EXPLORING THE OPIOID PRESCRIBING PRACTICES OF GENERAL PRACTITIONERS (GPS) IN WEST AND SOUTH ESSEX, UK

Introduction:The emerging evidence in recent studies shows that Opioid use and abuse have continued to grow at a significant rate, with fatal consequences. The evidence also indicates palpable apprehension and concern over the increasing opiate/ opioid prescription numbers by General Practitioners (GPs). This present study aims to explore the opioid prescribing practices of General Practitioners (GPs) in West and South Essex. The objectives are to answer the following questions: is an opiate prescription based on any available guideline? Is opioid prescribed primarily for pain management? How many times do the GPs prescribe opioids? How long are patients on pain prescription medications? Has the GPs attended training on the use of opioid for pain management? How many years has the GPs spent working as a practitioner? Finally, these researchers believe that answers to these question will add to the knowledge base towards improving the risk-benefit balance of prescribed opiates. Methods:A short self-questionnaire was sent to all GP practices in the South and West of Essex (n=25). There was a response rate of 80 per cent (20/25). Qualitative data from the questions were analysed using thematic analysis. In addition, nominal data were analysed using descriptive statistics to summarise the results. Results:The study found that most of the GPs who participated in the survey are experienced GPs, yet the majority are not complying with prescribing guidelineand thus, overprescribes opioid for pain management. Conclusion:The overprescribing practices of opioids by GPs are affected by an absence of robust guideline on managing chronic pain. Thus, we recommendcompliance with existing guideline and consultation on managing chronic pain over 16s to producea guideline on adult pain management.

Higher opioid doses were associated with somewhat higher chronic pain and higher levels of patient-reported opioid-related psychosocial problems, control concerns and depression. [10] Chronic pain has a high prevalence globally. In America, for instance, the opioid epidemic is one of the most significant public health problems that the USA faces. A recent report by the Medical Journal Lancet shows that opioid overdose death rates have increased steadily for more than a decade and doubled in 2013-17. [11] In Europe, opioid abuse is a severe public health issue, with an estimated 1.3 million problem opioid users reported in 2012. The report added that the abuse of heroin and other illicit opioids, prescription opioid ("RxO") abuse, also represents a component of the overall opioid abuse problem. AlthoughRxOs are amongst the highestsuccessful drugs for pain management, these medications also carry the risk of potential abuse and dependence. [12] In the United Kingdom, The House of Commons Home Affairs Committee has expressed concern concerning the lack of understanding and data collection surrounding prescription drug dependence. [13] The UK Office of National Statistics (ONS) reported that 4,359 deaths resulted from drug poisoning in 2018. This is up 16 per cent from the previous year, which was the highest annual increase since records began in 1993. The ONS reported deaths amongst men increased from 89.6 per million in 2017 to 105.4 per million in 2018 -two-thirds of these were linked to the misuse of drugs. Opioids continue to be the most frequently mentioned substances on death certificates of individuals. [14] Given the role of doctors in opioid's prescription, this study will review the literature to ascertain whether doctors' prescribing practices helped fuel the opioid epidemic and the higher death rate due to opioid abuse. Thus, the literature review will be applied to this study to conduct a systematic search to find the relevant studies.
The Aim and Objectives of this paper is to add to the knowledge of General practitioners in the United Kingdom who are essential stakeholder in the battle against prescription opioid abuse. Therefore their knowledge and understanding of opioid abuse and diversion are crucial as this will go a long way in the quest for primary care evidence-based clinical interventions. This will help to reduce opioid-related morbidity and mortality. In Essex, prescription opiate dependency is on the increase, very much like the whole country, and the pressure is on the substance misuse services locally to help out as there is a lack of adequate pain management services available. This study explores the opioid prescribing practices of General Practitioners (GPs) in West and South Essex. The objectives are to ascertain: 1) whether the opiate prescription is based on any available guideline 2) whether the prescription of opioid is primarily for pain management 3) how many times the GPs prescribe opioids 4) how long are patients on pain prescription medications 5) whether the GPs attended training on the use of opioid for pain management 6) the number of years the GPs spent working as a practitioner.
