Opioid Prescribing data for CNCP in LCCG 2016-2018

Background: Treating Chronic Non-Cancer Pain (CNCP) with long-term, high dose and more potent opioids puts patients at increased risk of harm, whilst providing limited pain relief. Socially deprived areas mapped from Index of Multiple Deprivation (IMD) scores show higher rates of high dose, strong opioid prescribing compared to more affluent areas. Objective: To explore if opioid prescribing is higher in more deprived areas of Liverpool (UK) and assess the incidence of high dose prescribing to improve clinical pathways for opioid weaning. Design and Setting: This retrospective observational study used primary care practice and patient level opioid prescribing data for N=30,474 CNCP patients across Liverpool Clinical Commissioning Group (LCCG) between August 2016 and August 2018. Method: A Defined Daily Dose (DDD) was calculated for each patient prescribed opioids. DDD was converted into a Morphine Equivalent Dose (MED) and patients stratified according to high (≥120mg) MED cut off. The association between prescribing and deprivation was analysed by linking GP practice codes and IMD scores across LCCG. Results: 3.5% of patients were prescribed an average dose above 120mg MED/day. Patients prescribed long-term, high dose, strong opioids were more likely to be female, aged 60+, prescribed three opioids and reside in the North of Liverpool where there is a higher density of areas in the IMD most deprived deciles. Conclusion: A small but significant proportion of CNCP patients across Liverpool are currently prescribed opioids above the recommended dose threshold of 120mg MED. Identification of fentanyl as a contributor to high dose prescribing resulted in changes to prescribing practice, and reports from NHS pain clinics that fewer patients require tapering from fentanyl. In conclusion, higher rates of high dose opioid prescribing continue to be evident in more socially deprived areas further increasing health inequalities.

背景：长期、高剂量且强效的阿片类药物治疗慢性非癌痛（Chronic Non-Cancer Pain, CNCP）会增加患者的不良事件风险，且疼痛缓解效果有限。基于多重贫困指数（Index of Multiple Deprivation, IMD）得分划定的社会贫困区域，其高剂量强效阿片类药物的处方率显著高于较富裕区域。
目的：探究英国利物浦市贫困程度更高的区域阿片类药物处方率是否更高，并评估高剂量处方的发生率，以优化阿片类药物减停的临床路径。
设计与研究场景：本回顾性观察研究纳入了2016年8月至2018年8月期间，利物浦临床委托组（Liverpool Clinical Commissioning Group, LCCG）内共30474名CNCP患者的基层医疗实践及患者级阿片类药物处方数据。
方法：为每位开具阿片类药物的患者计算规定日剂量（Defined Daily Dose, DDD），将其转换为吗啡等效剂量（Morphine Equivalent Dose, MED），并以≥120mg MED为截断阈值对患者进行分层。通过关联LCCG范围内的全科医生实践编码与IMD得分，分析处方行为与贫困程度之间的相关性。
结果：3.5%的患者日均处方剂量超过120mg MED。长期、高剂量使用强效阿片类药物的患者更大概率为女性、年龄≥60岁、同时开具3种阿片类药物，且居住在利物浦北部——该区域属于IMD评分最贫困的十分位组别，贫困区域密度更高。
结论：利物浦市目前存在一小部分但比例显著的CNCP患者，其阿片类药物处方剂量超过了120mg MED的推荐阈值。研究发现芬太尼是高剂量处方的重要诱因之一，这一发现推动了处方实践的调整；英国国民保健署（National Health Service, NHS）疼痛门诊报告显示，需要从芬太尼开始减停的患者数量有所减少。综上，社会贫困程度更高的区域仍存在较高的高剂量阿片类药物处方率，进一步加剧了健康不平等。