Patterns of analgesic prescribing and high-risk prescribing in primary care in Ireland 2014-2022 – a repeated cross-sectional study

Patterns of analgesic prescribing and high-risk prescribing in primary care in Ireland 2014-2022 – a repeated cross-sectional study | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Patterns of analgesic prescribing and high-risk prescribing in primary care in Ireland 2014-2022 – a repeated cross-sectional study View ORCID Profile Molly Mattsson , View ORCID Profile Ahmed Hassan Ali , View ORCID Profile Fiona Boland , View ORCID Profile Michelle Flood , View ORCID Profile Ciara Kirke , View ORCID Profile Emma Wallace , View ORCID Profile Derek Corrigan , View ORCID Profile Mary E Walsh , View ORCID Profile Tom Fahey , View ORCID Profile Brian MacKenna , View ORCID Profile Frank Moriarty doi: https://doi.org/10.1101/2025.04.08.25325447 Molly Mattsson 1 School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences , Dublin, Ireland Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Molly Mattsson Ahmed Hassan Ali 1 School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences , Dublin, Ireland Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Ahmed Hassan Ali Fiona Boland 2 Data Science Centre, RCSI University of Medicine and Health Sciences , Dublin, Ireland Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Fiona Boland Michelle Flood 1 School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences , Dublin, Ireland Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Michelle Flood Ciara Kirke 3 National Medication Safety Programme, HSE National Quality and Patient Safety Directorate , Dublin, Ireland Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Ciara Kirke Emma Wallace 4 Department of General Practice, University College Cork , Cork, Ireland Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Emma Wallace Derek Corrigan 5 Health Technology Assessment Directorate, Health Information and Quality Authority , Dublin, Ireland Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Derek Corrigan Mary E Walsh 1 School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences , Dublin, Ireland 6 School of Public Health, Physiotherapy and Sports Science, University College Dublin , Ireland Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Mary E Walsh Tom Fahey 7 Department of General Practice, RCSI University of Medicine and Health Sciences , Dublin, Ireland Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Tom Fahey Brian MacKenna 8 The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford , Oxford, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Brian MacKenna Frank Moriarty 1 School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences , Dublin, Ireland Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Frank Moriarty For correspondence: frankmoriarty{at}rcsi.ie Abstract Full Text Info/History Metrics Supplementary material Data/Code Preview PDF Abstract Background Pain is a significant burden on individuals, healthcare systems, and society. Analgesic drugs carry many therapeutic benefits; however, all drugs are associated with adverse effects and risk of harm. Non-steroidal anti-inflammatory drugs (NSAIDs) and opioids have been identified as particularly high-risk due to the risk of side effects and/or dependency. This study aims to examine how patterns of analgesic prescribing have changed in primary care in Ireland between 2014 and 2022. Methods Monthly data on medicines prescribed and dispensed in primary care on the means-tested General Medical Services (GMS) scheme in Ireland was used. Prevalence, initiations, discontinuations, chronic use, and high-risk prescribing, as defined by Scottish Polypharmacy Guidance, were summarised per year. Results The prevalence of overall analgesic use decreased slightly over time, with 48.3% of GMS-eligible individuals dispensed an analgesic in 2014 and 46.3% in 2022. This was largely driven by decreasing NSAID use, from 29.4% in 2014 to 25.0% in 2022. Prevalence for all other analgesic drug classes increased, however after age/sex adjustment, higher odds of use in 2022 vs 2014 only persisted for gabapentinoids and amitriptyline. Some forms of high-risk prescribing increased over time, including NSAIDs dispensed with oral anticoagulants, corticosteroids, and SSRIs, with fewer decreasing. Discussion There was an overall reduction of analgesic use in Ireland, driven by decreasing systemic NSAID use. While most other analgesic drug classes are increasing, this may largely be explained by changing demographics, particularly the age profile of the population. Despite this, interventions addressing rising high-risk prescribing may be needed. Statement of Significance Analgesic drug classes are an important focus for improving medication safety. The findings of this study suggest an overall reduction of analgesic use in Ireland, driven by a decrease in systemic NSAID use. Increasing use of other analgesic drug classes may largely be explained by a change in demographics, particularly