Finally, the publication is expected to add to the knowledge base towards improving the risk-benefit balance of prescribed opiates. Garrard (2016) stressed that a literature review is a survey of scholarly articles and any other appropriate source to a particular issue or study area. Doing so provides a description, summary, and critical evaluation of the studies under review concerning a new research problem. A fundamental goal of literature reviewing is identifying knowledge gaps. A research gap refers to unknown or underexplored areas that have the potential for further research. [15] Also, aknowledge gap is has been described as a topic for which missing or insufficient information limits the ability of a reviewer to conclude a question. [16] In other words, when we identify a research gap, we find a direction for potentially new and exciting research. The term research problem is often used as a synonym for research gaps. A problem statement signifies a gap in the knowledgethat, when scrutinised, results in a call for action or resolution. [16] [17] This literature review aims to fill the gap in the existing literatureby generating new knowledge about the effect of beliefs and knowledge in primary care prescribed opioids in opiate dependents service users open to Tier 3 drug services in West and South Essex. This literature review's primary aim is to identify the gap in the literature that will inform the current study. To achieve these aim and objectives, these researchers needed systematically search databases. Parahoo (2006) recommends that a combination of databases leads to good search outcome. [18] The Cumulative Index to nursing and allied health Literature (CINAHL), which is recognised as a comprehensive and authoritative source for professional literature related to nursing, biomedicine, and allied health, was searched. In addition, the Elton and Stephens Co-host (EBSCOhost), Medline, and Elsevier databasecomprise a wide range of online nursing and allied healthcare academic articles that have been peer-reviewed was also searched.

Methods:-
The above databases were searched individually using identified search terms as General Practitioners (GP), management, prescription, patients, treatment, opiates and opioid. Further advanced search using Boolean operatives such, "AND", "OR" "GP" AND "prescription" AND "trend" AND "primary care" OR "Opioid" OR "dependent"were used in searching for relevant and up-to-date studies pertinent to the current research. Aveyard (2014) stressed that search terms combined with Boolean operators optimise the search process. Boolean operators organise and connect key search terms by narrowing down extracted articles using the various operator. [19] The Boolean's search terms and operators were used to limit and widen the search as appropriate and allow the literature relating to the prescription of opioid in primary care to be searched. These include search terms, which reference precisely to opiate dependents.
The database search using keywords and Boolean operatives generated so many studies, 260 to be precise. However, inclusion and exclusion criteria were carefully used to select relevant papers with full-text, scholarly (peer-reviewed) academic journal, articles written in English between 2011 to 2021. Some of the databases were also combined in searches removing duplication. For example, a Grey literature search found ten studies. Still, six were excluded because they were editorial consultation papers, primarily reports and policy documents that did not meet the inclusion and exclusion criteria. Thus, the search produced forty-five results; search limiters were used to narrow the results. Limiters consisted of the inclusion of full-text studies and studies published in the United Kingdom and primary healthcare. The limiters enable the screening out of duplicated studies, abstracts and founding of only six studies that met the inclusion and exclusion criteria.
All selected studies under review relate to opioid abuse, dependence, and societal costs of its prescription. The studies clearly presented their results and analysis, accompanied by wide-ranging arguments elaborating on their findings and acknowledging their limitations. Cicero and Ellis (2017) study show that the growth in opioid prescribing for long-term pain conditions led to more people taking opioids at higher doses. Long-term and high doses of opioids are associated with higher criminal justice costs and serious adverse events, including opioid dependence and opioid-related deaths. The study also found that the frequent prescription opioids comprise oxycodone, hydrocodone, and morphine. They also found that the common illegal opioids include fentanyl and heroin. While illegal opioids and not the focus of their study, it is essential to know that many addictions and overdose to these illicit opioids stem from prescription opioid. [20] Ashaye et al. (2018) found that of the 703 trial participants with chronic musculoskeletal pain, 413 (59 per cent) patients were prescribed opioids. Among the participants that were prescribed an opioid, the total number of prescriptions of opioids issued per year fluctuates from 1 to 52. In total, 3319 opioid prescriptions were issued over the study period, of which 53 per cent were for potent opioids (tramadol, buprenorphine, morphine, oxycodone, fentanyl and tapentadol). One-quarter of the prescription was prescribed outside of National Institute for Health and Care Excellence (NICE) guidelines. They also found that over 1.5 million people with musculoskeletal problems receive opioids, and according to guidelines, 45 per cent over-prescribed, at a loss to the NHS of £100 million per year. This cost does not include managing the side effects of opioid reliance or addiction or treating people who have overdosed. The study concluded that the long-term prescribing of opioids for chronic musculoskeletal pain is common in primary care. [21] Krieger (2018) found that opioids are either prescribed by physicians as heavy strength painkillers for intense chronic or post-surgery pain or circulated illegally for their pain-relieving effect. [22] Bohnert et al.
