Changes in opioid prescribing during the COVID-19 pandemic in England: cohort study of 20 million patients in OpenSAFELY-TPP

Background The COVID-19 pandemic disrupted healthcare delivery, including difficulty accessing in-person care, which may have increased the need for strong pharmacological pain relief. Methods With NHS England approval, we used routine clinical data from >20 million general practice adult patients in OpenSAFELY-TPP. Using interrupted time series analysis, we quantified prevalent and new opioid prescribing prior to the COVID-19 pandemic (January 2018-February 2020), and during lockdown (March 2020-March 2021) and recovery periods (April 2021-June 2022), overall and stratified by demographics (age, sex, deprivation, ethnicity, geographic region) and to people in care homes. Outcomes The median number of people prescribed an opioid per month was 50.9 per 1000 patients prior to the pandemic. There was little change in prevalent prescribing during the pandemic, except for a temporary increase in March 2020. We observed a 9.8% (95%CI -14.5%, -6.5%) reduction in new opioid prescribing from March 2020, sustained to June 2022 for all demographic groups except people 80+ years. Among care home residents, in April 2020 new opioid prescribing increased by 112.5% (95%CI 92.2%, 134.9%) and parenteral opioid prescribing increased by 186.3% (95%CI 153.1%, 223.9%). Interpretation New opioid prescribing increased among older people and care home residents, likely reflecting use to treat end-of-life COVID-19 symptoms, but decreased among most other groups. Further research is needed to understand what is driving the reduction in new opioid prescribing and its relation to changes to health care provision during the pandemic. Funding The OpenSAFELY Platform is supported by grants from the Wellcome Trust (222097/Z/20/Z) and MRC (MR/V015737/1, MC\_PC\_20059, MR/W016729/1). In addition, development of OpenSAFELY has been funded by the Longitudinal Health and Wellbeing strand of the National Core Studies programme (MC\_PC\_20030: MC\_PC\_20059), the NIHR funded CONVALESCENCE programme (COV-LT-0009), NIHR (NIHR135559, COV-LT2-0073), and the Data and Connectivity National Core Study funded by UK Research and Innovation (MC\_PC\_20058) and Health Data Research UK (HDRUK2021.000). The views expressed are those of the authors and not necessarily those of the NIHR, NHS England, UK Health Security Agency (UKHSA) or the Department of Health and Social Care. Evidence before this study We searched Pubmed for publications between 1 March 2020 and 8 January 2023 using the following search terms: (“COVID-19” OR “SARS-CoV-2”) AND (“United Kingdom” OR “England” OR “Britain” OR “Scotland” OR “Wales”) AND (“opioid”). We also searched the reference list of relevant articles. We included research studies (excluding conference abstracts and editorials) that quantified opioid prescribing or use in the United Kingdom during the COVID-19 pandemic. Studies focussed solely on opioid substitution therapy for treatment of opioid use disorder were excluded. We identified four studies. One described opioid use among a cohort of people on a waiting list for hip or knee arthroplasty in Scotland (n=548) and found higher rates of long-term opioid use during the COVID-19 pandemic compared with historical controls. The second study quantified changes in opioid prescribing using English aggregate prescription data. This study found no changes in opioid prescribing after the start of the COVID-19 pandemic. The third study of 1.3 million people with rheumatic and musculoskeletal diseases found a decrease in new opioid users among people with certain conditions, but not in the number of overall prescriptions. The last study of 34,711 people newly diagnosed with cancer and 30,256 who died of cancer in Wales found increases in strong opioid prescribing in both populations. Added value of this study This is the largest study (>20 million patients) of opioid prescribing during the COVID-19 pandemic in a representative sample of the population of England. We used person-level data to quantify changes in the number of people prescribed opioids and identified that prevalent opioid prescribing changed little, with the exception of a temporary increase at the start of the first lockdown. However, we also identified meaningful reductions in new opioid prescribing. While our findings confirm previous studies quantifying variation in opioid prescribing by sex, ethnicity, region and deprivation, we showed that changes to new prescribing during the COVID-19 pandemic were experienced approximately similarly across these subgroups. The exceptions were older people and people in care homes. The latter group experienced substantial increases in new opioid prescribing (especially parenteral opioids, which are used in palliative care) coinciding with periods of greatest COVID-19 morbidity and mortality. Implications of all the available evidence The COVID-19 pandemic resulted in substantial disruptions to the healthcare system. Despite concerns that difficulty or delays in providing care during the pandemic may have led to shifts from non-pharmacological treatments to greater opioid prescribing, we observed no increases in prescribing prevalence in most demographic groups in England. The one major exception is people residing in care homes, where the observed prescribing patterns suggest use to treat end of life symptoms, consistent with best practice. However, our findings do not preclude increased prescribing in high risk subgroups, such as people on procedure waiting lists. Further research to quantify changes in this population is warranted. ### Competing Interest Statement BG has received research funding from the Bennett Foundation, the Laura and John Arnold Foundation, the NHS National Institute for Health Research (NIHR), the NIHR School of Primary Care Research, NHS England, the NIHR Oxford Biomedical Research Centre, the Mohn-Westlake Foundation, NIHR Applied Research Collaboration Oxford and Thames Valley, the Wellcome Trust, the Good Thinking Foundation, Health Data Research UK, the Health Foundation, the World Health Organisation, UKRI MRC, Asthma UK, the British Lung Foundation, and the Longitudinal Health and Wellbeing strand of the National Core Studies programme; he has previously been a Non-Executive Director at NHS Digital; he also receives personal income from speaking and writing for lay audiences on the misuse of science. BMK is also employed by NHS England working on medicines policy and clinical lead for primary care medicines data. AM has represented the RCGP in the health informatics group and the Profession Advisory Group that advises on access to GP Data for Pandemic Planning and Research (GDPPR); the latter was a paid role. AM is a former employee and interim Chief Medical Officer of NHS Digital. AM has consulted for health care vendors, the last time in 2022; the companies consulted in the last 3 years have no relationship to OpenSAFELY. ### Funding Statement The OpenSAFELY Platform is supported by grants from the Wellcome Trust (222097/Z/20/Z) and MRC (MR/V015737/1, MC\_PC\_20059, MR/W016729/1). In addition, development of OpenSAFELY has been funded by the Longitudinal Health and Wellbeing strand of the National Core Studies programme (MC\_PC\_20030: MC\_PC\_20059), the NIHR funded CONVALESCENCE programme (COV-LT-0009), NIHR (NIHR135559, COV-LT2-0073), and the Data and Connectivity National Core Study funded by UK Research and Innovation (MC\_PC\_20058) and Health Data Research UK ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study was approved by the Health Research Authority (Research Ethics Committee reference 20/LO/0651) and by the London School of Hygiene and Tropical Medicine Ethics Board (reference 21863). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Primary care records managed by the GP software provider, TPP were linked to Office of National Statistics (ONS) death data through OpenSAFELY and were linked, stored and analysed securely within the OpenSAFELY platform: https://opensafely.org/ as part of the NHS England OpenSAFELY COVID-19 service. Data include pseudonymised data such as coded diagnoses, medications and physiological parameters. No free text data are included. All code is shared openly for review and re-use under MIT open license (https://github.com/opensafely/opioids-covid-research). Detailed pseudonymised patient data are potentially re-identifiable and therefore not shared.