Opioid prescribing rates are increasing and show notable geographical variations across England. They are highest in the North and in areas of social deprivation, a study on primary care prescribing has shown. Virtually all the low prescribing areas were in the south of England and nine of the ten highest prescribing areas were northern clinical commissioning groups (CCGs).

The investigators assessed opioid prescribing in primary care in England between August 2010 and February 2014 using mg morphine equivalent as the measure of quantity. They adopted this strategy on the basis that because of the association between adverse effects and opioid dose it is more appropriate to analyse risk relating to dose rather than prescription count (as has been done in a number of previous studies).

Eight opioids were included in the study: buprenorphine, codeine, dihydrocodeine, fentanyl, methadone, morphine, oxycodone and tramadol. Primary care prescribing data were obtained from the Health and Social Care Information Centre.

Over the study period total opioid prescribing showed a steady increase. Tramadol was the most prescribed opioid, followed by buprenorphine and then methadone. Fentanyl was the drug least prescribed.

Buprenorphine, codeine, oxycodone and tramadol prescribing showed the greatest rates of increase while methadone and dihydrocodeine prescribing decreased, see table 1, above.

Virtually all the low prescribing areas were in the south of England. Nine of the ten highest prescribing areas were northern CCGs, the exception being Bristol in the south west. Comparison of prescribing rates with scores on the Index of Social Deprivation showed a strong relationship (r = 0.56, P < 0.0001). When latitude was included as a covariate, the correlation was stronger (r = 0.43, P < 0.001).

The authors acknowledge that their data were not able to identify prescriptions issued specifically for chronic non-cancer pain as opposed to other indications. However, the paper does identify a number of important trends.

Tramadol prescribing is increasing in England and there are potential associated public health risks as tramadol-related deaths are also increasing.

The authors provide three possible explanations for the increase in prescribing: tramadol has filled the ‘void’ created by the withdrawal of co-proxamol; tramadol is being prescribed in preference to NSAIDs because of concerns about complications associated with the latter; and tramadol is perceived as a drug that lies in between weak and strong opioids, avoiding the risks and stigma associated with strong opioid medications.

This paper provides an overall summary of opioid prescribing in England, its rate of change, and regional differences in prescribing.

It shows a north-south gradient and that opioid prescribing rates are highest in areas of social deprivation.

The authors conclude:

‘This study exposes increasing rates of prescription of a class of drugs whose use for chronic pain is controversial, with potential for abuse, and an association with serious adverse effects and premature death.’

Dr Jez Thompson

Mordecai L, Reynolds C, Donaldson LJ, de C Williams AC. Patterns of regional variation of opioid prescribing in primary care in England: a retrospective observational study. Br J Gen Pract 2018; DOI: https://doi.org/10.3399/bjgp18X695057