(2011) examined the association of maximum prescribed daily opioid dose with the risk of opioid overdose death among patients with cancer, chronic pain, acute pain, and substance use disorders. They found that for patients receiving opioid prescriptions for pain, higher opioid doses were associated with an increased risk of opioid overdose death. [23] In a cohort study, Dunn et al. (2009) examined the rates of opioid overdose and their association with the average prescribed daily opioid dose among patients receiving medically prescribed chronic opioid therapy. They found an increased risk of overdose among patients receiving medically prescribed opioids at higher dosage levels. Most opioid overdoses were medically severe, and 12 per cent were fatal. [24] A recent study involving 1,968,742 new opioid users without cancer from primary care electronic health records across the UK found that between 2006 and 2017, codeine was the most commonly prescribed opioid. There was a 5-fold increase in codeine prescriptions, a 7-fold increase in tramadol prescriptions, and a 30-fold increase in oxycodone prescriptions for non-cancer pain. When individual patient factors were taken into consideration, Yorkshire, the Humber,the North West and South-West regions of England were linked with a considerable higher risk of long-term opioid use. The study also found that only 3.5 per cent of prescribers had significantly higher prescribing practices leading to long-term use after adjusting patient factors, where they did, rates were up to 3.5 times higher than the population average. [25] In conclusion, this literature review has highlighted the association between higher prescribed opioid doses and the risk for overdose and overdose death. The finding supports the calls for action aimed at promoting the safe practice in opioid prescribing. The result is in line with the views of Dr William Shanahan, Medical Director and Clinical Director of Addictions, Priory Hospital Roehampton. He reported that opioid overdoses increased by 87 per cent to 12,000, and deaths increased by 41 per cent to 2,000 in the year. Dr Shanahan added that in 2020 50 million prescriptions for opioids were written, a 35 per cent increase over ten years. Of the 115,000 prescriptions written every day, five results in death. There are three times more deaths in the North East of the UK than in London, partly reflecting a more significant usage of opioids amongst the socially disadvantaged. Thus, these data call for an examination of practice in opioid prescribing. [26] In terms of the Research Design, the chosen approach in this study is qualitative, which enable these researchers to collect in-depth data on live experience GPs prescribing opioid for opiate dependents service users open to Tier 3 drug services in West and South Essex. Phenomenology is one of the theories associated with a qualitative methodology. Many authors define phenomenology as "the lived experience", mainly seen in topics of this nature.
[27] Phenomenology is the most suitable method for this study because it studies conscious human experiences in day-to-day life.
[28] The interpretive, qualitative approach is chosen because these researchers want to focus on individual GP's perspective from a living experience perspective.
This exploresthe opioid prescribing practices of General Practitioners (GPs) in West and South Essex. Essex Specialist Treatment and Recovery Service (Essex STaRS) is a specialised substance misuse service set within Essex Partnership University NHS Foundation Trust (EPUT). It provides a detailed assessment of clients with opioid and other addictions in the community referred by Open Road, a partnership agencythat offers psychosocial support. Part of the role by Essex Stars is to providesubstitute prescribing for opioids to achieve stabilisation and detoxification, as well as hepatitis B vaccination and Hepatitis Ctesting and referral to treatment, motivational interviewing and so on. Essex STaRScovers Essex, including Basildon, Harlow, Colchester and Chelmsford, and surrounding areas. In the South and West of Essex, Essex Stars offers assessments in Basildon and Harlow, respectively. Essex Stars and Open Road clientsengage with regular reviews and ongoing monitoring and support through close liaison with the general practitioner.
The West and South Essex, as of August 2020, has a total of 92 General Practices, from which 20 participants were randomly selected.The semi-structured interview technique was most appropriate for this study. However, all participating GPs were sent a pre-preparedself-questionnairedue to the UK Government's non-contact policy of COVID 19. For the GP who completed and returned the survey, the data from the questionnaire was then extracted and put onto the computer software package Microsoft Excel using pre-prepared spreadsheets. All data was anonymised. Practices not wishing to participate could opt-out. Data were analysed using Microsoft Excel and then displayed using tables and graphs.For example, table one shows that the data collection conformsto the ethical requirement.

Results:-
There were 20 participant GPs; of these, 12 were from the South of Essex and eight from the North of Essex. Please see Table 1 for demographic details of GP practices.  The six questions in table 2 and subsequent themes are illustrated further in figure 1 to 6 below. The use of the charts is intended to condense the same information in table 2 into easy-to-understand formats that clearly and effectively communicate the findings of this study.

