The safer management of controlled drugs: Annual update 2022
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National trends in the prescribing of controlled drugs
Notes on data: Data on prescribing is collected by ePACT2 – an online application that provides authorised users with access to prescription data held by NHS Business Services Authority. For prescribing in the NHS, including hospitals and dental services, we have extracted data from this application for the years 2020, 2021 and 2022 to provide overall figures and trend analysis. For non-medical prescribing, the NHS Community Pharmacist Consultation Service, and requisitions and prescribing in independent primary care, the data for 2022 was supplied directly by NHS Business Services Authority.
We have not updated the data for 2021 that we published in our 2022 annual report. This is because there may be changes to overall figures as ePACT2 may be updated over time.
This year, we include our raw analysis in open format files. This will enable teams with a remit in controlled drugs to make more use of this data.
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 2022
Total controlled drug items prescribed by NHS primary care services:
73,880,442 items in 2022
73,807,554 items in 2021
(a small increase of less than 0.5%)
The cost of this was £547,248,678 in 2022 compared with £575,120,712 in 2021 (a decrease in cost of 5%).
The most notable prescribing trends in NHS primary care in 2022 include:
- Marked increases in prescribing volumes of medicines that are licensed to treat attention deficit hyperactivity disorder (ADHD), such as dexamfetamine, lisdexamfetamine and methylphenidate. This is also echoed in the private prescribing trends.
- An increase in testosterone prescribing, which could be linked to increased awareness of its use for women experiencing menopause.
- A reduction in prescribing of pethidine, co-proxamol, temazepam and fentanyl.
- A reduction in prescribing of diamorphine. We did not see any corresponding increase of prescribing of morphine.
- An increase in non-medical prescribing overall, with pharmacists now undertaking just over half of this.
- Reductions in prescribing by NHS dentists, possibly linked to dental access issues.
- Higher prescribing of opioids in the North of England, which echoes trends we have seen in previous years.
Figure 3 shows overall prescribing levels in 2022 compared with the previous year.
Figure 3: Prescribing of controlled drugs by schedule in 2022
| Schedule 2 up by 1% |
9,226,618 total items in 2022 9,109,102 total items in 2021 |
|---|---|
| Schedule 3 up by 1% |
26,008,549 total items in 2022 25,836,714 total items in 2021 |
| Schedule 4 down by 2% |
13,062,052 total items in 2022 13,342,781 total items in 2021 |
| Schedule 5 up by less than 0.5% |
25,583,223 total items in 2022 25,518,957 total items in 2021 |
Of all prescribing of controlled drugs in primary care:
- Schedule 2 accounted for 12%
- Schedule 3 accounted for 35%
- Schedule 4 accounted for 18%
- Schedule 5 accounted for 35%
Patterns of prescribing in NHS primary care
In 2022, of the most prescribed controlled drugs, there was a reduction in prescribing for a number of controlled drugs compared with 2021 (figure 4).
Figure 4: Reductions in prescribing of controlled drugs in 2022
| Diamorphine (Schedule 2) down by 65% |
8,979 total items in 2022 25,402 total items in 2021 |
|---|---|
| Temazepam (Schedule 3) down by 23% |
555,427 total items in 2022 720,110 total items in 2021 |
| Co-proxamol (Schedule 5) down by 14% |
6,728 total items in 2022 7,833 total items in 2021 |
| Oxazepam (Schedule 4) down by 12% |
52,267 total items in 2022 59,346 total items in 2021 |
| Pethidine (Schedule 2) down by 12% |
7,157 total items in 2021 8,123 total items in 2022 |
| Fentanyl (Schedule 2) down by 8% |
812,439 total items in 2022 879,786 total items in 2021 |
| Nitrazepam (Schedule 4) down by 7% |
313,265 total items in 2022 335,309 total items in 2021 |
| Co-dydramol (Schedule 5) down by 6% |
1,426,820 total items in 2022 1,522,217 total items in 2021 |
| Phenobarbital (Schedule 3) down by 5% |
161,063 total items in 2022 169,776 total items in 2021 |
| Zopiclone(Schedule 4) down by 4% |
4,681,170 total items in 2022 4,872,068 total items in 2021 |
| Methadone (Schedule 2) down by 3% |
1,785,152 total items in 2022 1,836,787 total items in 2021 |
| Dihydrocodeine (Schedule 5) down by 2% |
1,432,483 total items in 2022 1,460,884 total items in 2021 |
| Diazepam (Schedule 4) down by 2% |
4,339,653 total items in 2022 4,448,994 total items in 2021 |
At the same time, of the most prescribed controlled drugs, there was an increase in prescribing in 2022, compared with 2021 (figure 5).
