The safer management of controlled drugs: Annual update 2023

Prescribing trends in primary care

In this section, we highlight trends of the most prescribed controlled drugs.

Overall prescribing of controlled drugs in Schedules 2 to 5 in 2023

Total controlled drug items prescribed by NHS primary care services:

73,830,666 items in 2023

73,880,442 items in 2022
(a small decrease of less than 0.5%)

The cost of this was £572,477,393 in 2023 compared with £547,248,678 in 2022 (an increase in cost of 5%) even though the number of items had decreased.

The most notable prescribing trends in NHS primary care in 2023 include:

• Continued increases in prescribing volumes of medicines that are licensed to treat attention deficit hyperactivity disorder (ADHD), such as dexamfetamine, lisdexamfetamine and methylphenidate. This trend is also echoed in NHS hospital prescribing for dispensing in the community, as well as in the private prescribing trends, which may reflect a lack of access to NHS care. Figure 14 shows the NHS hospital prescribing trends over the last 5 years.
• Similar to last year, an increase in testosterone prescribing, which could be linked to increased awareness of its use for women experiencing menopause.
• A reduction in prescribing of pholcodine (after changes to clinical guidance and availability), pethidine, co-proxamol, fentanyl and diamorphine. We have also seen reduced fentanyl patch prescribing in certain age groups.
• An increase in non-medical prescribing. Similar to last year, pharmacists account for over half of non-medical prescribing.
• A continued trend in reduced prescribing by NHS dentists, possibly linked to dental access issues.

Figure 2 shows overall prescribing levels in 2023 compared with the previous year.

Figure 2: Prescribing of controlled drugs by schedule in 2023

Of all prescribing of controlled drugs in primary care in 2023:

• Schedule 2 accounted for 13%
• Schedule 3 accounted for 35%
• Schedule 4 accounted for 17%
• Schedule 5 accounted for 35%

Patterns of prescribing in NHS primary care

Of the most prescribed controlled drugs in 2023, there was a reduction in prescribing for a number of controlled drugs compared with 2022 (figure 3).

Figure 3: Reductions in prescribing of controlled drugs in 2023

At the same time, of the most prescribed controlled drugs, there was an increase in prescribing in 2023, compared with 2022 (figure 4).

Figure 4: Increases in prescribing of controlled drugs in 2023

Looking at the proportions of controlled drugs in different schedules prescribed in 2023:

• pregabalin and gabapentin accounted for 63% of all Schedule 3 prescribing
• diazepam and zopiclone accounted for 68% of all Schedule 4 prescribing
• co-codamol accounted for 59% of all Schedule 5 prescribing
• methylphenidate, lisdexamfetamine and dexamfetamine accounted for 23% of all Schedule 2 prescribing (see figure 5)
• morphine sulfate accounted for 29% of all Schedule 2 prescribing

Figure 5: Number of items of methylphenidate, lisdexamfetamine and dexamfetamine prescribed in NHS primary care in England, 2017 to 2023

NHS non-medical prescribing

Overall prescribing of controlled drugs by non-medical prescribers (healthcare professionals other than a doctor or dentist) increased during 2023:

5,440,585 items prescribed in 2023

5,152,958 items prescribed in 2022
(an increase of 6%)

Figure 6: Non-medical prescribing of controlled drugs in 2023

Prescribing by pharmacists accounted for 53% of all non-medical prescribing in 2023 (2,908,340 items) compared with 51% in 2022. Given the year-on-year increasing volume of non-medical prescribing, this year we provide some more detailed information about the range of controlled drugs being prescribed by pharmacists and nurses (figures 7 and 8).

Pharmacist prescribing

Figure 7 shows the controlled drugs prescribed by pharmacists at volumes in excess of 10,000 items during 2023.

Figure 7: Pharmacist prescribing of controlled drugs in 2023

Nurse prescribing

Figure 8 shows controlled drugs that were prescribed by nurses at volumes in excess of 10,000 items during 2023. It is important to note that the high volume of items of methadone prescribed is likely to reflect nurses practising in services that offer opioid substitution therapy.

Figure 8: Nurse prescribing of controlled drugs

We have also seen a range of controlled drugs prescribed by other non-medical prescribers. The vast majority of this appears to be consistent with the expected scope of practice of these healthcare professionals, such as paramedics and physiotherapists. However, we have noted several instances where medicines such as dexamfetamine, lisdexamfetamine and methylphenidate have been prescribed by healthcare professionals who are unlikely to have expertise in this specialist area.

