Elsevier

The Lancet Psychiatry

Volume 6, Issue 2, February 2019, Pages 140-150
The Lancet Psychiatry

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

https://doi.org/10.1016/S2215-0366(18)30471-1Get rights and content

Summary

Background

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

Methods

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

Findings

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

Interpretation

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

Funding

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

Introduction

Opioids are commonly and appropriately prescribed to reduce the intensity of acute, end-of-life, and cancer pain. However, they can cause harm such as addiction and abuse, particularly at higher doses.1, 2 The UK has seen a rising number of opioid-related deaths,3 while the USA has severely restricted access to prescribed opioids.4 Concerns have particularly been raised about the use of strong opioids in chronic pain, for which there is little evidence of clinical benefit.5

There has been a call for greater monitoring of opioid prescribing in the UK.6 Guidelines released in 2010 promoted a cautious approach to any planned long-term prescribing of opioids.7 The Opioids Aware resource, launched in 2016, was formed through collaborations among many of the UK's relevant major regulatory bodies, and gives guidance about the hazards associated with opioid prescribing.8

Several reports have been published about trends in non-cancer opioid prescribing in the UK National Health Service (NHS), with research to date examining only a subset of treatments, practices, and conditions.9, 10 For example, a widely reported paper explored prescribing trends in the Clinical Practice Research Datalink (CPRD) up to 2015;6 however, this study did not account for opioid strength, analysed only the five most commonly prescribed drug–dose pairs in detail, and is likely to be unrepresentative of the full picture. A study from 2018 reported increased opioid prescribing for a limited period from 2010 to 2014.11

We therefore aimed to use the full NHS England primary care prescribing dataset to assess trends and variation in prescribing of opioids in primary care from 1998 to 2018 robustly and comprehensively, and to assess factors associated with high-dose opioid prescribing behaviour in general practices. We also provide an open tool at OpenPrescribing.net where readers can find the latest data about opioid prescribing for each of England's general practices and clinical commissioning groups (CCGs).

Research in context

Evidence before this study

Concerns have been raised about the use of strong opioids and at high doses, especially in management of chronic pain; better monitoring and audit has been advocated. We reviewed the literature published in English on PubMed describing the trends and variation in opioid prescribing for chronic non-cancer pain in the UK since Jan 1, 2010, onwards. We screened abstracts for relevance after using combinations of the search terms “opioid” AND/OR “opiate”, “prescribing”, “chronic pain”, and “NHS” AND/OR “UK”. We also reviewed relevant reports from public bodies. The consensus is for an increase in prescribing of opioids in primary care in England, but most data are several years out of date at publication and very few correct for opioid strength or analyse high-dose prescriptions separately. Few publications cover the entire country or contain robust statistical analyses. None provides detailed data or tools to allow readers to investigate detailed prescribing information for their local area.

Added value of this study

There has been a substantial increase in opioid prescribing in the National Health Service (NHS) in England between 1998 and 2016; failing to account for the different potencies of opioid being prescribed would underestimate this increase by a factor of 3·7. We provide detailed prescribing data at the individual practice level, available to all through an interactive online tool at OpenPrescribing.net.

Implications of all the available evidence

Our study provides a framework for monitoring of primary care opioid prescribing in routinely available data and provides a tool for anyone to use for further research, such as local audits and improvement projects. Future work with patient-level data could reveal more detailed high-dose opioid prescribing patterns.

Section snippets

Data sources and preparation

We used two sources of data: monthly practice-level data covering October, 2010, to August, 2018; and annual prescription cost analysis data, aggregated nationally, covering 1998 to 2017.

The monthly prescribing datasets published by NHS Digital contain one row for each different medication and dose, in each prescribing organisation in NHS primary care in England, describing the number of prescriptions issued and the total cost. These data are sourced from community pharmacy claims data and

Results

From the practice-level data available between October, 2010, and August, 2018, 8123 standard general practices were included. For analyses relating to the latest 6 months (7194 practices), we excluded practices with a current status of closed (n=0) or dormant (n=166) according to NHS Digital organisation datasets, and those with non-standard CCG codes (n=1), leaving 7026 practices included from all 195 CCGs. All prescription cost analysis data were extracted successfully.

Between 1998 and 2016,

Discussion

In this retrospective database study, we found a substantial increase in opioid prescribing between 1998 and 2016. We also found that measuring opioid prescribing in terms of number of items, without correcting for OME, would underestimate the true increase in prescribing between 1998 and 2016 by a factor of 3·7 (34% vs 127%). We report wide variation in opioid prescribing across general practices and CCGs in England, particularly in costs, but with relatively little change in variation over

Data sharing

Complete codes are provided online.

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