Figure 5: Increases in prescribing of controlled drugs in 2022
| Lisdexamfetamine (Schedule 2) up by 45% |
387,490 total items in 2022 266,918 total items in 2021 |
|---|---|
| Dexamfetamine (Schedule 2) up by 35% |
78,824 total items in 2022 58,494 total items in 2021 |
| Testosterone (Schedule 4) up by 15% |
334,161 total items in 2022 291,309 total items in 2021 |
| Methylphenidate (Schedule 2) up by 12% |
1,334,860 total items in 2022 1,188,128 total items in 2021 |
| Pregabalin (Schedule 3) up by 5% |
8,636,909 total items in 2022 8,243,352 total items in 2021 |
| Midazolam (Schedule 3) up by 5% |
354,614 total items in 2022 338,178 total items in 2021 |
NHS non-medical prescribing
Overall prescribing of controlled drugs by non-medical prescribers (healthcare professionals other than a doctor or dentist) increased during 2022:
4,799,328 items prescribed in 2021
5,152,958 items prescribed in 2022
(an increase of 7%)
Figure 6: Non-medical prescribing of controlled drugs in 2022
| Pharmacist prescribing up by 12% |
2,645,819 total items in 2022 2,361,921 total items in 2021 |
|---|---|
| Nurse prescribing up by 3% |
2,499,873 total items in 2022 2,427,897 total items in 2021 |
| Paramedic prescribing down by 30% |
5,897 total items in 2022 8,415 total items in 2021 |
| Physiotherapist prescribing up by 19% |
1,171 total items in 2022 984 total items in 2021 |
| Radiographer prescribing up by 181% |
101 total items in 2022 36 total items in 2021 |
| Podiatrist prescribing up by 33% |
97 total items in 2022 73 total items in 2021 |
Prescribing by pharmacists accounted for 51% of all non-medical prescribing in 2022 (2,645,819 items). This is an increase of 12% since 2021. It is the first time that pharmacists have undertaken more than half of all non-medical prescribing as a professional group. Pharmacist prescribers are increasingly working in GP practices and primary care networks and this trend is likely to continue, particularly as all newly-qualified pharmacists will be independent prescribers by 2026.
Paramedic prescribing has decreased by 30% in contrast to an increase last year of 153%. Independent paramedic prescribers are not yet able to legally prescribe controlled drugs. Although recommendations were made to change the law, this has not yet progressed. The decrease in prescribing could be because of better awareness of this issue, certainly in part because NHS England CDAO teams have also been working to follow this up through their monitoring activities during the year.
Although we report increases in prescribing by podiatrists, physiotherapists and radiographers, the figures have increased from a relatively low base in both 2021 and 2020.
Going forward, although non-medical prescribing is increasing, it raises the question of how services ensure this is done safely and effectively. Services that employ non-medical prescribers should have systems to make sure they are working within the limits of their competency. They must also provide staff with appropriate supervision, which includes allocating an appropriate senior member of the relevant clinical team to provide day-to-day supervision. We have seen some good examples of this in our inspections of GP surgeries during 2022, as in the following example.
This practice had started periodic in-house prescribing assessments, which were completed by a GP trainer. This was to ensure that nurse prescribers continued to be competent. The practice encouraged advanced nurse prescribers (ANPs) to write reflections following their annual prescribing audit to identify any learning needs and support their personal revalidation process. The practice also supported continuing professional development for non-medical prescribers.
Peer support among the advanced clinical practitioners enabled them to discuss clinical cases and to use the discussions as learning opportunities. Any specific topics that were identified as learning needs were raised with the primary care network manager, who would then organise a specialist to present at one of the Friday lunchtime training sessions. These training sessions were often recorded so if staff were unable to attend they could access the training at a more convenient time.
We provide guidance on non-medical prescribing to support GP practices with this, and some of the principles are transferable to other settings.