Discussion:-
The literature review in this study is organised to critically analyse existing studies publications on compliance of primary care physicians (GPs) with existing opioid management guidelines,the GPs level of training in opiate prescriptions opioid prescription, the disturbing emerging trend of opiate overprescribing. Thus, this qualitative study exploresthe opioid prescribing practices of General Practitioners (GPs) in West and South Essex. The objectives are to examine compliance with opiate prescribing protocol and guideline; explore the extent to which opiate is prescribed for pain management; investigate the preponderance of opiate prescription; investigate how long patients are kept on opiate prescription; determine whether or the GPs attain training on the use of opioid for pain management and consider the practice experience of the opiate prescribing doctors.
The complaint of pain is a frequent presence at GP practices. General Practitioners see many people of various ages and backgrounds. Without clear opioid prescribing guidelines, they are faced with the difficulty of balancing managing patients with pain presentations who may be at increased risk of experiencing uncontrolled pain to those with possibly drug-seeking behaviours. Chronic primary pain cannot be accounted for by another diagnosis or where it is not the symptom of an underlying condition (this is known as chronic secondary pain). It manifests with considerable functional disability and emotional distress. Examples include widespread chronic pain and chronic musculoskeletal pain and conditions such as chronic pelvic pain. All GPs prescribed opioids for acute and chronic pain in our study, but none of the GPs prescribed opioid substitution therapy such as methadone or buprenorphine. This is, of course, a specialist prescribing, and most GPs are uncomfortable initiating the controlled drugs without specialist input and ongoing support. Keeping with some other studies looking at the prescribing patterns, the GPS had expressed concerns about their ability to prescribe opioids safely. However, just over half of the cohort of GPs in this survey felt they had good knowledge of opioid prescribing; however, 4 out of 10 GPs that responded did not have an adequate understanding of prescribing opiate management.
Similar to other studies, several of the GPs in this present study expressed concern with the adequacy of training they had received. There were 10 (50 per cent) GPs that reported the only training on pain management and use of opioids was in medical school. There was a consensus that further training was needed to increase the confidence in prescribing opioids amongst GPs.Other studies looking at the prescribing patterns of opioids by GPs have commented on the belief in the appropriateness of opioids within certain constraints. To a lesser extent, the age of the GP influences prescribing practices. In our study age of the prescriber was not a significant factor in prescribing opioids. As with other studies, there is a concern with the risk and abuse of opioids. Besides the lack of dissatisfaction with their training on pain, 50% of GPs surveyed admitted a lack of clarity on guidelines might have influenced their overprescribing. Just eightout 20 strongly agreed that their prescribing is based on available guidelines, and out of that 8, only 3GPs strongly agreed that they prescribed within the confines of available guidelines; however, 60 per cent of GP surveyed either were not sure or disagreed that they do not prescribe base on guidelines. This is disturbing proportions of GPs, and if this is a trend locally, this highlights the importance of further training of identified GPs. Even more striking is the fact that 30% admitted they are prescribing opiates but not for pain management, giving the risks of dependency, morbidity and mortality from patients on long term opiate use; this needs to urgently address through a more comprehensive national guidelines and more training for GPs at both primary care network level and maybe countywide level.
The frequency of prescribing and the length of time patients are left on their opiate prescriptions is also a source of concern identified during this survey. 60 per cent of GPs surveyed agreed or strongly agree that they leave patients on their opiate prescriptions for too long, and 55% of GPs surveyed admitted to prescribing opiates more than 20 times in a month. One obvious factor influencing overprescribing is the length of time spent working as GPs, 65 per cent of GPs surveyed have worked as GPs for 10 years or less, this iterates the need for more available workshops, courses and training for these newly qualified GPs, and possibly a requirement for their GP trainees to do a special interest or at least one workplace assessments in either an addiction service or a pain management service.
NHS ethics approval is not required as this is a service evaluation and will not generate transferable data. Service evaluation seeks to assess how well a service is achieving its intended aims. It is undertaken to benefit the people using a particular healthcare service and is designed and conducted with the sole purpose of defining or judging the current service. [29] Data have been stored and will be used in compliance with GDPR 2018. None of the data is identity revealing. Data usage is compliant with the initial purpose for which it was gathered, that is, to evaluate an intensive care course. The results of this service evaluation and recommendations made will be shared with the local primary care physicians through their primary care network (PCN) or their Clinical Commissioning Groups (CCG). It will also be available to local commissioners who commission both Public Health England and seven different CCG clinical services in Essex County.

Conclusions:-
The literature review in this study was organised to critically analyse existing studies on opioid prescription, which provides an overview of the knowledge available. The review found that doctors are overprescribing driven mainly by a lack of knowledge or usage of existing guidelines on managing chronic pain.
