In England, most of the population access healthcare via the National Health Service (NHS). However, as waiting times for NHS services continue to be a cause for concern, a growing number of people are turning to private healthcare. This can include hospitals, clinics or other providers that are independent but complementary to the NHS. Private healthcare provides many of the same services as the NHS, including surgeries, ongoing medical care and prescriptions. There is, therefore, a risk that patients may obtain prescriptions concurrently from NHS and private prescribers, or multiple prescribers. This is a particular concern for prescription medications such as opioids.
Opioids are strong analgesics that are often prescribed in primary care for chronic pain. In recent years, there has been mounting evidence demonstrating the risks of opioids, including abuse potential and overdoses – particularly when used at high doses and for long periods. Despite evidence suggesting that the harms of opioids outweigh the benefits, prescribing of these products has been on the rise in England over the last three decades. This has led to a subsequent increase in opioid dependence, overdose, and deaths associated with their use.
Opioids used in healthcare in the UK are controlled under the Misuse of Drugs Act 1971 and the Misuse of Drugs Regulations 2001. This legislation aims to prevent the misuse of drugs and includes specific requirements for the private prescription of Schedule 2 and 3 controlled drugs, including opioids. Since 2007, private prescribers in England have been required to write prescriptions for Schedule 2 and 3 controlled drugs on a special prescription form, allowing data to be captured. However, to date, an analysis of this data has not been openly published and the recent trends of controlled opioid prescribing within private healthcare are unclear. To address this, researchers conducted a retrospective observational study to evaluate trends and geographical variation of controlled opioids prescribed by private prescribers in England.
Design and Methods of the Study
The researchers obtained the most up-to-date data from the NHS Business Services Authority (BSA) using three freedom of information (FOI) requests. The data summarises the number of controlled opioid prescriptions dispensed for England at the Area Team Levels (2014-2019) and the Sustainability and Transformation Partnerships (STP) (2020-2021) regions for BNF Chemical Substances under section 7.4.2 in quarterly splits between January 2014 and November 2021. Data on the number of registered private prescribers in England were obtained from NHS Digital.
These data were analysed while measures were taken to control for changes in population and the number of private prescribers in England. The types of opioids were then summed and a percentage of the total for each type and percentage change over time were calculated. The researchers also aimed to establish how many items of controlled opioids were dispensed in each of the nine regions in England.
Results of the Study
The data showed that between 128,341 and 129,040 controlled opioid items were dispensed by private prescribers in England between January 2014 and November 2021. The volume of controlled opioids prescribed by private prescribers decreased by 50.4% between January 2014 and December 2020 (calculations for 2021 were omitted due to incomplete data). When controlling for the number of private prescribers in England, trends decreased by 64% from 4.09 items/private prescriber in 2014 to 1.49 items/prescriber in 2020.
A total of 14 different opioids were dispensed by private prescribers in England. Codeine was included by the NHS BSA in the first FOI request (2014-2018) but only appeared once in the second quarter of 2018. Methadone was the most commonly prescribed opioid, accounting for 36% of total items. This was followed by morphine (18%), buprenorphine (16%), oxycodone (12%), and tramadol (11%). These five types of opioids accounted for 93% of all controlled opioids dispensed in England between 2014 and November 2021. The number of items dispensed decreased over time for most types of opioids, except for oxycodone and hydromorphone, which increased.
For the latest data (1st January to 20th November 2021), the North West of London (n = 5,313) and Staffordshire and Stoke on Trent (n = 571) dispensed the most items of opioids. West Yorkshire and Harrogate Health and Care Partnership (n = 2) and Somerset (n = 2) prescribed the fewest.
Conclusions
This study provides a much-needed update on the trends and geographical variations of controlled opioids dispensed by private prescribers in England. Furthermore, it builds on previous research, published in 1995, that used a sample of data from community pharmacies over one year and focused on injectable methadone for people with opioid addiction. In comparison, the present study examined all types of controlled opioids over an eight-year period.
However, the researchers do note some limitations. For example, as electronic prescribing of Schedule 2 and 3 controlled drugs by private prescription is not permitted, it is also not possible to assess the doses, duration or indication of use. It is also not known what proportion of the English population visited a private prescriber over the study period. Nonetheless, the current data indicates that the decrease in controlled opioid prescriptions by private prescribers in England is in line with the UK’s National Institute for Health and Care Excellence (NICE) guidelines for chronic primary pain that advises against the use of opioids. The authors conclude that these findings “provide an important insight into another avenue for which people obtain controlled opioids in the community.”
