, it declared a law governing the import and distribution of the opiates, cocaine, and marijuana nationwide. This essay examines the idea of degeneration and how it came to play this crucial role in the foundation of Mexico's modern war on drugs.

[The use of opium in Roman society and the dependence of Princeps Marcus Aurelius]

Opium was known and frequently used in Roman society. Medical practice recognized its usefulness as an analgesic, soporific, anti-tussic or anti-diarrheic agent, as well as other currently unsupported uses with quasi-magical properties. It was additionally used as an ingredient in antidotes, panaceas and poisons. The authors present a non-exhaustive compilation of opium use according to medical doctors, writers and encyclopaedists of the time. Mythological and literary representations of the opium poppy reflected its diverse roles, being associated with prosperity and fertility, sleep, death and the underworld and with the art of medicine. Despite its free and routine use, there is no solid evidence of addiction, except the putative case of emperor Marcus Aurelius, consistently reported as one of the most likely cases of addiction to opium.

A 50-year-old woman addicted to heroin: review of treatment of heroin addiction

Heroin addiction is a complicated medical and psychiatric issue, with well-established as well as newer modes of treatment. The case of Ms W, a 50-year-old woman with a long history of opiate addiction who has been treated successfully with methadone for 9 years and who now would like to consider newer alternatives, illustrates the complex issues of heroin addiction. The treatment of heroin addiction as a chronic disease is reviewed, including social, medical, and cultural issues and pharmacologic treatment with methadone and the more experimental medication options of buprenorphine and naltrexone.

[Eradication of opium smoking in Taiwan during the Japanese colonial period (1895-1945)]

Eradication of opium smoking during the Japanese colonial period is one of the most proud medical accomplishments in Taiwan. The mission was accomplished mainly due to a governmental policy of gradual prohibition in 1897 and the establishment of the Government Center Hospital for Opium Addicts in 1930. Professor Tsungming Tu, medical director of the Government Center Hospital, was responsible for the unique medical treatment of opium addiction there. The latter consisted of an immediate withdrawal of opium smoking which was partly substituted by small amounts of morphine in gradual reduction, and at the same time special pills were given to enhance the sympathetic activity also to lessen the withdrawal symptoms. By such treatment, the habit of opium smoking could often be eliminated in a few weeks. The success rate was 46%. Shortly after the World War II, the number of opium smokers in Taiwan became negligible. In early colonial period, however, there were grass roots movements as well as private efforts by physicians of Western medicine to treat opium addiction. In 1898, the Flying Phoenix Society which was a laymen organization worshipping deities began to use supernatural power to force the addicts to stop opium smoking. More than thirty thousand were enlisted and the success rate was 58%. In 1908, the enthabitual treatment in a private correction infirmary called 'Newmatou' consisted of a substitute treatment using morphine to replace opium and a gradual reduction in morphine dosage afterwards. All addicts were hospitalized until treatment goal was achieved. Among 55 addicts thus treated, 53 (96%) were ridded of opium smoking habit. The treatment method was almost identical to that employed by Professor Tu. Another physician, Dr. Ching-yue Lin, who worked at the Red Cross Hospital in Taipei, also used substitute treatment, replacing opium by heroine, and obtained a success rate of 80%. Dr. Lin published his comprehensive study on opium addiction and treatment in the Journal of the Formosan Medical Association in 1908. Therefore, Dr. Tu's enthabitual treatment seemed to be not so unique. Previous treatments employed by physicians at 'Newmatou' infirmary and by Dr. Lin at the Red Cross Hospital were strikingly similar or nearly the same. This review may help us reassess the prevailing opinion regarding the history of eliminating opium smoking in Taiwan.

Francis Thompson (1859-1907): a medical truant and his troubled heart

Francis Thompson was born in 1859 in Preston and grew to manhood in Ashton-under-Lyne in Lancashire. After six years registered as a medical student at Owens College, Manchester, he set off for London to retrace the footsteps of Thomas De Quincey (1785-1859). His early experience in London followed closely that of the earlier English Opium Eater until he was rescued by Wilfrid Meynell (1852-1948) who recognized his nascent literary flair. Thompson's poetry earned him respect and reputation and his prose brought him a reasonable income, but he never weaned himself from laudanum and he died of tuberculosis in 1907. Not every truant is honoured by a lapidary inscription in his alma mater, even though he may be overlooked in an arbitrary census.