the age profile of the population. Analgesic use, and high-risk prescribing remains high and suggest a need for enhanced availability of and access to non-pharmacological services and interventions, as well as improved education and deprescribing support for healthcare professionals. Background Pain is one of the most common reasons people seek medical care 1 . The prevalence of chronic pain estimated at 20-44% in different studies 2 - 4 . Pain management is a complex process influenced by clinical and patient-specific factors including diagnostic uncertainty, individual patient preferences, and challenges associated with managing both physical and mental health multimorbidities 5 , 6 . Pharmacological management of pain depends on the type and duration of pain experienced. While drug treatments may offer many therapeutic benefits, all drugs have potential for adverse effects and harm, and some pose risk of dependency. Harm associated with acute pain treatment is more likely to be short-term or reversible, however prolonged analgesic use for chronic pain may present a variety of risks requiring careful consideration. Among the risks of analgesic treatments, opioids are particularly high-risk and are no longer recommended as a first-line treatment for any form of chronic pain. In Ireland they are not routinely recommended for most cases of acute pain except in in-patient settings for short-term use as part of balanced multimodal analgesia 7 . Despite these guidelines, recent research in Ireland has shown an increase in opioid prescribing among individuals with public health cover rising from 14.4% in 2010 to 16.3% in 2019, with the greatest increase in the ≥65 years age group 8 . However, trends in opioid prescribing should be considered in the context of overall analgesic prescribing patterns. Changes may reflect variation in prevalence of pain conditions and the balance between medication initiation, chronic use and discontinuation. Decreased opioid use may lead to greater use of alternative analgesics, each with their own risks. For example, non-steroidal anti-inflammatory drugs (NSAIDs) are another important focus for medication safety, given increased risks of gastrointestinal bleeding, acute kidney injury, and adverse cardiovascular events, particularly in older adults 9 . Similarly gabapentinoid prescribing has increased globally since they were initially introduced along with increased misuse and abuse 10 , and increased mortality when used in combination with opioids 11 . Reduction of medication-related harm has become an increasing priority internationally, driven by the World Health Organisation’s (WHO) Third Global Patient Safety Challenge, Medication Without Harm 12 . One of the challenge’s three focus areas is higher-risk situations, which includes prescribing of specific medications like opioids and NSAIDs. Several other national/international initiatives to reduce medication harm with some focus on analgesics have been developed. Scotland’s Polypharmacy Guidance highlights indicators of potentially inappropriate prescribing, including multiple indicators relating to NSAIDs, opioids and gabapentinoidss 13 . Similarly, three of the eleven Organisation for Economic Co-operation and Development (OECD) quality indicators for prescribing in primary care relate to analgesic drugs 14 . In addition, more specific interventions to assess and improve higher-risk prescribing have been implemented in various settings. In the UK, the roll-out of the PINCER intervention has involved training pharmacists working in general practice to provide feedback, education, and support to GP practices, systematically identifying and proactively reviewing high-risk prescribing, including NSAID use 15 . Given the increasing global emphasis on reducing medication-related harm and the well-documented risks associated with analgesics, it is important to understand prescribing trends in different settings. Primary care plays a key role in pain management and accounts for the largest volume of analgesia prescribing, making changes in prescribing practices particularly important with patient safety implications. Therefore, this study aims to examine changes in analgesic prescribing in Irish primary care between 2014 and 2022. By identifying trends in prescribing practices, the research will provide evidence that can inform patient safety initiatives and policy decisions. Methods This is a repeated cross-sectional study of medicines dispensed in primary care in Ireland from 2014 to 2022. The protocol for the overarching project has been previously published 16 . The study was approved by the RCSI University of Medicine and Health Sciences Research Ethics Committee (ref: REC202201015) and Health Service Executive (HSE) Reference Research Ethics Committee B (ref: RRECB1022FM). Population and data sources This study includes individuals eligible for the General Medical Services (GMS) scheme which is based on age and income and covers approximately 32% of the population, typically those