Last year we looked at the importance of ensuring that non-medical prescribing is undertaken appropriately, including ensuring it is within the prescriber’s scope of practice. Professional regulators all have expectations of their registrants and provide guidance for safe and effective prescribing. We also provide guidance on supporting non-medical prescribers in primary care, and many elements of this are transferable to other settings.

NHS dental prescriptions for controlled drugs

Total controlled drug items prescribed by NHS dentists:

28,819 items in 2023

30,790 items in 2022
(a decrease of 6%)

Dentists working in the NHS can prescribe 3 controlled drugs on NHS dental prescription forms to patients:

Dihydrocodeine: as in previous years, this was the most prescribed medicine, accounting for 82% of total dental prescribing in 2023.

23,714 items prescribed in 2023

25,826 items prescribed in 2022
(a decrease of 8%)

Diazepam: Between 2022 and 2023 prescribing increased by 6%

Temazepam: Between 2022 and 2023, prescribing decreased by 14%

Reduced access to dental treatment continues to be a national issue. These patterns in decreased prescribing could be a result of this.

ePACT2 Opioid comparators dashboard

Last year, we looked at prescribing of opioids in a specific geographical area. When we looked at this data again, we found the number of patients receiving opioid pain medicines per 1,000 patients in early 2024 remained similar compared with the same period in 2023 (figure 9). Prescribing is still highest in the north of England, which reflects previous years.

Figure 9: Patients receiving opioid pain medicines by region in 2023 (12 April to 9 May 2023) and 2024 (29 February to 27 March 2024)

Full details about the dashboard specifications are on the NHS Business Services Authority website.

We also looked at prescribing of ‘high oral morphine equivalent’ volume of opioid prescribing, in combination with other medicines, such as gabapentinoids, antidepressants and z-drugs (figure 10). The risk of harm increases substantially at doses above an oral morphine equivalent of 120mg/day, but there is no increased benefit. Risk can be increased further when this is prescribed alongside these other medicines.

Figure 10: High oral morphine equivalent prescribing with other medicines, 29 February to 27 March 2024

The dashboard provides a useful snapshot of data that prescribers and their teams can look at to help identify and manage higher risk prescribing. This data is available at practice level to support this work. Some academic health science networks have produced useful webinars on the functionality of the dashboard and also compiled a range of resources and opioid deprescribing toolkits that can help to support teams working to reduce the risk of harm from opioids.

Fentanyl patch prescribing

Last year we looked at how fentanyl patches are prescribed for older adults. We have followed up on this in 2023 (figure 11).

Figure 11: Fentanyl patch prescribing by age band

Total number of items prescribed:

• 727,614 total items prescribed in 2023 (including 3,277 with ages unknown)
• 856,722 total items prescribed in 2022 (including 4,149 with ages unknown)

Overall there has been a 15% decrease in the prescribing of fentanyl patches in 2023 compared with 2022 (prescribing reduced by 8% between 2021 and 2022). This year, the biggest year-on-year reduction in prescribing (19% reduction) was in the group aged 80 and over. Although it is not possible to tell if this reduced prescribing is specifically a result of deprescribing initiatives, it may be seen as a positive trend, given the importance of ensuring that prescribing of these medicines is clinically appropriate, especially on an extended basis in older adults.

Prescribing in NHS hospitals for community pharmacy dispensing

In 2023, hospital prescribing (on FP10HP prescription forms that can be dispensed in a community pharmacy) was also broadly in line with 2022 (figures 12 and 13).

