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

Curtis, Helen J; Croker, Richard; Walker, Alex J; Richards, Georgia C; Quinlan, Jane

doi:10.1016/s2215-0366(18)30471-1

Cited by 163 publications

(248 citation statements)

References 23 publications

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“…Although our results show that opioids are being increasingly prescribed for chronic noncancer pain over time, this is at odds with the pattern of general opioid use in some countries. For instance, reports from Scandinavian countries suggest stable opioid dispensing in Demark, Sweden and Norway between 2006 and 2014 , whereas in the UK, the prescribing of opioids in general practice doubled between 2000 and 2012 , then began to decline from 2016 to 2017 . In the USA following reports in 2017 that the prescription of opioids is now a contributor to reduced life expectancy in the USA and their life expectancy is lower than most high‐income countries , opioid mitigation strategies may have reduced opioid prescribing.…”

Section: Discussionmentioning

confidence: 99%

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What proportion of patients with chronic noncancer pain are prescribed an opioid medicine? Systematic review and meta‐regression of observational studies

et al. 2020

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Mathieson S, ). What proportion of patients with chronic noncancer pain are prescribed an opioid medicine? Systematic review and meta-regression of observational studies (Review). J Intern Med 2020; 287: 458-474.Guidelines now discourage opioid analgesics for chronic noncancer pain because the benefits frequently do not outweigh the harms. We aimed to determine the proportion of patients with chronic noncancer pain who are prescribed an opioid, the types prescribed and factors associated with prescribing. Database searches were conducted from inception to 29 October 2018 without language restrictions. We included observational studies of adults with chronic noncancer pain measuring opioid prescribing. Opioids were categorized as weak (e.g. codeine) or strong (e.g. oxycodone). Study quality was assessed using a risk of bias tool designed for observational studies measuring prevalence. Individual study results were pooled using a random-effects model. Meta-regression investigated study-level factors associated with prescribing (e.g. sampling year, geographic region as per World Health Organization). The overall evidence quality was assessed using Grading of Recommendations Assessment, Development and Evaluation criteria. Of the 42 studies (5,059,098 participants) identified, the majority (n = 28) were from the United States of America. Eleven studies were at low risk of bias. The pooled estimate of the proportion of patients with chronic noncancer pain prescribed opioids was 30.7% (95% CI 28.7% to 32.7%, n = 42 studies, moderate-quality evidence). Strong opioids were more frequently prescribed than weak (18.4% (95% CI 16.0-21.0%, n = 15 studies, low-quality evidence), versus 8.5% (95% CI 7.2-9.9%, n = 15 studies, low-quality evidence)). Meta-regression determined that opioid prescribing was associated with year of sampling (more prescribing in recent years) (P = 0.014) and not geographic region (P = 0.056). Opioid prescribing for patients with chronic noncancer pain is common and has increased over time.

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Section: Discussionmentioning

confidence: 99%

“…The proportion of patients with chronic noncancer pain, including chronic low back pain, who are prescribed opioids is not well understood. Opioid prescribing data have been reported from individual healthcare settings . However, there are no systematic reviews that have synthesized these data in the chronic noncancer pain population.…”

Section: Introductionmentioning

confidence: 99%

What proportion of patients with chronic noncancer pain are prescribed an opioid medicine? Systematic review and meta‐regression of observational studies

et al. 2020

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“…However, the effectiveness of such USA state laws is currently under investigation [52]. In England, if every general practice prescribed highdose opioids at the same rate as the lowest decile of practices, a cost saving of £24.8 million and 543,000 fewer high-dose opioid prescriptions could be achieved in 6 months [5]. Thus, investing in resources and programs tailored to people taking opioids in primary care such as the service evaluated by Scott et al [53] could reduce the need for people on high doses to visit emergency departments.…”

Section: Implications For Practice and Policymentioning

confidence: 99%

“…High doses of opioids are associated with greater morbidity [1,2], mortality [3], and cost [4]. Despite this, the prescribing of high-dose opioids remains relatively common in high-income countries [5][6][7].…”

Section: Introductionmentioning

confidence: 99%

Factors associated with the prescribing of high-dose opioids in primary care: a systematic review and meta-analysis

