Rheumatic and musculoskeletal diseases (RMDs) are defined as problems of the joints, muscles, and bones. It is estimated that around 20% of adults consult primary care (the first point of care for such conditions) for an RMD in the UK annually, with the conditions representing a significantly high disease burden globally. The recommended treatment of RMDs involves a multi-disciplinary approach, including advice, self-care, and referral for non-pharmacological interventions such as physiotherapy, exercise, and weight management. Analgesics may also be prescribed to help manage associated pain.
The COVID-19 pandemic prompted a government-issued ‘stay at home’ order and ‘lockdown’ in the UK. Among the services affected was primary care whereby remote consultations replaced traditional ‘face-to-face’ healthcare. Figures show that these restrictions resulted in an approximately 30% reduction in primary care consultations per person, with lower consultation rates observed until June 2020. However, there are no published studies addressing how changes in primary healthcare services affected people with RMDs during the first 18 months of the pandemic.
A recent study aimed to address this by describing patterns of RMD-related primary care consultations and prescribing immediately prior to, during, and after UK pandemic-related restrictions. The researchers address the hypotheses that “there would be a reduction in consultations and an increase in analgesic prescribing, both in volume and strength, to manage RMDs.”
Methods of the Study
Researchers analysed routinely collected electronic primary care record data from the Clinical Practice Research Datalink (CPRD) from 01/04/17 to 01/10/2020. The CRPD Aurum collates anonymised data of over 40 million patients including 15 million currently registered patients (over 20% of the UK population) from practices in England (99%) and Northern Ireland (1%) only.
The study outcomes were the prevalence and incidence of primary care consultations for RMDs and associated analgesic prescribing.
All analgesic prescriptions within BNF chapters for opioid analgesics, non-opioid analgesics, and NSAID medications were included, as well as gabapentinoids and duloxetine.
Results of the Study
The numerator population (individuals presenting with an RMD-related primary care consultation) included 6,057,747 patients from practices in England and Northern Ireland. The denominator population remained largely constant over the study period at around 13.5 million individuals.
RMD Prevalence and Incidence
The monthly prevalence of individuals consulting with RMDs increased gradually between April 2017 and January 2020 with a monthly percentage change (MPC) of 0.3% from 256.53 to 317.86 per 10,000 persons. Between, February 2020 and April 2020 there was an MPC of –16.0% to 225.39 in March and 126.56 per 10,000 persons in April 2020. Finally, from May 2020 to October 2021 there was an increase in MPC of 2.3% in the number of prevalent RMD consulters, but the prevalence rate did not recover to pre-pandemic levels.
Did overall prescribing of painkillers increase during COVID-19?
Between April 2017 and January 2020, prescribing of basic analgesics, weak, strong, and very strong opioids, NSAIDs, and neuropathic analgesics fell gradually while there was a slight increase in prescribing of moderate opioids (MPC 0.2%) and SNRIs (MPC 0.1%). From March 2020, prescribing of all analgesics fell at a greater rate with the largest relative change seen for NSAIDs (MPC –13.1%), basic analgesics (MPC –17.8%), neuropathic analgesics (MPC –15.9%). From May 2020 to October 2021, prescribing of analgesia remained much lower than pre-pandemic, with only modest relative increases in basic (MPC 1-8%), moderate opioids (MPC 1.4%), NSAIDs (MPC 1.4%), and neuropathics (MPC 2.2%). SNRIs demonstrated the greatest relative increase in prescribing (MPC 3.5%).
Did prescribing of painkillers per person increase during COVID-19?
There was a clear reduction in overall analgesia prescribing in the pre-pandemic period; however, in contrast, the percentage of all RMD consultations with either a prevalent or incident (first) analgesic prescription increased in all analgesic groups between March and May 2020, except for incident prescribing for NSAIDs and SNRIs. This increase was evident for all analgesic groups, except SNRIs, which remained relatively static. The upsurge was greatest for very strong opioid analgesics (MPC 18.3%), and this category was the second most prescribed analgesics to NSAIDs from April 2020 until the end of the study.
Overall, RMD-associated analgesic prescribing showed a general decline from early 2020, with an upturn from April 2020 for all analgesic categories, though this did not return to pre-pandemic levels. The proportion of RMD-associated consultations in which an analgesic was prescribed increased in March 2020, with notable upsurges in all analgesic groups, particularly strong analgesics. Furthermore, increases in prescribing were again seen during the second UK lockdown in moderate and strong opioids and neuropathic medications.
Conclusions
These findings support previous research that has linked deprivation to opioid prescribing. The researchers suggest that these increases in prescribing as a proportion of RMD consultations may be due to the lack of available non-pharmacological management options during the lockdown periods. Furthermore, it may be that only patients with severe RMD symptoms presented to primary care prompting a higher proportion of consultations to result in the prescribing of more, and stronger, analgesia.
It may also be possible that the observed increase in psychological distress through the pandemic period resulted in heightened pain experiences and the corresponding increases in analgesic prescribing as a proportion of RMD consultations. It will be important to observe how consultation rates and analgesia prescribing continue to evolve as in-person consultation rates continue to increase following the peak of the COVID-19 pandemic. Moreover, it will be important to assess the trajectory of the conditions of those presenting with RMDs during the COVID-19 pandemic to assess whether there is a reduction in analgesia prescribing with improved access to physical and psychological therapies.