more socioeconomically deprived than the general population 17 . Data on GMS prescribing is held by the Health Service Executive (HSE) Primary Care Reimbursement Service (PCRS), which processes pharmacy claims for dispensed medications. The PCRS pharmacy claims database is a national source widely used in pharmaceutical policy and pharmacoepidemiology research in Ireland 17 . Data for this study were obtained from the PCRS through an information request and provided to the research team under a data transfer agreement. Analgesics were identified using WHO Anatomical Therapeutic Chemical (ATC) Classification codes and include opioids, paracetamol, NSAIDs, topical analgesics, antimigraine preparations, gabapentinoids, and low-dose amitriptyline. See Supplementary Table 1. Data were at the level of individual medications dispensed to a patient. For each item, information included anonymised identifiers for individuals, date of dispensing, sex and age group of the individual, drug ATC code, product name and strength, quantity dispensed, and cost. Anonymised identifiers were created by the PCRS for the purpose of data sharing and cannot be linked to actual individuals by the researchers or others. Defined daily doses were applied to relevant ATC codes based route of administration 18 . Outcomes Outcomes were derived to capture patterns of prescribed analgesia utilisation, including: Age group and sex-specific volume of use Prevalence of use, both overall and by age group and sex Prevalence of initiations, discontinuations, and chronic use Prevalence of high-risk use (defined below). All outcomes were calculated for each year from 2014 to 2022. Outcomes were derived for all drug classes. For opioids, outcomes were further calculated for each individual drug, as well as weak and strong opioids and long-acting opioid formulations as outlined in Supplementary Table 1. Systemic NSAIDs, outcomes were also derived for COX-2 inhibitors and non-selective NSAIDs, and among topical products for lidocaine plasters, capsaicin, and topical NSAIDs. Products containing paracetamol were calculated for all paracetamol products, including opioid combinations, and non-combination products. Outcomes were also derived for other analgesics, specifically pregabalin, gabapentin, and low-dose amitriptyline. Number of dispensings, cost, and standard doses were expressed as rates per 1,000 population by sex and age group. PCRS annual reports provide numbers of eligible individuals at the end of each calendar year 19 . Standard doses, accounting for prescription quantity, potency, pack size and strength, based on WHO Defined Daily Doses (DDD), 20 were calculated for all medications. For opioids, oral morphine equivalents (OME) were also calculated. These were derived to both single and combination medications, with strengths mapped to standard dose for each component ingredient in the case of the latter (see Supplementary Table 2). Pattern of use outcomes derived include prevalence of use, initiations, discontinuations, and chronic use, as well as high-risk polypharmacy dispensing indicators as defined by the Scottish Polypharmacy Guidance 13 . Prevalence, initiations, discontinuations, and chronic use were all further calculated by age group and sex. High-risk dispensing indicators related to NSAIDs dispensed with medications increasing the risk of bleeding, acute kidney injury, or seizures, opioids dispensed with medications increasing the risk of falls and delirium (outlined in Supplementary Table 3), and opioids and gabapentinoids dispensed at doses increasing the risk of dependency. Prevalence was calculated as the proportion of individuals with any occurrence, and percentage of dispensings of the relevant analgesic drug class considered high risk. An overview of the included outcomes is provided in Supplementary Table 4. In addition to describe outcomes over time, the aim of the analysis was to explore trends in prevalence and determine whether a linear trend was present over time. To examine the prevalence of individual drug classes and the percentage of people with a high-risk dispensing, univariable and multivariable regression analyses were conducted, using a generalised linear model with a logit link and the binomial distribution. Univariable models included year as an independent variable, and multivariable models further adjusted for age group and sex. All analyses were conducted using Stata version 18 (College Station, TX: StataCorp LLC). Statistical significance was set at p<0.05. Results The number of GMS eligible patients during the study period decreased from 1,768,700 in 2014 to 1,568,379 in 2022 (see Supplementary Table 5). Trends over time are reported descriptively as changes for the full GMS population. The prevalence of all analgesic use decreased slightly during the study period, with 48.3% of all GMS eligible individuals dispensed an analgesic in 2014 and 46.3% in 2022. The largest decrease in prevalence for a drug class was systemic NSAIDs, from 29.4% in 2014 to 25.0% in 