Richards

Mahtani

Muthee

et al. 2020

BMC Med

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Background: The risks of harms from opioids increase substantially at high doses, and high-dose prescribing has increased in primary care. However, little is known about what leads to high-dose prescribing, and studies exploring this have not been synthesized. We, therefore, systematically synthesized factors associated with the prescribing of high-dose opioids in primary care. Methods:We conducted a systematic review of observational studies in high-income countries that used patientlevel primary care data and explored any factor(s) in people for whom opioids were prescribed, stratified by oral morphine equivalents (OME). We defined high doses as ≥ 90 OME mg/day. We searched MEDLINE, Embase, Web of Science, reference lists, forward citations, and conference proceedings from database inception to 5 April 2019. Two investigators independently screened studies, extracted data, and appraised the quality of included studies using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. We pooled data on factors using random effects meta-analyses and reported relative risks (RR) or mean differences with 95% confidence intervals (CI) where appropriate. We also performed a number needed to harm (NNT H ) calculation on factors when applicable. Results:We included six studies with a total of 4,248,119 participants taking opioids, of whom 3.64% (n = 154,749) were taking high doses. The majority of included studies (n = 4) were conducted in the USA, one in Australia and one in the UK. The largest study (n = 4,046,275) was from the USA. Included studies were graded as having fair to good quality evidence. The co-prescription of benzodiazepines (RR 3.27, 95% CI 1.32 to 8.13, I 2 = 99.9%), depression (RR 1.38, 95% CI 1.27 to 1.51, I 2 = 0%), emergency department visits (RR 1.53, 95% CI 1.46 to 1.61, I 2 = 0%, NNT H 15, 95% CI 12 to 20), unemployment (RR 1.44, 95% CI 1.27 to 1.63, I 2 = 0%), and male gender (RR 1.21, 95% CI 1.14 to 1.28, I 2 = 78.6%) were significantly associated with the prescribing of high-dose opioids in primary care.Conclusions: High doses of opioids are associated with greater risks of harms. Associated factors such as the coprescription of benzodiazepines and depression identify priority areas that should be considered when selecting, identifying, and managing people taking high-dose opioids in primary care. Coordinated strategies and services that promote the safe prescribing of opioids are needed. Study registration: PROSPERO, CRD42018088057

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“…Since the 1990s, there has been a shift in the prescribing of opioids from managing 72 acute pain and pain in terminally ill patients, to more wide-spread prescribing for a 73 wide range of long-term pain conditions (Curtis et al, 2019). 74…”

Section: Introduction (628) 68mentioning

confidence: 99%

Anxiety enhances pain in a model of osteoarthritis and is associated with altered endogenous opioid function and reduced opioid analgesia

Lillywhite

Woodhams

Watson

et al. 2020

Preprint

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Title (20 words): Anxiety enhances pain in a model of osteoarthritis and is 1 associated with altered endogenous opioid function and reduced opioid 2 analgesia 3 4 Abstract 238 words, introduction 629 words, discussion 1138 words 26 27 28 29 30 31 32 Abstract (239) 34Chronic pain states such as osteoarthritis (OA) are often associated with negative 35 affect, including anxiety and depression. This is, in turn, associated with greater 36 opioid analgesic use, potentially contributing to current and future opioid crises. We 37 utilise an animal model to investigate the neurobiological mechanisms underlying 38 increased opioid use associated with high anxiety and chronic pain. 39 Combining a genetic model of negative affect, the Wistar Kyoto (WKY) rat, and intra-40 articular injection of monosodium iodoacetate (MIA; 1mg), our model of high anxiety 41 and augmented OA-like pain behaviour mirrors the clinical problem. Effects of 42 morphine (0.5-6mg.kg -1 ) on pain behaviour and spinal nociceptive neuronal activity 43 were determined in WKY rats, and normo-anxiety Wistar rats, 3 weeks after MIA 44 injection. WKY rats developed augmented OA-like pain, and had blunted inhibitory 45 responses to morphine, when compared to Wistar rats. Potential alterations in 46 endogenous opioid function were probed via systemic blockade of opioid receptors 47 Significance Statement (116) 56 Chronic pain affects large numbers of people, and pain management often relies on 57 poorly effective opioid analgesics, the iatrogenic effects of which are increasingly 58 recognised. The endogenous opioid system -the target for exogenous opioid 59 analgesics -plays key roles in emotional affective states and pain control, but the 60 complex interplay between anxiety, chronic pain, and endogenous opioid system 61 function is challenging to study in people. Here, we have addressed this using a 62 clinically-relevant experimental model. Anxiety-like behaviour was associated with 63 increased chronic arthritis-like pain behaviour, altered opioid receptor function, and 64 reduced efficacy of opioid analgesics. We provide new evidence, which may explain 65 why chronic pain patients with comorbid high anxiety have higher opioid analgesic 66 use. 67Studies were in accordance with UK Home Office Animals (Scientific Procedures) 126 Act (1986) and ARRIVE guidelines (Kilkenny et al., 2012). A total of 183 male rats 127 were used for this study; Wistar n = 97 (Charles River, Margate, United Kingdom), & 128Wistar Kyoto n = 86 (WKY; Envigo, Bicester, United Kingdom). Males only were 129 used to reduce variability in the data, and to maintain consistency with previous 130 studies characterising this model. Wistar rats were used as the most genetically 131 similar control strain to WKY. Rats were group housed by strain in groups of 4 on a 132 12-hour light/dark cycle in a specific pathogen-free environment with ad libitum 133 access to standard rat chow and water. Treatments were randomly assigned to rats, 134 and experimenters were blinded to all treatment group...

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

Cited by 163 publications

References 23 publications

What proportion of patients with chronic noncancer pain are prescribed an opioid medicine? Systematic review and meta‐regression of observational studies

What proportion of patients with chronic noncancer pain are prescribed an opioid medicine? Systematic review and meta‐regression of observational studies

Factors associated with the prescribing of high-dose opioids in primary care: a systematic review and meta-analysis

Anxiety enhances pain in a model of osteoarthritis and is associated with altered endogenous opioid function and reduced opioid analgesia

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