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

John Bailey; Simon Gill; Rob Poole

doi:10.3399/BJGPO.2021.0217

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Table 1. UK studies of opioid prescribing in primary care

Study	Study period	Location	Study population	Findings
NTA (2011)¹	1991–2009	England	All prescriptions	Five-fold increase in prescribing opioids.Regional variations in prescribing.
Ruscitto et al (2015)⁴⁶	1995–2010	Tayside	Primary care	Increase in opioid prescribing.Larger increase in “strong”^a opioid prescribing.Associated factors: polypharmacy, social deprivation.
Curtis et al (2019)²	1998–2018	England	Primary care	Increases in prescribing between 1998 and 2016.Increase in ME amount prescribed much greater.Prescriptions decreased after 2016.Associated factor: geographical variation.
Zin et al (2014)¹³	2000–2010	England	Primary care	“Huge” increase in “strong”^a opioid prescribing.Majority (88%) for non-cancer pain.
Cartagena Farias et al (2017)³⁵	2000–2015	England	Primary careNon-cancer pain	Increasing numbers of people prescribed opioids.Prescribing for longer periods.Associated factors: age, social deprivation, regional variation.
Bedson et al (2016)⁴⁸	2002–2013	England	Primary careMusculoskeletal pain	Long-term prescribing increased to 2009; slight decrease after 2011.Increased prescribing of long-acting opioids.
Green et al (2012)⁴⁹	2004-2007(?)^b	North Staffordshire	Primary careJoint painAged >50	Factors associated with increased rates of prescription.Factors associated with “strong”^a opioid use.
Foy et al (2016)³³	2005–2012	West Yorkshire	Primary careNon-cancer pain	Prescribing of weaker opioids doubled.Six-fold increase in “stronger”^a opioid prescribing.Patient and prescriber factors associated with stepping up to “stronger” opioids.
Davies et al (2019)¹¹	2005–2015	Wales	Primary careNon-cancer pain	Large increase in prescribing of “strong”^a opioids.Associated factors: age, social deprivation, anxiety or depression diagnosis.
Jani et al (2020)⁵⁰	2006–2017	England	Primary care	Increased prescribing of opioids: codeine, morphine, tramadol, oxycodone.Initiated high doses tend to be maintained.Associated factors: social deprivation, regional variation, polypharmacy.
Mordecai et al (2018)³⁴	2010–2014	England	Primary care	Increase in amount (in ME) prescribed.Associated factors: social deprivation; regional variation.
Ponton & Sawyer (2018)³⁶	2012(?)^b	South East England	Primary carePatients prescribed high doses	Identified patients prescribed doses ≥120 mg ME of “strong”^a opioids as candidates for specialist input.
Ashaye et al (2018)⁵¹	2011–2012	London and Midlands	Primary careMusculoskeletal pain	Long-term prescribing common.Possible overprescribing in more than a quarter of patients receiving “strong”^a opioids.
Public Health England (2019)³²	2015–2018	England	Primary care	Prescriptions and proportion of population prescribed opioids declining from historically high rates.High rates of long-term prescribing.Associated factor: social deprivation, polypharmacy.
Bastable & Rann (2019)³⁷	2018	East England	Primary carePatients prescribed high doses	Identified patients prescribed opioid doses ≥120 mg ME.Co-prescribing of Z-drugs, benzodiazepines, and gabapentinoids.

ME = Morphine equivalent..
^a Drugs categorised as “strong” vary between studies, but always include morphine, oxycodone, and fentanyl.
^b This is estimated from the published text, which does not indicate the data collection period.

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Table 2. Opioid prescribing in Practice A and Practice B in the index week 2017

	Practice A	Practice B	Both practices
Number of patients in practice (all ages)	14 355	8486	22 841
Prescriptions for opioids: including compound drugs	914	734	1648
non-compound drugs	389	275	664
Patients prescribed opioids: including compound drugs	821 (5.7%)^a	667 (7.9%)^a	1488 (6.5%)^a
non-compound drugs	337 (2.3%)	246 (2.9%)	583 (2.6%)
Patients with estimated daily dose ≥120 mg ME	34^b (2.37)^c	19 (2.24)^c	53 (2.32)^c
as above + use for more than 1 year	25 (1.74)	14 (1.65)	39 (1.71)
Patients with dose ≥60 mg & <120 mg ME in one drug	28^d (1.95)	21 (2.47)	49 (2.15)
as above + other opioid(s)	15 (1.04)	4 (0.47)	19 (0.83)

^a% of all practice patients prescribed these drugs. ^bIn this practice there were an additional 4 patients with a cancer diagnosis. ^cNumber per thousand patients. ^dIn this practice there was 1 additional patient with a cancer diagnosis.
Results in bold are the main findings of the study.

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Table 3. Longitudinal high-dose prescribing data from Practice A

	2017	2018	2019	2020	2021
Registered patients	14 355	14 584	14 797	15 809	16 140
≥60<120 mgME	27 (1.88)^a	25 (1.71)^a	24 (1.62)^a	23 (1.45)^a	24 (1.49)^a
≥120 mgME	34 (2.37)^a	37 (2.54)^a	37 (2.50)^a	36 (2.28)^a	36 (2.23)^a
≥120 mgME >1 year	25 (1.74)^a	28 (1.92)^a	30 (2.03)^a	32 (2.02)^a	31 (1.92)^a

^a n per 1000 registered patients.

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Table 4. Age profile of patients prescribed LTHD opioids in the two practices in the index week 2017

	Age, years
	0–24	25–34	35–44	45–54	55–64	65–74	75–84	≥85
Practice A
Patients in age group, n	4006	1729	1735	2404	1772	1524	902	283
% of all patients in age group	28	12	12	17	12	11	6	2
Long-term high dose users, n	0	1	2	7	5	3	5	2
n/1000 patients	0	0.58	1.15	2.91	2.82	1.97	5.54	7.07
Practice B
Patients in age group, n	2632	1170	1119	1236	972	836	410	106
% of all patients in age group	31	14	13	15	11	10	5	1
Long-term high dose users, n	0	2	4	3	3	0	3	0
n/1000 patients	0	1.71	3.57	2.43	3.09	0	7.32	0
Combined
Patients in age group, n	6638	2899	2854	3640	2744	2360	1312	389
% of all patients in age group	29	13	12	16	12	10	6	2
Long-term high dose users, n	0	3	6	10	8	3	8	2
n/1000 patients	0	1.03	2.10	2.75	2.91	1.27	6.10	5.14

Supplementary Data

Bailey_BJGPO.2021.0217_Supp.pdf -
Supplementary material is not copyedited or typeset, and is published as supplied by the author(s). The author(s) retain(s) responsibility for its accuracy.