2022. Prevalence for all other analgesic drug classes increased during the study period; opioids increased from 19.7% in 2014 to 20.8% in 2022, paracetamol from 29.7% in 2014 to 32.0% in 2022, topical analgesics from 14.0% to 14.9%, and other analgesics (low-dose amitriptyline, pregabalin, and gabapentin) from 7.6% in 2014 to 9.6% in 2022. For opioids, the individual drugs with the highest prevalence were codeine (which increased from 12.8% to 14.9%), tramadol (which decreased from 7.3% to 5.4%) and oxycodone (which increased from 1.2% to 2.1%), see Supplementary Table 6. All drug classes saw a decrease in prevalence of use in 2020, coinciding with the onset of the COVID-19 pandemic. Although prevalence increased again after 2020 for all drug classes, 2021 and 2022 prevalence were lower for all drug classes compared to 2019, with the exception of other analgesics (gabapentin, pregabalin, and low-dose amitriptyline). See Figure 1 and Supplementary Table 6. Download figure Open in new tab Figure 1. Prevalence of analgesic use between 2014 and 2022 by drug class For opioids, prevalence of use was consistently highest in the 75+ age group, remaining stable around 35%, followed by the 65-69, 55-64, and 70-74 age groups. Opioid use prevalence was stable throughout the study period for most age groups; however, decreases were seen for both 16-24 and 25-34 year olds, and an increase was seen for 65-69 year olds. Similar results were seen for gabapentinoids, with the highest prevalence seen in the oldest age groups. For systemic NSAIDs, prevalence decreased for all age groups during the study. The highest prevalence was amongst middle-aged adults, with the highest prevalences in those aged 45-54 years (39.2% in 2014 and 36.1% in 2022), followed by the 55-64, and 35-44 age groups. Comparatively lower prevalence was seen for the oldest age groups, with prevalence in those aged ≥75 decreasing from 28.8% to 22% (see Figure 2 and Supplementary Table 7). Download figure Open in new tab Download figure Open in new tab Figure 2. Prevalence of opioid (top) and systemic NSAID (bottom) use between 2014 and 2022 by age group Females had a higher prevalence of use for all drug classes; for opioids this was 23-24% during the study versus 16-17% in males. Prevalence of systemic NSAID use decreased from 33% to 29% in women, and from 25% to 20% in men (see Figure 3 and Supplementary Table 7). Rates of dispensings, cost, DDDs, and OMEs calculated by age group and sex followed a similar pattern to the prevalence of use. Full results are available as supplementary data (see data availability statement). Download figure Open in new tab Figure 3. Prevalence of use of opioids (solid lines) and NSAIDs (dashed lines) for females (blue) and males (orange) between 2014 and 2022 In regression models adjusting for age group and sex, the odds of being dispensed all drug classes decreased over the study, with the exception of other analgesics i.e. gabapentionoids and amitriptyline (see Table 1 ). View this table: View inline View popup Download powerpoint Table 1. Unadjusted and adjusted regression for the yearly change in prevalence of use (i.e. receipt of any dispensing) and high-risk dispensings Between 2015 and 2022, initiations of opioids (12.7% versus 14.0%) and paracetamol (13.2% versus 14.5%) increased slightly ( Table 2 ). The prevalence of initiations dropped in 2020 for all drug classes and remained below 2019 levels in 2021 and 2022. Discontinuations remained relatively stable for all drug classes over the study period, while there were increases in prevalence of chronic use of opioids (6.1% versus 7.5%), paracetamol (5.0% versus 7.7%), and other analgesics (4.7% and 6.2%). The percentage of all opioid dispensings constituting chronic use increased from approximately 30% to 35%, while the percentage of chronic paracetamol dispensings increased from 29% to 38% of all paracetamol dispensings (see Supplementary Table 6). Full results by age group and sex are available as supplementary data (see data availability statement, and absolute numbers of individuals are reported in Supplementary Table 8. View this table: View inline View popup Download powerpoint Table 2. Prevalence (%) of initiations, discontinuations, and chronic use of analgesic drug classes in the GMS population 1 The prevalence of high-risk dispensings varied during the study period. All high-risk NSAID dispensings relating the risk of bleeding increased, with the exception of non-selective NSAIDs (dispensed with antiplatelets. The largest changes were seen for non-selective NSAIDs dispensed with SSRIs and opioids dispensed with sedating agents in those aged ≥65 years. Among those receiving NSAIDs, the percentage also dispensed an SSRI increased from 3.0% to 4.2%. The percentage of those aged ≥65 years receiving an opioid dispensing with two or more sedating or anticholinergic drugs decreased from 15.4% in 2014 to 14.0% in 2022. Indicators relating to NSAIDs and risk of acute kidney injury decreased during the study period. See Supplementary