NHS dental prescriptions for controlled drugs
Total controlled drug items prescribed by NHS dentists:
30,790 items in 2022
37,931 items in 2021
(a decrease of 19%)
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 84% of total dental prescribing in 2022.
25,826 items prescribed in 2022
32,516 items prescribed in 2021
(a decrease of 21%)
Diazepam and temazepam: these accounted for 16% of all dental prescribing in 2022. Between 2021 and 2022, prescribing of both medicines decreased (by 6% and 16% respectively).
These patterns in decreased prescribing could be a result of issues related to reduced access to NHS dental treatment.
ePACT2 Opioid comparators dashboard
Last year, we highlighted the newly-released ePACT2 Opioid prescribing comparators dashboard. We showed examples of some of the reports in the dashboard to demonstrate how useful this can be in understanding more about local prescribing issues.
We also 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 2023 remained similar compared with the same period in 2022. Prescribing is still highest in the north of England. This aligns with what we have found in previous years (figure 7).
Figure 7: Number of patients receiving opioid pain medicines per 1,000 patients by region in 2022 (15 April to 12 May 2022) and in 2023 (12 April to 9 May 2023)
| Region | Number of patients receiving opioid pain medicines (2023) | Number of patients receiving opioid pain medicines per 1,000 patients (2023) | Number of patients receiving opioid pain medicines (2022) | Number of patients receiving opioid pain medicines per 1,000 patients (2022) |
|---|---|---|---|---|
| London | 83,122 | 8 | 83,091 | 8 |
| South East | 133,490 | 14 | 133,503 | 14 |
| East of England | 102,000 | 14 | 102,356 | 14 |
| South West | 109,434 | 18 | 109,391 | 18 |
| Midlands | 219,778 | 19 | 213,790 | 19 |
| North West | 173,375 | 22 | 175,924 | 23 |
| North East and Yorkshire | 242,692 | 27 | 247,650 | 27 |
Full details about the dashboard specifications are on the NHS Business Services Authority website.
More prescribing data from this dashboard is available in our published analytics tables.
Fentanyl patch prescribing
We have also looked at how fentanyl patches are prescribed for older adults.
Figure 8: Fentanyl patch prescribing by age band
| Age: 0-59 | Age: 60-69 | Age: 70-79 | Age: 80+ | Total number of items prescribed |
|---|---|---|---|---|
| 313,611 | 176,841 | 169,966 | 192,155 | 852,573 |
Although we have seen an overall reduction in the prescribing of fentanyl (all pharmaceutical forms, down 8% in 2022), prescribing for people over 70 years old forms a high proportion of all fentanyl patch prescribing. Although prescribing of fentanyl patches can be clinically appropriate in older people, these figures are a reminder of the need for a regular review of prescribing to ensure this is the case, and to reduce the risk of adverse effects.
Prescribing in NHS hospitals for community pharmacy dispensing
In 2022, hospital prescribing (on FP10HP prescription forms that can be dispensed in a community pharmacy) was also broadly in line with 2021.
Total controlled drug items across Schedules 2 to 5 prescribed in hospital using an FP10(HNC) or FP10SS form:
956,529 items in 2022
971,971 items in 2021
(a decrease of 2%)
The cost of this was £ 15,876,710 in 2022 compared with £15,735, 985 in 2021 (an increase of less than 1%).
Of all prescribing of controlled drugs in hospitals for dispensing in a community pharmacy:
- Schedule 2 accounted for 53%
- Schedule 3 accounted for 17%
- Schedule 4 accounted for 20%
- Schedule 5 accounted for 10%
Figure 9: Decreases in hospital prescribing of controlled drugs for community pharmacy dispensing in 2022
| Temazepam (Schedule 3) down by 24% |
2,152 total items in 2022 2,841 total items in 2021 |
|---|---|
| Methadone (Schedule 2) down by 15% |
282,184 total items in 2022 330,620 total items in 2021 |
| Midazolam (Schedule 3) down by 14% |
2,106 total items in 2022 2,444 total items in 2021 |
| Buprenorphine (Schedule 3) down by 14% |
123,600 total items in 2022 143,238 total items in 2021 |
| Chlordiazepoxide (Schedule 4) down by 15% |
1,511 total items in 2022 1,775 total items in 2021 |
Figure 10: Increases in hospital prescribing of controlled drugs for community pharmacy dispensing in 2022
| Lisdexamfetamine (Schedule 2) up by 30% |
46,309 total items in 2022 35,747 total items in 2021 |
|---|---|
| Dexamfetamine (Schedule 2) up by 29% |
5,627 total items in 2022 4,359 total items in 2021 |
| Methylphenidate (Schedule 2) up by 19% |
161,943 total items in 2022 135,693 total items in 2021 |
NHS Community Pharmacist Consultation Service
The national NHS Community Pharmacist Consultation Service (CPCS) was launched in October 2019. It 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.
