Research PaperPrescription opioids: Regional variation and socioeconomic status – evidence from primary care in England
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
References (52)
National opioid pharmacotherapy statistics (NOPSAD)
(2017)- et al.
Opioid use behaviors, mental health and pain--development of a typology of chronic pain patients
Drug and Alcohol Dependence
(2009) - et al.
Predictors of higher-risk chronic opioid prescriptions in an academic primary care setting
Substance Abuse
(2016) - et al.
Pharmaceutical opioid use and dependence among people living with chronic pain: Associations observed within the pain and opioids in treatment (POINT) cohort
Pain Medicine
(2015) Vital signs: Overdoses of prescription opioid pain relievers–United States, 1999–2008
Morbidity and Mortality Weekly Report
(2011)Cities data tool
(2011)- et al.
Patterns of drug use and associated harms among rural injecting drug users: Comparisons with metropolitan injecting drug users
The Australian Journal of Rural Health
(2006) - et al.
The extent and correlates of community-based pharmaceutical opioid utilisation in Australia
Pharmacoepidemiology and Drug Safety
(2016) English indices of deprivation 2015
(2015)Health survey for England - 2011
(2012)
High correlations between levels of consumption and mortality related to strong prescription opioid analgesics in British Columbia and Ontario, 2005–2009
Pharmacoepidemiology and Drug Safety
Prescribed opioids in primary care: Cross-sectional and longitudinal analyses of influence of patient and practice characteristics
BMJ Open
Chronic pain and use of opioids: A population-based pharmacoepidemiological study from the Norwegian prescription database and the Nord-Trondelag health study
Pain
Neighborhood socioeconomic status and receipt of opioid medication for new back pain diagnosis
Journal of the American Board of Family Medicine: JABFM
Trends and sex differences in prescription opioid deaths in British Columbia, Canada
Injury Prevention
Disproportionate longer-term opioid use among U.S. Adults with mood disorders
Pain
Long-term opioid use in non-cancer pain
Deutsches Arzteblatt International
Differences in prevalence of prescription opiate misuse among rural and urban probationers
The American Journal of Drug and Alcohol Abuse
Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: A cross-sectional study, systematic reviews and qualitative study
Southampton UK
The definition of opioid-related deaths in Australia: Implications for surveillance and policy
Drug and Alcohol Review
The impact of neighborhood socioeconomic status and race on the prescribing of opioids in emergency departments throughout the United States
Journal of General Internal Medicine
Geographical variation in cardiovascular disease, risk factors, and their control in older women: British Women’s Heart and Health Study
Journal of Epidemiology and Community Health
Identification of challenges to the availability and accessibility of opioids in twelve European countries: Conclusions from two ATOME six-country workshops
Journal of Palliative Medicine
American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2--guidance
Pain Physician
Geographic variation in opioid prescribing in the U.S
Journal of Pain
Prescription opioid use among disabled Medicare beneficiaries: Intensity, trends, and regional variation
Medical Care
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