Table 9 and Figure 4 . Full results by age group and sex are available as supplementary data (see data availability statement). In regression analysis, the change over time in the odds of having a high-risk dispensing was similar after adjusting for age group and sex ( Table 1 ). Download figure Open in new tab Figure 4. Prevalence of high-risk dispensing among users of the relevant analgesic drug class relating to bleeding risk (red), acute kidney injury risk (blue) and dependency risk (grey) * Indicators with prevalence 13% not shown Discussion The prevalence of analgesic use in Ireland across most drug classes increased between 2014 and 2022, including opioids, gabapentinoids, and paracetamol. However, this increase was offset by a decrease in NSAID use, and overall the prevalence of analgesia use decreased slightly. This is consistent with previous research on analgesia prescribing in Ireland 8 , 21 . Previous research has identified higherrates of analgesia dispensings in Ireland compared to England 22 . The results of this study indicate higher prevalence of opioid use compared to Australia 23 . Additionally, the overall prevalence of analgesic use in Ireland appears higher than in Germany, the UK, and France 24 . However, the regression results, accounting for age-group and sex changes in the population over the study period, indicate a lower chance over time of an individual being prescribed any analgesic class, with the exception of gabapentinoids and low-dose amitriptyline. Importantly, the prevalence of several forms of high-risk dispensing is rising, independent of demographic changes, particularly those relating to bleeding risk with NSAIDs. All analgesic drug classes saw a decrease in prevalence of use in 2020, coinciding with the COVID-19 pandemic. Although this increased since, 2021 and 2022 prevalence remained lower than in 2019 for all drug classes bar gabapentinoids and amitriptyline. Previous research in England found that the ‘lockdown’ measures accompanying the COVID-19 pandemic did not impact opioid prescribing in primary care 25 , with similar results identified in the Netherlands 26 . Canadian research on the experience of patients with chronic pain during the pandemic suggested a negative impact on patients’ experience of their care, with changes in treatment impacted by lack of access to prescribers/cancellation of medical appointments, and increased medication prescribing in compensation for stopping physical/psychological treatments 27 . A similar increase was not seen in Ireland, and in fact the observed decrease in 2020 could suggest the pandemic impacted access to prescribed analgesic drugs. The prevalence of opioid, NSAID, and gabapentinoid use were all persistently higher in women compared to men. It is well-established that women have a higher prevalence of chronic pain and are prescribed more analgesics compared to men, although the mechanisms behind this discrepancy are not fully understood 28 . The highest prevalence of opioid and gabapentinoid use was consistently seen in the oldest age groups. Middle-aged groups had the highest prevalence of systemic NSAID use, with lower prevalence among the oldest groups. NSAIDs in older adults have been identified as high-risk prescribing, given renal and cardiovascular harms 29 , and the lower prevalence in these age groups is therefore a positive sign. The prevalence of high-risk opioid dispensing with two or more sedatives in those aged ≥65 years decreased during the study period, which may suggest a move away from inappropriate polypharmacy in this vulnerable age group. The prevalence of NSAIDs dispensed with an SSRI increased, which may be a result of the global increase in SSRI-prescribing in recent years 30 - 32 , a trend which has also been seen in Ireland 33 . Conversely, NSAIDs dispensed with drugs increasing the risk of acute kidney injury decreased slightly. In recent years there have been efforts made to reduce this type of high-risk prescribing. In the UK, the rollout of the pharmacist-led PINCER intervention, targeting patients at risk of medication-harm, across 343 general practices reduced hazardous prescribing by 16.7% at six months and 15.3% at 12 months postintervention 34 . Similarly, the Data-Driven Quality Improvement in Primary Care (DQIP) randomised controlled trial in Scotland found that an intervention, comprising professional education, informatics, and financial incentives to review patients’ records to assess appropriateness, significantly reduced targeted high-risk prescribing 35 . The iSIMPATHY project, introduced pharmacists in Scotland, Northern Ireland, and Ireland to conduct medication reviews 36 . In Ireland, 70.7% of the polypharmacy indicator occurrences identified were resolved post review, 37 suggesting structured medicines review are an important strategy to consider for improving quality of prescribing. Ireland has historically had comparatively high rates of inappropriate prescribing, with one study comparing prescribing in 45-64 year olds in the GMS