Time trends and prescribing patterns of opioid drugs in UK primary care patients with non-cancer pain: A retrospective cohort study
Autoři:
Meghna Jani aff001; Belay Birlie Yimer aff001; Therese Sheppard aff001; Mark Lunt aff001; William G. Dixon aff001
Působiště autorů:
Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, United Kingdom
aff001; Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford, United Kingdom
aff002
Vyšlo v časopise:
Time trends and prescribing patterns of opioid drugs in UK primary care patients with non-cancer pain: A retrospective cohort study. PLoS Med 17(10): e32767. doi:10.1371/journal.pmed.1003270
Kategorie:
Research Article
doi:
https://doi.org/10.1371/journal.pmed.1003270
Souhrn
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.
Klíčová slova:
Cancer risk factors – Codeine – Medical risk factors – Morphine – Opioids – Pain – Primary care – Oxycodone
Zdroje
1. Smolina K, Gladstone E, Morgan SG. Determinants of trends in prescription opioid use in British Columbia, Canada, 2005–2013. Pharmacoepidemiol Drug Saf. 2016;25:553–9. doi: 10.1002/pds.3989 26947145
2. Boudreau D, Von Korff M, Rutter CM, Saunders K, Ray GT, Sullivan MD, et al. Trends in long-term opioid therapy for chronic non-cancer pain. Pharmacoepidemiol Drug Saf. 2009;18:1166–75. doi: 10.1002/pds.1833 19718704
3. Jani M, Dixon WG. Opioids are not just an American problem. BMJ. 2017;359:j5514. doi: 10.1136/bmj.j5514 29212773
4. Rudd R, Aleshire A, Zibbell J, Gladden M. Increases in drug and opioid overdose deaths—United States, 2000–2014. MMWR Morb Mortal Wkly Rep. 2016;64:1378–82.
5. Office for National Statistics. Deaths related to drug poisoning in England and Wales: 2016 registrations. Newport: Office for National Statistics; 2017 [cited 2018 Apr 23]. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2016registrations.
6. Office for National Statistics. Opioid drug deaths by cause, 1993 to 2015. Newport: Office for National Statistics; 2015 [cited 2019 Jul 22]. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/drugusealcoholandsmoking/adhocs/006149opioiddrugdeathsbycause1993to2015.
7. Curtis HJ, Croker R, Walker AJ, Richards GC, Quinlan J, Goldacre B. Opioid prescribing trends and geographical variation in England, 1998–2018: a retrospective database study. Lancet Psychiatry. 2019;6:140–50.
8. Mordecai L, Reynolds C, Donaldson LJ, de Williams ACC. Patterns of regional variation of opioid prescribing in primary care in England: a retrospective observational study. Br J Gen Pract. 2018;68:e225–33. doi: 10.3399/bjgp18X695057 29440012
9. Taylor S, Annand F, Burkinshaw P, Greaves F, Kelleher M, Knight J, et al. Dependence and withdrawal associated with some prescribed medicines. London: Public Health England; 2019.
10. Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011;171:686–91. doi: 10.1001/archinternmed.2011.117 21482846
11. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, et al. Opioid prescriptions for chronic pain and overdose. Ann Intern Med. 2010;152:85. doi: 10.7326/0003-4819-152-2-201001190-00006 20083827
12. Rhodes D. NHS accused of fuelling rise in opioid addiction. BBC News. 2018 Mar 15 [cited 2018 Apr 23]. http://www.bbc.co.uk/news/uk-england-43304375.
13. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83. doi: 10.1016/0021-9681(87)90171-8 3558716
14. UK Data Service. 2011 UK Townsend Deprivation Scores. Colchester: UK Data Service; 2011 [cited 2019 Jul 19]. https://www.statistics.digitalresources.jisc.ac.uk/dataset/2011-uk-townsend-deprivation-scores.
15. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315:1624–45.
16. Pye SR, Sheppard T, Joseph RM, Lunt M, Girard N, Haas JS, et al. Assumptions made when preparing drug exposure data for analysis have an impact on results: an unreported step in pharmacoepidemiology studies. Pharmacoepidemiol Drug Saf. 2018;27:781–8. doi: 10.1002/pds.4440 29667263
17. Snijders TAB, Bosker RJ. Multilevel analysis: an introduction to basic and advanced multilevel modeling. 2nd edition. Thousand Oaks (CA): SAGE Publications; 2012.
18. Knowles J, Frederick C. merTools: tools for analyzing mixed effect regression models. Version 0.5.0. Comprehensive R Archive Network; 2016 [cited 2020 Sep 29]. https://cran.r-project.org/web/packages/merTools/index.html.