This survey has highlighted the emerging trend of overprescribing by local GPs in the West and South Essex GP Practices, much in keeping with observed trends nationally and possibly globally. This overprescribing is driven by a lack of knowledge or usage of available guidelines on managing chronic pain. Ashaye et al. (2018) pointed out 59 per cent in their trial of 703 participants were prescribed opioids for their chronic musculoskeletal pain, with a total of 3319 opioid prescriptions issued within the study period and 25 per cent of these prescribed outside NICE guidelines and with the study concluding that the long-term prescribing of opioids for chronic musculoskeletal pain is common in primary care. [21] There is a clear correlation between overprescribing of opiates by primary care physicians and the increasing morbidity and mortality from opiates oversedation and respiratory depression. Bohnert et al. (2011) found out that for patients receiving opioid prescriptions for pain, higher opioid doses were associated with an increased risk of opioid overdose death. [23] In their cohort study, Dunn et al. (2009) found an increased risk of overdose among patients receiving medically prescribed opioids at higher dosage levels. Most opioid overdoses were medically severe, and 12 per cent were fatal. [24] Most people with chronic pain understandably expect aprecise diagnosis and effective treatment plan; however,the complexityof their clinical presentations and the fact that GPs and specialists alike find chronic pain very challenging to manage is often not possible. This mismatch between patient expectations and treatment outcomes can affect the therapeutic relationship between healthcare professionals and patients. The potential negative consequence of this is the prescribing of ineffective but harmful drugs.
Rose et al. (2019) qualitative literature review exploring the drivers influencing over-prescribing by GPs in primary care and recommendations to reduce unnecessary prescribing [30] had similar findings with our studies. The main themes and drivers of overprescribing were GP attitudes and feelings and anxiety/fear concerning prescribing; external factors such as pressures from time, patient demands and expectation and more importantly, lack of education as the primary drivers affecting GP over-prescribing.
The King's Fund Inquiry into the Quality of General Practice specifically focused on England published was in 2011. This highlighted the need to prescribe against safety indicators developed by the Royal College of General Practitioners (GP); it further said these indicators could be as evidence of further discussions during appraisal and also as a prompt for auditing significant events. Also, it recommended that GPs adhere to their Quality and Outcomes Framework that stipulates careful assessment of medication reviews to determine if they are of high quality.
[31]The authors of this study agree with all of these recommendations, and we also recommend the following: Training of GPs in the use of local and national guidelines, these training and workshops can be at the primary care network, CCG or local practice level. GPS should have workshops in adhering to the use of the soon to be published National Institute for Health and Clinical Excellence (NICE) Guideline on managing chronic pain in the over 16s. The National Institute for Health and Clinical Excellence (NICE) has now published in April 2021 the new guideline NG 193 'Chronic pain (primary and secondary) in over 16s: assessment and management of all types of chronic pain'. In this guideline, the preferred approach in patient-centred management is the non-pharmacological management of chronic primary pain and the use of existing guidelines to manage chronic secondary pain. The GPs are now advised not to prescribe opiates in the management of new cases of chronic primary pain and consider the benefit/risk approach in their clinical judgments on patients already on existing opiates or opioids. The authors strongly advise GPs to use this new guideline and other existing guidelines in their opioid prescribing practice. GPs should also be aware of Local and other National Clinical guidelines in managing chronic secondary pain. These guidelines and the above recommendations would minimise overprescribing and reduce morbidity and mortality. The authors believe this new guideline will go a long way in giving much-needed clarity to the needless use of opioids in chronic primary pain and the importance of GPs in discussing with patients evidence-based nonpharmacological approaches.
The GPs should make the best use of other Information sources currently available to support prescribing in general practice, including General Medical Council Good Medical Practice. This is freely available from the GMC website, and printed pamphlets are sent to all doctors through the post. In addition, the British National Formulary (BNF) is freely available to all prescribers in the NHS through a website and a printed book delivered to most GP practices regularly.
Finally, we must emphasise at this juncture that the findings of this study are limited to a small sample of primary care practices and patients in Essex. Further studies with a larger sample size are required to increase the reliability and validity of the results and additional training and support for GPs in applying the evidence in practice and how to support their patients appropriately.  2011) Improving the quality of care in general practice: Report of an independent inquiry commissioned by The King's Fund, https://www.kingsfund.org.uk/sites/default/files/improving-quality-of-caregeneral-practice-independent-inquiry-report-kings-fund-march-2011_0.pdf.