population in Ireland and the general population in Northern Ireland finding the prevalence in Ireland of potentially inappropriate prescribing more than double that in Northern Ireland 38 . Recent research has shown an overall reduction in high-risk prescribing in Ireland, with strong associations with age and number of chronic medications and with significant variation between prescribers 39 . Greater availability of prescribing data in Ireland would enable audit and feedback interventions for quality improvement of prescribing in these areas. Previous educational interventions involving audit and feedback to improve the quality of prescribing had positive results in Ireland, e.g. the Red-Green antibiotics initiative aimed at community prescribers, which saw an overall increase of 4.3% in prescribing of recommended antibiotics in the first 15 months of the initiative 40 . This study includes individuals eligible for the GMS scheme, which is means-tested and covers approximately 32% of the population. Previous research has identified a higher prevalence of pain among older adults and individuals from disadvantaged backgrounds 3 . A recent study on opioid prescribing in England found a strong association of socioeconomic deprivation with opioid prescribing in primary care 41 . In addition to deprivation being linked to higher analgesic prescribing, it is also linked to developing multimorbidity earlier in life and a more rapid accumulation of physical and mental health conditions 42 , which due to treatment complexity and the single disease focus of clinical guidelines underpinning care may contribute to high-risk prescribing and inappropriate polypharmacy 43 . In that context, it is therefore likely that the Irish GMS population has higher prevalence of analgesia use compared to the general population. Waiting times for GMS patients to access specialist care are extensive, resulting in patients with severe degenerative related chronic pain potentially waiting several years for joint replacement surgery, thus requiring strong analgesics in the meantime. In January 2025, over 61,000 individuals were awaiting an initial orthopaedic out-patient appointment and nearly 12,000 an orthopaedic inpatient appointment (including joint replacement procedures), with around 7,500 and 1,000 people respectively waiting for more than 12 months 44 . Additionally, access to non-pharmacological interventions, including exercise programmes, psychological therapies, acupuncture, and other treatments (e.g. transcutaneous electrical nerve stimulation) for GMS patients is often limited, despite some or all of these interventions being routinely recommended for multiple types of pain (e.g. osteoarthritis, rheumatoid arthritis, sciatica) 45 - 47 . For chronic primary pain (i.e. pain with no underlying condition adequately accounting for the pain or its impact), National Institute for Health and Care Excellence (NICE) guidelines recommend non-pharmacological interventions as primary interventions, with the use of opioids, gabapentinoids, paracetamol, and NSAIDs all discouraged 48 . Although these recommendations have come under criticism for their restrictiveness 49 , access to these non-pharmacological interventions is vital. The main strength of this study is the use of comprehensive data, which has high accuracy and completeness given its primary purpose for pharmacy reimbursement. Further, dispensing-level data linked to individuals permitted examination of patterns of analgesic in greater detail than is possible with aggregate data. A limitation is the study only includes data relating to the means-tested GMS eligible population, with the older and more disadvantaged population not fully representative of the general population. Secondly, the data lacks details of indication for the prescription and patients’ diagnoses, so although drug classes examined are almost exclusively used for pain, we could not examine medication use by type of pain. Although all dispensings related to prescriptions issued in primary care, some of these medications may have been originally initiated in specialist settings. Finally, as we do not have access to eligibility start or end dates, or data on mortality, we are not eligible to account for these factors when analysing initiation and discontinuation patterns, and as data used relates to dispensings, we do not have information on individuals’ adherence to dispensed medicines. Conclusions The findings of this study suggest an overall reduction of analgesic use in Ireland, driven by a decrease in use of systemic NSAIDs. Although prevalence of use for most other drug classes is increasing, this may largely be explained by the increasingly older age profile of the population. Despite improvements in some high-risk indicators, prescribing which increases risk of bleeding and chronic use of some drug classes remains a concern, and suggests a need for effective medicines review services, enhanced availability of non-pharmacological interventions, as well as measures