Economic manifestations of opiate addiction: evidence from historical data from colonial Indonesia

The aim of this paper is to demonstrate, using an example, the utility of historical data to illuminate important questions in the field of drug dependence research. The literature on the consumption of addictive substances often characterizes users as being one of two types: "addicts" and "casual users." An econometric characterization of the responses of opium consumers in the late-colonial Netherlands Indies to changes in the price of opium and other important variables is provided, which explicitly acknowledges the existence of different types of opium smokers, as modeled in the underlying theory. The results reveal systematic differences between the behavior of groups of high-intensity consumers and groups of low-intensity consumers. While the findings show that both groups showed similar total price elasticities, the high-intensity consumers were affected predominantly via changes in the number of users rather than in per capita consumption. In the course of the analysis, various analytic methods that are new to the field of drug dependence research are introduced.

Milk of Paradise?

One cannot have an idea of this multifaceted theme without its medical and cultural-historical background. After a history of several thousand years as a remedy and consumer good, around 1800 this poppy drug was in the focus of public attention due to Brownianism, at first as an often self-prescribed unspecific remedy against physical and mental pain. Many representatives of the early Romanticism knew it from personal experience. However, it was the publication of Thomas de Quincey's Confessions of an English Opium-Eater (1821/1822) which made it a subject of international debate in accordance with the programmatic statements of writers of that epoque and corresponding to the antibourgeois attitude of these men. It became a motif of a counter-world experience and a subject and cause of lyric-subjective reflection as well as a possible premise of poetic creativity.

Heinrich Heine and syphilis

Though Heinrich Heine died 151 years ago, the underlying illness responsible for his suffering of many years has never been fully clarified. The diagnosis put forward most frequently in retrospect was that of a venereal disease. However, this diagnosis was the result of an interpretation in disregard of the historical context. Only by evaluating and interpreting the entire source material in its historical context (Heine's complete works, his correspondence, records of conversations kept by contemporaries and prescriptions) can this diagnosis be confirmed on a reliable basis. Above all, medical records dated 1848 and their interpretation in the context of contemporary syphilis nosology and therapy show that Heinrich Heine was treated for syphilis from 1848 onward. After 8 years confinement to the proverbial 'mattress grave', Heine's death can ultimately be explained by his long-standing and well-documented abuse of opium.

75 years of opioid research: the exciting but vain quest for the Holy Grail

Over the 75-year lifetime of the British Pharmacological Society there has been an enormous expansion in our understanding of how opioid drugs act on the nervous system, with much of this effort aimed at developing powerful analgesic drugs devoid of the side effects associated with morphine--the Holy Grail of opioid research. At the molecular and cellular level multiple opioid receptors have been cloned and characterised, their potential for oligomerisation determined, a large family of endogenous opioid agonists has been discovered, multiple second messengers identified and our understanding of the adaptive changes to prolonged exposure to opioid drugs (tolerance and physical dependence) enhanced. In addition, we now have greater understanding of the processes by which opioids produce the euphoria that gives rise to the intense craving for these drugs in opioid addicts. In this article, we review the historical pathway of opioid research that has led to our current state of knowledge.

Damaged goods: return to sender. A review of the historical medical records of repatriated Chinese miners

After the Anglo-Boer (South African) War (1899-1902), there was a shortage of unskilled labor on the South African gold mines. Chinese men were imported to make up for the deficit. This article reviews the records of indentured Chinese mine workers examined for repatriation in 1905. The records tell of high proportions of social disorders, respiratory diseases, musculoskeletal disorders, opium addiction, and injury. These reflect the social and physical conditions to which these men were exposed in the mines.

History of Addiction: A UK Perspective

The level of substance misuse in Britain has fluctuated over recent centuries, reaching its nadir in the early twentieth century. Since then, the trends for alcohol and drug abuse (though not for tobacco consumption) have risen steadily. British physicians have played a major role in the emergence of the addiction concept, from the initial challenge to Galen's theories to the now widely adopted Alcohol Dependence Syndrome. While treatment has been influenced by contemporary attitudes, it has been generally underpinned by pragmatism and has avoided the punitive responses seen in other parts of the world.

Opiate addiction and the entanglements of imperialism and patriarchy in Manchukuo, 1932-45

In the Japanese colonial state of Manchukuo, opiate addiction was condemned by officials and critics alike. But the state-sponsored creation of a monopoly, opium laws, and rehabilitation programs failed to reduce rates of addiction. Further, official media condemnation of opiate addiction melded with local Chinese-language literature to stigmatise addiction, casing a negative light over the state's failure to realise its own anti-opiate agenda. Chinese writers were thus transfixed in a complex colonial environment in which they applauded measures to reduce harm to the local population while levelling critiques of Japanese colonial rule. This paper demonstrates how the Chinese-language literature of Manchukuo did not simply parrot official politics. It also delegitimised Japanese rule through opiate narratives that are gendered, consistently negative, and more critical of the state than might be expected in a colonial literature.

