North-south divide revealed as prescription of opioid drugs rise

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The prescription of opioid drugs by GPs in England is steadily rising, especially in more deprived communities, even though they can cause complications and adverse effects and do not work for chronic pain, a UCL study has revealed.

The study, led by Dr Luke Mordecai, a pain research fellow at University College London Hospital (UCLH) found that over a 43 month period between 2010 and 2014 there was a rise in opioid prescribing.

It also revealed a north-south divide with nine out of ten of the highest prescribing areas located in the north of England. “There was an association between social deprivation and higher opioid prescription,” wrote the authors in the British Journal of General Practice.

They said opioids were rightly given to people to cope with cancer pain and short-lived acute pain. However, the widespread prescribing of opioids for people with long-term pain was controversial because “opioids are ineffective in much chronic pain beyond modest effects in the short term”.

They are also potentially dangerous particularly with long term use and larger regular doses, leading to problems such as addiction and abuse, hyperalgesia, gastrointestinal disturbance, immunological dysfunction, risk of fracture in older people and increased mortality.

The US has seen an alarming rise in the rate of opioid prescriptions over recent years with tripling in the last decade. In England, Scotland and Wales, deaths attributed to opioids have also increased with nearly 900 in 2001 compared with 500 in 2011.

Even weak opioids such as codeine and dihydrocodeine carried risks with deaths related to codeine up from 73 in 2012 to 130 in 2013 and dihydrocodeine accounting for 103 and 102 deaths over the same years.

Despite the risks and fact that they do not work, the study said many GPs prescribed them because they thought it was unethical to refuse their patients painkillers. The study looks at the total amount in grams of each of eight commonly prescribed opioid drugs and found a rise in six of them.

The most prescribed opioid drug in England over the 43 months of the study, from August 2010 to February 2014, was tramadol. It is not as weak as over-the-counter codeine but does not have the stigma of the powerful morphine.

The authors – Dr Mordecai, Carl Reynolds, respiratory registrar at St Mary’s Hospital, London, Liam J Donaldson, professor of public health at London School of Hygiene and Tropical Medicine, and Dr Amanda C de C Williams, reader in clinical health psychology, at UCL – call on policymakers to identify the reasons for the variation to enable avoidable harm to be addressed.

They also say there is not enough capacity in the specialist pain service with as few as one in five people with problematic pain having access to specialist pain services, and that only 40% of those services offer best practice in the form of multidisciplinary team assessment and treatment. They argue that good practice needs now to be extended from specialist to primary care.

Guidelines from the British Pain Society and Map of Medicine had produced guidelines aimed at standardising care for the most common forms of pain, which, if followed could lead to a reduction in opioid prescriptions and an improvement in the care of those suffering pain.

The authors also recommended a national database of patients taking large amounts of opioids “This is a high-risk demographic which should be known to and regularly followed up by specialist services,” they conclude. “This would hopefully help avoid further escalations of doses as well as attempt to help patients with specialist opioid reduction programmes.”

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