to reduce waiting times for specialist care. It is important that further meaningful analgesic drug utilisation research is enabled, through timely access to appropriate data, in order to support policies and practices to ultimately improve medication appropriateness and patient safety. Data availability The datasets analysed during the current study are not publicly available as this was not covered by the Data Exchange Agreement between RCSI and HSE-PCRS. Data can be requested from HSE-PCRS via an information request as detailed at https://www.hse.ie/eng/staff/pcrs/pcrs-publications/ . Full results for initiations, discontinuations, chronic use, and high-risk dispensings by age group and sex are available from Zenodo (doi: 10.5281/zenodo.14870683) Author contributions FM conceived the study. All authors were involved in the design of the study. MM and FM collected and curated the data. MM, FM, AHA developed the analysis plan. MM and FM conducted the analysis of the data. All authors were involved the interpretation of the analysis results. MM drafted the manuscript, and MF, AHA, EW, FB, CK, MEW, DC, TF, BMacK, and FM critically revised the manuscript. FM acquired funding for the study. Table legends Table 1 Unadjusted and adjusted regression for the yearly change in prevalence of use and high-risk dispensings Table 2. Prevalence (%) of initiations, discontinuations, and chronic use of analgesic drug classes in the GMS population Table 3. Prevalence (%) of high risk dispensings in the GMS population Figure legends Figure 1. Prevalence of use by drug class Figure 2a. Prevalence of opioid use by age group Figure 2b. Prevalence of systemic NSAID use by age group Figure 3 Prevalence of use of opioids (solid lines) and NSAIDs (dashed lines) for females (blue) and males (orange) Figure 4. Percentage of dispensings of the relevant analgesic drug class considered high risk Acknowledgements We would like to acknowledge the wider Controlled Drug Prescribing (CDRx) team. References 1. ↵ St. Sauver JL , Warner DO , Yawn BP , et al. Why Patients Visit Their Doctors: Assessing the Most Prevalent Conditions in a Defined American Population . Mayo Clinic Proceedings . 2013/01/01/ 2013 ; 88 ( 1 ): 56 – 67 . doi: 10.1016/j.mayocp.2012.08.020 OpenUrl CrossRef PubMed Web of Science 2. ↵ Dahlhamer J , Lucas J , Zelaya C , et al. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults - United States, 2016 . MMWR Morb Mortal Wkly Rep . Sep 14 2018 ; 67 ( 36 ): 1001 – 1006 . doi: 10.15585/mmwr.mm6736a2 OpenUrl CrossRef PubMed 3. ↵ Yong RJ , Mullins PM , Bhattacharyya N. Prevalence of chronic pain among adults in the United States . Pain . 2022 ; 163 ( 2 ) 4. ↵ Fayaz A , Croft P , Langford RM , Donaldson LJ , Jones GT . Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies . BMJ Open . 2016 ; 6 ( 6 ): e010364 . doi: 10.1136/bmjopen-2015-010364 OpenUrl CrossRef PubMed 5. ↵ Wang J , Doan LV . Clinical pain management: Current practice and recent innovations in research . Cell Rep Med . Oct 15 2024 ; 5 ( 10 ): 101786 . doi: 10.1016/j.xcrm.2024.101786 OpenUrl CrossRef PubMed 6. ↵ Skou ST , Mair FS , Fortin M , et al. Multimorbidity . Nat Rev Dis Primers . Jul 14 2022 ; 8 ( 1 ): 48 . doi: 10.1038/s41572-022-00376-4 OpenUrl CrossRef PubMed 7. ↵ National Clinical Programme for Anaesthesia . Guidance for quality and safety of opioid prescribing in Acute Hospitals Dublin: HSE ; 2022 . 8. ↵ Norris BA , Smith A , Doran S , Barry M. Trends in strong opioid prescribing in Ireland: A repeated cross-sectional analysis of a national pharmacy claims database between 2010 and 2019 . Pharmacoepidemiol Drug Saf . Aug 2021 ; 30 ( 8 ): 1003 – 1011 . doi: 10.1002/pds.5247 OpenUrl CrossRef PubMed 9. ↵ Davis A , Robson J. The dangers of NSAIDs: look both ways . Br J Gen Pract . Apr 2016 ; 66 ( 645 ): 172 – 3 . doi: 10.3399/bjgp16×684433 OpenUrl FREE Full Text 10. ↵ Driot D , Jouanjus E , Oustric S , Dupouy J , Lapeyre-Mestre M. Patterns of gabapentin and pregabalin use and misuse: Results of a population-based cohort study in France . Br J Clin Pharmacol . Jun 2019 ; 85 ( 6 ): 1260 – 1269 . doi: 10.1111/bcp.13892 OpenUrl CrossRef PubMed 11. ↵ Bharat C , Gisev N , Barbieri S , et al. Prescription opioid use among people with opioid dependence and concurrent benzodiazepine and gabapentinoid exposure: An analysis of overdose and all-cause mortality . International Journal of Drug Policy . 2024/01/01/ 2024 ; 123 : 104287 . doi: 10.1016/j.drugpo.2023.104287 OpenUrl CrossRef PubMed 12. ↵ Medication Without Harm - Global Patient Safety Challenge on Medication Safety ( World Health Organization ) ( 2017 ). 13. ↵ Polypharmacy Guidance , Realistic Prescribing (Scottish Government) ( 2018 ). 14. ↵ OECD . Health care quality indicators . https://www.oecd-ilibrary.org/content/data/e3667ffb-en 15. ↵ Avery AJ , Rodgers S , Cantrill JA , et al. A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis . The Lancet . 