Research Paper
Prescription opioids: Regional variation and socioeconomic status – evidence from primary care in England

https://doi.org/10.1016/j.drugpo.2018.10.013Get rights and content

Abstract

Background

This study aimed to quantify opioid prescriptions dispensed from primary care practices throughout England and investigate its association with socioeconomic status (SES).

Methods

This cross-sectional study used publicly available data in 2015, including practice-level dispensing data and characteristics of registrants from the United Kingdom (UK) National Health Service Digital, and Index of Multiple Deprivation (IMD) data from Department of Communities and Local Government. Practices in England which issued opioid prescriptions that could be assigned a defined daily dose (DDD) in the claim-based dispensing database were included. The total amount of opioid prescriptions dispensed (DDD/1000 registrants/day) was calculated for each practice. The association between dispensed opioid prescriptions and IMD was analyzed by multi-level regression and adjusted for registrants’ characteristics and the clustered effect of Clinical Commissioning Groups. Subgroup analysis was conducted for practices in London, Birmingham, Manchester and Newcastle.

Results

Of the 7856 included practices in England, the median and interquartile range (IQR) of prescription opioids dispensed was 36.9 (IQR: 23.1, 52.5) DDD/1000 registrants/day. The median opioid utilization (DDD/1000 registrants/day) amongst practices varied between Manchester (53.1; IQR: 36.8, 71.4), Newcastle (48.9; IQR: 38.8, 60.1), Birmingham (35.3; IQR: 23.1, 49.4) and London (13.9; IQR: 8.1, 18.8). Lower SES, increased prevalence of patients aged more than 65 years, female gender, smoking, obesity and depression were significantly associated with increased opioid prescriptions. For every decrease in IMD decile (lower SES), there was a significant increase of opioid utilization by 1.0 (95% confidence interval: 0.89, 1.2, P < 0.001) DDD/1000 registrants/day.

Conclusion

There was substantial variation in opioid prescriptions among practices from Northern and Eastern England to Southern England. A significant association between increased opioid prescriptions and greater deprivation at a population level was observed. Further longitudinal studies using individual patient data are needed to validate this association and identify the potential mechanisms.

Introduction

Opioids have been considered the standard care for managing acute severe pain and chronic pain (Rosenblum, Marsch, Joseph, & Portenoy, 2008). In the past decade, there has been a marked increase in opioid-related deaths in several developed countries that coincided with an increasing opioid utilization (Centers for Disease Control & Prevention, 2011; Gladstone, Smolina, & Morgan, 2016; Jauncey, Taylor, & Degenhardt, 2005). At a regional level, drug utilization studies in North America and Australia have also suggested there may be a link between regional opioid utilization, opioid-related harms and socioeconomic status (Degenhardt et al., 2016; Fischer, Jones, & Rehm, 2013; Havens et al., 2007; McDonald, Carlson, & Izrael, 2012; Morden et al., 2014; Zerzan et al., 2006).

Geographical variation in opioid prescriptions and over-the-counter opioids have been found in the United States (US) (McDonald et al., 2012; Morden et al., 2014; Zerzan et al., 2006) and Australia (Degenhardt et al., 2016). In the US, there was a 7.3-times variation between states with the highest and lowest number of prescription opioids dispensed (McDonald et al., 2012). In Australia, according to sales data, major cities had lower opioid utilization than remote areas, and there was a 2.5-fold difference between areas with the highest and lowest opioid utilization in 2013 (Degenhardt et al., 2016). Furthermore, higher opioid-related morbidity and mortality have been observed in regions with higher opioid utilization in North America (Fischer et al., 2013; Havens et al., 2007).