19. Zin CS, Chen LC, Knaggs RD. Changes in trends and pattern of strong opioid prescribing in primary care. Eur J Pain. 2014;18:1343–51. doi: 10.1002/j.1532-2149.2014.496.x 24756859
20. Department of Health. Controlled drugs (supervision of management and use) regulations 2013: information about the regulations. London: Department of Health; 2013 [cited 2020 Sep 29]. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/214915/15-02-2013-controlled-drugs-regulation-information.pdf.
21. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain. 2007;8:573–82. doi: 10.1016/j.jpain.2007.02.432 17499555
22. Park TW, Saitz R, Ganoczy D, Ilgen MA, Bohnert ASB. Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study. BMJ. 2015;350:h2698. doi: 10.1136/bmj.h2698 26063215
23. Gomes T, Juurlink DN, Antoniou T, Mamdani MM, Paterson JM, van den Brink W. Gabapentin, opioids, and the risk of opioid-related death: a population-based nested case–control study. PLOS Med. 2017;14:e1002396.
24. Brummett CM, Waljee JF, Goesling J, Moser S, Lin P, Englesbe MJ, et al. New persistent opioid use after minor and major surgical procedures in us adults. JAMA Surg. 2017;152:e170504. doi: 10.1001/jamasurg.2017.0504 28403427
25. Brat GA, Agniel D, Beam A, Yorkgitis B, Bicket M, Homer M, et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ. 2018;360:j5790. doi: 10.1136/bmj.j5790 29343479
26. Barnett ML, Olenski AR, Jena AB. Opioid-prescribing patterns of emergency physicians and risk of long-term use. N Engl J Med. 2017;376:663–73. doi: 10.1056/NEJMsa1610524 28199807
27. Faculty of Pain Medicine. Opioids aware: a resource for patients and healthcare professionals to support prescribing of opioid medicines for pain. London: Faculty of Pain Medicine; 2018 [cited 2018 Apr 24]. http://www.fpm.ac.uk/faculty-of-pain-medicine/opioids-aware.
28. Moisset X, Trouvin AP, Tran VT, Authier N, Vergne-Salle P, Piano V, et al. [Use of strong opioids in chronic non-cancer pain in adults. Evidence-based recommendations from the French Society for the Study and Treatment of Pain.] Press Med. 2016;45:447–62. doi: 10.1016/j.lpm.2016.02.014 27067628
29. O’Brien T, Christrup LL, Drewes AM, Fallon MT, Kress HG, McQuay HJ, et al. European Pain Federation position paper on appropriate opioid use in chronic pain management. Eur J Pain. 2017;21:3–19. doi: 10.1002/ejp.970 27991730
30. Frank JW, Levy C, Matlock DD, Calcaterra SL, Mueller SR, Koester S, et al. Patients’ perspectives on tapering of chronic opioid therapy: a qualitative study. Pain Med. 2016;17:1838–47.
31. Bridges SL. Chronic pain. In: Craig R, Mindell, editors. Health survey for England–2011. Volume 1. Health, social care and lifestyles. London: Health and Social Care Information Centre; 2012 [cited 2020 Sep 29]. https://files.digital.nhs.uk/publicationimport/pub09xxx/pub09300/hse2011-ch9-chronic-pain.pdf.
Článek vyšel v časopise
PLOS Medicine
2020 Číslo 10
- Mikroplasty a jejich riziko pro zdraví: Co všechno víme?
- Vhodná dávka levothyroxinu u obézních pacientů s hypotyreózou
- Jak a kdy u celiakie začíná reakce na lepek? Možnou odpověď poodkryla čerstvá kanadská studie
- Prof. Jan Škrha: Metformin je bezpečný, ale je třeba jej bezpečně užívat a léčbu kontrolovat
- FDA varuje před selfmonitoringem cukru pomocí chytrých hodinek. Jak je to v Česku?
Nejčtenější v tomto čísle
- Association of technologically assisted integrated care with clinical outcomes in type 2 diabetes in Hong Kong using the prospective JADE Program: A retrospective cohort analysis
- Correction: Social distancing to slow the US COVID-19 epidemic: Longitudinal pretest–posttest comparison group study
- The impact of continuous quality improvement on coverage of antenatal HIV care tests in rural South Africa: Results of a stepped-wedge cluster-randomised controlled implementation trial
- Variation in racial/ethnic disparities in COVID-19 mortality by age in the United States: A cross-sectional study