Trends In Long-term Opioid Prescribing In Primary Care Patients With Musculoskeletal Conditions: An Observational Database Study
20% of adults present to UK primary care with a musculoskeletal (MSK) condition each year. Despite uncertain effectiveness and potential adverse events, national guidelines such as those from NICE advocate use of opioids after use of weaker analgesics for MSK conditions. In the USA there has been a considerable increase in long-term opioid use but it is unclear this is also true in the UK, and whether there is also an increase in use of stronger opioids in those on long-term opioids.
This was an observational database study undertaken in the Clinical Practice Research Datalink (CPRD) from 2002-2013. Patients aged over 18 who consulted for a MSK condition at the start of a long-term opioid episode were identified. A 6-month period of no opioid use followed by 90 days or more of prescribed opioids was defined as a long-term opioid episode. An episode ended if there were no further prescriptions for 6 months. Patients with cancer were excluded. Each year was divided into quarters starting January-March 2002. Incident prescribing of long-term opioid episodes was determined (annual and quarterly) and stratified according to age, gender, and type of opioid. Opioids were grouped as short or long-acting, non-controlled or controlled drugs. Prescribing trends were analysed using joinpoint regression.
121,133 patients from a total population of 5,167,159 started at least one episode of long-term opioids between 2002 and 2013. Females aged over 65 were more likely to start a new episode. The median episode length was 231 (IQR 99, 681) days. 38.2% of episodes lasted over one year and 23.7% more than two years. The annual incidence of prescribed long-term opioids increased from 2002 (42.0 per 10,000 person-years) to 2009 (57.4/10,000) and remained stable until decreasing from 2011 to 2013 (47.3/10,000). Two years after starting a new episode of long-term opioids in 2002, 5.2% of those still being prescribed opioids were using long-acting controlled opioids. This had increased to 38.8% by 2013.
The incidence of long-term MSK related opioid prescribing in the UK increased by 37% from 2002 to 2009 but declined from 2011 onwards. NICE 2008 osteoarthritis guidelines advocate opioid use, but were not associated with increasing use. The decline in 2011 coincided with the implementation of the US National Drug Control Policy to reduce prescribed opioid abuse, and may reflect a ‘spill over’ effect from this. Though opioid use is decreasing, there is a large shift towards using stronger controlled drugs. Regulations to monitor prescribed opioids use have now been actioned in the UK and further research is required to determine if these are effective in promoting appropriate opioid prescribing.
- John Bedson
- Ying Chen
- Richard Hayward
- Kelvin Jordan