Total controlled drug items across Schedules 2 to 5 prescribed in hospital using an FP10(HNC) or FP10SS form:

978,220 items in 2023

956,529 items in 2022
(an increase of 2%)

The cost of this was £16,420,698 in 2023 compared with £15,876,710 in 2022 (an increase of 3%)

Of all prescribing of controlled drugs in hospitals for dispensing in a community pharmacy:

• Schedule 2 accounted for 51%
• Schedule 3 accounted for 16%
• Schedule 4 accounted for 20%
• Schedule 5 accounted for 12%

Note: Percentages may not add to 100% due to rounding

Figure 12: Key reductions in hospital prescribing of controlled drugs for community pharmacy dispensing in 2023

Figure 13: Key increases in hospital prescribing of controlled drugs for community pharmacy dispensing in 2023

Figure 14: Number of items of methylphenidate, lisdexamfetamine and dexamfetamine prescribed in hospital for dispensing in the community in community in England, 2017 to 2023

NHS Community Pharmacist Consultation Service

The national NHS Community Pharmacist Consultation Service (CPCS) aims to reduce pressure on primary and urgent care services, including emergency departments and out-of-hours GP services. The service refers people to community pharmacies for advice, treatment, and urgent repeat prescriptions, and may supply certain controlled drugs in specific circumstances for a limited period.

Of all controlled drugs supplied in 2023, the majority supplied were in Schedule 5. We continue to see increases in the number of controlled drugs supplied through the CPCS. This could be associated with pressures in primary care, particularly in relation to timely access to GP services.

The controlled drugs most commonly supplied by the service in 2023 were:

• co-codamol (in a range of forms, including tablets and capsules) 30/500mg, 15/500mg and 8/500mg
• codeine 15mg and 30mg tablets
• dihydrocodeine 30mg tablets
• morphine sulphate oral solution 10mg/5ml
• clonazepam 500mcg tablets
• clobazam 10mg tablets
• co-dydramol 10/500mg tablets
• diazepam 2mg tablets
• zopiclone 7.5mg tablets

Private controlled drug prescribing in independent primary care

Total controlled drug items prescribed privately across independent primary care services:

390,788 items in 2023

225,482 items in 2022

This is an increase of 73%. As in 2022, the main contribution towards this trend comes from the increased prescribing of Schedule 2 controlled drugs licensed to treat ADHD.

Of all private prescribing of controlled drugs in independent primary care:

• Schedule 2 accounted for 97%
• Schedule 3 accounted for 3%

(Schedule 4 and 5 prescribing collectively accounted for less than 1% overall. Even though there is no requirement for Schedule 4 and 5 controlled drugs to be prescribed on the private prescription form FP10PCD, this sometimes still happens, which is why we always see a small percentage of these medicines in the data).

Private prescribing of Schedule 2 controlled drugs

Prescribing of Schedule 2 controlled drugs alone increased by 80%:

378,049 total items in 2023

211,130 total items in 2022

This figure does not include unlicensed cannabis-based products for medicinal use and has largely been driven by the increase in prescribing for medicines licensed for ADHD (figures 15 and 16).

Figure 15: Schedule 2 controlled drugs prescribed in independent primary care in 2023

Figure 16: Number of items of methylphenidate, lisdexamfetamine and dexamfetamine prescribed annually in independent primary care in England, 2017 to 2023

We continue to monitor arrangements around safe prescribing of medicines to treat ADHD for people whose care is shared between different services. Although there were shortages of these medicines during 2023 and into 2024, we continue to see increased prescribing volumes. Increasing volumes is particularly evident in the private sector, which may be a result of long waiting times for access to NHS care.

Private prescribing of Schedule 3 controlled drugs

12,411 total items prescribed in 2023

13,383 total items prescribed in 2022
(a decrease of 7%)

Pregabalin: is the most prescribed drug in Schedule 3, accounting for 56% of all Schedule 3 prescribed items:

6,922 total items in 2023

7,395 total items in 2022
(a decrease of 6%)

Prescribing of some other Schedule 3 controlled drugs has reduced in 2023 compared with 2022 (figure 17):

Figure 17: Reductions in private prescribing of Schedule 3 controlled drugs in 2023

Requisitions

Requisitions are documents that allow the appropriate people to order medicines for use in their professional practice, such as ordering a stock of controlled drugs that are later administered to patients.

The volume of requisitions has increased in the last year:

15,739 total items requisitioned in 2023

10,725 total items requisitioned in 2022
(an increase of 47%)

Looking at where these requisitions came from in 2023:

• 74% of all requisitions were from NHS providers (compared with 65% in 2022)
• 26% were from independent organisations (compared with 35% in 2022)

The top 10 controlled drugs on requisition remained the same in 2023 as for 2022. Figure 18 shows the most commonly requisitioned controlled drugs in 2023.

Figure 18: Requisitions of Schedule 2 and 3 controlled drugs in 2023