Historical review: Molecular and cellular mechanisms of opiate and cocaine addiction

The National Institute on Drug Abuse was founded in 1974, and since that time there have been significant advances in understanding the processes by which drugs of abuse cause addiction. The initial protein targets for almost all drugs of abuse are now known. Animal models that replicate key features of addiction are available, and these models have made it possible to characterize the brain regions that are important for addiction and other drug effects, such as physical dependence. A large number of drug-induced changes at the molecular and cellular levels have been identified in these brain areas and rapid progress is being made in relating individual changes to specific behavioral abnormalities in animal models of addiction. The current challenges are to translate this increasingly impressive knowledge of the basic neurobiology of addiction to human addicts, and to identify the specific genes that make some individuals either particularly vulnerable or resistant to addiction. In this article, I present a historical review of basic research on opiate and cocaine addiction.

Coleridge's choleras: cholera morbus, Asiatic cholera, and dysentery in early nineteenth-century England

Samuel Taylor Coleridge suffered from a variety of bowel disorders throughout his life; though a large part of his ailment was caused by his famous opium habit, he continuously sought an organic origin, and on at least two separate occasions, in 1804 and 1831-32, he ascribed his disorders to attacks of "cholera." With Asiatic cholera apparently first reaching England in late 1831, there was considerable argument among both physicians and the general public as to whether it was a distinctly new disease, or merely a severer variation of traditional English cholera, known as "cholera morbus." Coleridge took a particular interest in these discussions. In this paper, we attempt to establish the exact nature of his attacks of illness, and point to the complexities of describing and framing new diseases and bowel disorders in the early nineteenth century.

A tale of two policies: the French connection, methadone, and heroin epidemics

The law enforcement and treatment policies of the Nixon administration are often credited with ending the epidemic of heroin addiction that rose in America's cities in the 1960s. In this article it is argued that although the interventions did in fact cause a major change in heroin distribution and use, the epidemic did not end in any simple way. The decline in heroin and increase in methadone that resulted from the Nixon policies lead to a shift for many addicts in both clinical and street settings from one narcotic to another. The temporary shortage of heroin that resulted from law enforcement was quickly compensated for with methadone, as well as with new distribution systems from Southeast Asia and Mexico. In the end, the interventions caused a change in an enduring "heroin system," a change that left that system in a stronger form in terms of supply and in a situation of continuing growth in terms of the number of addicts.

History and current status of opioid maintenance treatments: blending conference session

Opiate addiction is a chronic, relapsing disorder. Left untreated, high morbidity and mortality rates are seen. Pharmacotherapies for this disorder using mu opiate agonists (methadone and levomethadyl acetate) and partial agonists have been developed in the last 40 years. Agonist pharmacotherapy with oral methadone for the treatment of opiate dependence was developed in clinical pharmacology studies at Rockefeller University by Dole, Nyswander, and Kreek. Further studies by this laboratory and others established that moderate to high dose treatment with methadone (80-120 mg) reduced or eliminated opiate use in outpatient settings with consequent reductions in morbidity and up to 4-fold reductions in mortality. Levomethadyl acetate (LAAM), a congener of methadone, is biotransformed to active metabolites responsible for its longer duration of action. The Federal Regulations regarding the dispensation of methadone and LAAM have recently been revised to facilitate the treatment of patients under a "medical maintenance" model. Future regulatory reform will likely involve the establishment of rules for "office based opioid treatment."

[The indication for heroin prescription - considerations with the historical example of the opiate addicted Swiss author Friedrich Glauser (1896 - 1938)]

Traditional indications for the prescription of opioids to addicts are continuous opioid abuse despite qualified addiction treatment or temporary substitution treatment, if temporarily detoxification is not possible due to external circumstances. These criteria are demonstrated by an historical example, the treatment of the opioid addicted Swiss author Friedrich Glauser (1896-1938). From a modern public health perspective, however, opioid abuse is mainly conceptualised as risk behaviour with aversive consequences for the individual abuser and the public. These consequences should be reduced by prescription of hygienically safe heroin. In this concept, the failure of former addiction treatment is not a necessary condition for heroin prescription. Difficulties in reaching an agreement about indications for heroin prescription are partially results of inherent contradictions between an individual centered traditional medical concept and a public health concept about the goals of opioid addiction treatment.