The controlled drugs most commonly supplied by the service in 2022 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 10 mg tablets
- co-dydramol 10/500mg tablets
- diazepam 2mg and 5mg tablets
Private controlled drug prescribing in independent primary care
Total controlled drug items prescribed privately across independent primary care services:
225,482 items in 2022
131,999 items in 2021
This is an increase of 71% – the main contribution towards this trend comes from the increased prescribing of schedule 2 controlled drugs licenced to treat ADHD.
Of all private prescribing of controlled drugs in independent primary care:
- Schedule 2 accounted for 94%
- Schedule 3 accounted for 6%
Private prescribing of Schedule 2 controlled drugs
Prescribing of Schedule 2 controlled drugs alone increased by 80%:
211,130 total items in 2022
117,431 total items in 2021
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.
Figure 11: Schedule 2 controlled drugs prescribed in independent primary care
| Methylphenidate accounted for 47% (up by 88%) |
98,115 total items in 2022 52,080 total items in 2021 |
|---|---|
| Lisdexamfetamine accounted for 42% (up by 87%) |
89,297 total items in 2022 47,831 total items in 2021 |
| Dexamfetamine accounted for 8% (up by 46%) |
15,830 total items in 2022 10,831 total items in 2021 |
Last year, we highlighted concerns about increased prescribing volumes of Schedule 2 controlled drugs combined with shared care arrangements, which meant that this was an area of risk. We raise this risk again in this report and will continue to monitor this.
We did not see any significant reductions in private prescribing for other Schedule 2 controlled drugs during 2022.
Private prescribing of Schedule 3 controlled drugs
13,383 total items prescribed in 2022
14,022 total items prescribed in 2021
(a decrease of 5%)
Pregabalin: although the volume prescribed was lower, it was still the most prescribed drug in Schedule 3, accounting for 55% of all Schedule 3 prescribed items:
7,395 total items in 2022
7,798 total items in 2021
(a decrease of 5%)
Midazolam: we saw an increase in private primary care prescribing:
977 total items in 2022
622 total items in 2021
(an increase of 57%)
Prescribing of some other Schedule 3 controlled drugs has reduced in 2022 compared with 2021 (figure 12):
Figure 12: Reductions in prescribing of Schedule 3 controlled drugs in 2022
| Temazepam down by 30% |
595 total items in 2022 848 total items in 2021 |
|---|---|
| Gabapentin down by 11% |
964 total items in 2022 1,083 total items in 2021 |
| Buprenorphine down by 7% |
2,150 total items in 2022 2,311 total items in 2021 |
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 decreased in the last year:
12,444 total items requisitioned in 2022
14,384 total items requisitioned in 2021
(a decrease of 13%)
Looking at where these requisitions came from in 2022:
- 62% of all requisitions were from NHS providers (compared with 59% in 2021)
- 38% were from independent organisations (compared with 41% in 2021)
The top 10 controlled drugs on requisition remained the same in 2022 as for 2021, apart from methadone, which was replaced by lisdexamfetamine. Figure 13 shows the most commonly requisitioned controlled drugs in 2022.
Figure 13: Requisitions of Schedule 2 and 3 controlled drugs in 2022
| Pregabalin | 16% of all requisitions (1,826 total items) |
|---|---|
| Methylphenidate | 12% of all requisitions (1,522 total items) |
| Gabapentin | 8% of all requisitions (1,026 total items) |
| Morphine sulfate | 8% of all requisitions (1,008 total items) |
| Midazolam | 8% of all requisitions (1,030 total items) |
| Oxycodone | 7% of all requisitions (826 total items) |
| Buprenorphine | 5% of all requisitions (666 total items) |
| Fentanyl | 5% of all requisitions (662 total items) |
| Lisdexamfetamine | 4% of all requisitions (549 total items) |
| Tramadol | 4% of all requisitions (438 total items) |