A variety of factors may be attributed to the observed variation in opioid prescribing, such as population demographic characteristics (McDonald et al., 2012), prevalence of pain related co-morbidities (Painter, Crofford, & Talbert, 2013), healthcare provider clinical knowledge (Reames, Shubeck, & Birkmeyer, 2014), accessibility of appropriate services (McDonald et al., 2012), insurance coverage and benefit policy (Zerzan et al., 2006). Socioeconomic status (SES) has been identified as a major determinant in the variation of regional opioid utilization as it is associated with chronic pain conditions, persistent opioid utilization and aberrant medication-taking behaviors (Day, Conroy, Lowe, Page, & Dolan, 2006; Department of Health, 2012). Other factors are less important because opioids are classified as controlled substances which are restricted for use in pain management and strict regulations govern prescribing.

Previous studies using aggregate-level data of prescription opioids dispensed in the US (McDonald et al., 2012) and sales data of over-the-counter and prescription opioids in Australia (Degenhardt et al., 2016) found that lower SES was associated with higher opioid utilization. However, the generalizability of these results is limited due to the measure of SES used. Instead of using a validated composite tool to measure SES, published studies only applied selected dimensions, such as income and education to represent SES, and hence may lead to biased conclusions (Banta-Green, Merrill, Doyle, Boudreau, & Calsyn, 2009; Joynt et al., 2013; McDonald et al., 2012; Parsells Kelly et al., 2008; Stover et al., 2006; Svendsen, Fredheim, Romundstad, Borchgrevink, & Skurtveit, 2014; Toblin, Mack, Perveen, & Paulozzi, 2011).

In the United Kingdom (UK), regional variation in health care provision has been identified in several diseases and regarded as an important health equity issue (Lawlor, Bedford, Taylor, & Ebrahim, 2003; Shah et al., 2016; Williams & Drinkwater, 2009). However, research on the variation in opioid utilization and its association with SES remain lacking. Locally, a cross-sectional study conducted in 111 of the 192 practices (780,000 registrants) in Leeds and Bradford found that higher number of opioid prescribing was associated with lower SES (Foy et al., 2016), but this association has not been investigated at the national level. Therefore, this study aimed to examine the association between SES and the number of prescription opioids dispensed in England general practices using a validated composite indicator for SES.

Section snippets

Study design and data sources

This cross-sectional study used publicly available aggregate-level statistics and datasets from multiple UK government sources. The most up-to-date information on SES (in 2015) was linked with opioid utilization and other population characteristics data by the identifier at practice level (Table 1). Practices in England which had opioid prescriptions dispensed in 2015 with an identifiable number of registrants and Index of Multiple Deprivation (IMD) scores were included as the basic unit for

Opioid utilization and registrants’ characteristics among practices

Of the 7856 practices included from England, the median number of registrants was 6565 (IQR: 3974, 9898), and median amount of prescription opioid dispensed was 36.9 (IQR: 23.1, 52.5) DDD/1000 registrants/day. The median IMD score across the 7856 practices in England was 22.4 (IQR: 12.4, 37.0) with a median decile of 4 (IQR: 2, 7) (Table 2).

Geographical distribution of opioid utilization among CCGs

The 7856 practices were grouped into 209 CCGs in England. The prescription opioids dispensed (DDD/1000 registrants/day) in each CCG ranged from 14.1 to

Main findings

This study found regional variation in opioid utilization and registrant characteristics among practices across England and within the four primary urban areas. The geographical distribution of opioid utilization also varied across CCGs in England. There was substantial variation in opioids dispensed among practices from Northern and Eastern England to Southern England which mirrors general geographical health inequalities between those from deprived and affluent areas. The highest opioid

Acknowledgements

The lead author (Teng-Chou Chen) was funded by the Vice-Chancellor's Scholarships for Research Excellence for a PhD studentship at University of Nottingham from 2014 to 2017. Dr Li-Chia Chen was granted the Data Driven Discovery Summer Placement Internship from the University of Nottingham in 2016 that supported the undergraduate student (Miriam Kerry) to work on this project. The funding bodies had no role in the design, collection, analysis, and interpretation of data; in writing the

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