2012 ; 379 ( 9823 ): 1310 – 1319 . doi: 10.1016/S0140-6736(11)61817-5 OpenUrl CrossRef PubMed Web of Science 16. ↵ Mattsson M , Boland F , Kirke C , et al. Evaluation of policies and practices to support safe and appropriate analgesic and sedative prescribing: The CDRx (controlled drug prescribing) protocol . Res Social Adm Pharm . Sep 2022 ; 18 ( 9 ): 3588 – 3595 . doi: 10.1016/j.sapharm.2022.03.004 OpenUrl CrossRef PubMed 17. ↵ Sinnott SJ , Bennett K , Cahir C. Pharmacoepidemiology resources in Ireland-an introduction to pharmacy claims data . Eur J Clin Pharmacol . Nov 2017 ; 73 ( 11 ): 1449 – 1455 . doi: 10.1007/s00228-017-2310-7 OpenUrl CrossRef PubMed 18. ↵ Norweigan Institute of Public Health . ATC/DDD Index 2024 . Updated 2024-01-26. https://atcddd.fhi.no/atc_ddd_index/ 19. ↵ Primary Care Reimbursement Service (PCRS ). Eligibility reports. HSE . Accessed July, 2024 . https://www.sspcrs.ie/portal/annual-reporting/report/eligibility 20. ↵ WHO Collaborating Centre for Drug Statistics Methodology . DDD - Definition and general considerations . Accessed July, 2024 . https://www.whocc.no/ddd/definition_and_general_considera/ 21. ↵ Moriarty F , Bennett K , Fahey T. Opioid and analgesic utilization in Ireland in 2000 and 2015: A repeated cross-sectional study . Pharmacol Res Perspect . Jan 2022 ; 10 ( 1 ): e00899 . doi: 10.1002/prp2.899 OpenUrl CrossRef 22. ↵ Mattsson M , Flood M , MacKenna B , et al. Trends in analgesia prescribing in primary care in Ireland and England between 2014 and 2022 - a repeated cross-sectional study . medRxiv . 2024 :2024.06.04.24308266. doi: 10.1101/2024.06.04.24308266 OpenUrl Abstract / FREE Full Text 23. ↵ Lalic S , Ilomäki J , Bell JS , Korhonen MJ , Gisev N. Prevalence and incidence of prescription opioid analgesic use in Australia . British Journal of Clinical Pharmacology . 2019/01/01 2019 ; 85 ( 1 ): 202 – 215 . doi: 10.1111/bcp.13792 OpenUrl CrossRef PubMed 24. ↵ Jacob L , Kostev K. Prevalence of pain medication prescriptions in France, Germany, and the UK - a cross-sectional study including 4,270,142 patients . Postgraduate Medicine . 2018/01/02 2018 ; 130 ( 1 ): 32 – 36 . doi: 10.1080/00325481.2018.1391658 OpenUrl CrossRef 25. ↵ Nawaf Sindi O , Alshaikh FS , Godman B , Kurdi A. The impact of the COVID-19 pandemic lockdown measures on the prescribing trends and utilization of opioids in the English primary care setting: segmented-liner regression analysis . Expert Rev Clin Pharmacol . Jun 2022 ; 15 ( 6 ): 787 – 793 . doi: 10.1080/17512433.2022.2093715 OpenUrl CrossRef PubMed 26. ↵ Ellerbroek H , Schellekens AFA , Kalkman GA , et al. Opioid prescribing in the Netherlands during the COVID-19 pandemic: a national register-based study . BMJ Open . 2024 ; 14 ( 8 ): e082369 . doi: 10.1136/bmjopen-2023-082369 OpenUrl Abstract / FREE Full Text 27. ↵ Lacasse A , Pagé MG , Dassieu L , et al. Impact of the COVID-19 pandemic on the pharmacological, physical, and psychological treatments of pain: findings from the Chronic Pain & COVID-19 Pan-Canadian Study . PAIN Reports . 2021 ; 6 ( 1 ) 28. ↵ !!! INVALID CITATION !!! 40, 41 ; 29. ↵ Wongrakpanich S , Wongrakpanich A , Melhado K , Rangaswami J. A Comprehensive Review of Non-Steroidal Anti-Inflammatory Drug Use in The Elderly . Aging Dis . Feb 2018 ; 9 ( 1 ): 143 – 150 . doi: 10.14336/ad.2017.0306 OpenUrl CrossRef PubMed 30. ↵ Luo Y , Kataoka Y , Ostinelli EG , Cipriani A , Furukawa TA . National Prescription Patterns of Antidepressants in the Treatment of Adults With Major Depression in the US Between 1996 and 2015: A Population Representative Survey Based Analysis. Original Research . Frontiers in Psychiatry . 2020-February-14 2020 ; 11 doi: 10.3389/fpsyt.2020.00035 OpenUrl CrossRef 31. Archer C , MacNeill SJ , Mars B , Turner K , Kessler D , Wiles N. Rise in prescribing for anxiety in UK primary care between 2003 and 2018: a population-based cohort study using Clinical Practice Research Datalink . British Journal of General Practice . 2022 ; 72 ( 720 ): e511 . doi: 10.3399/BJGP.2021.0561 OpenUrl Abstract / FREE Full Text 32. ↵ Lalji HM , McGrogan A , Bailey SJ . An analysis of antidepressant prescribing trends in England 2015–2019 . Journal of Affective Disorders Reports . 2021/12/01/ 2021 ; 6 : 100205 . doi: 10.1016/j.jadr.2021.100205 OpenUrl CrossRef PubMed 33. ↵ McCool A , Lukas K , Hayes P , Kelly D. Antidepressant medication prescribing patterns in Irish general practice from 2016 to 2020 to assess for long-term use . Ir J Med Sci . Oct 2022 ; 191 ( 5 ): 2239 – 2246 . doi: 10.1007/s11845-021-02833-7 OpenUrl CrossRef PubMed 34. ↵ Rodgers S , Taylor AC , Roberts SA , et al. Scaling-up a pharmacist-led information technology intervention (PINCER) to reduce hazardous prescribing in general practices: Multiple interrupted time series study . PLoS Med . Nov 2022 ; 19 ( 11 ): e1004133 . doi: 10.1371/journal.pmed.1004133 OpenUrl CrossRef PubMed 35. ↵ Dreischulte T , Donnan P , Grant A , Hapca A , McCowan C , Guthrie B. Safer Prescribing — A Trial of Education, Informatics, and Financial Incentives . New England Journal of Medicine . 2016 ; 374 ( 11 ): 1053 - 1064 . doi : doi: 10.1056/NEJMsa1508955 OpenUrl CrossRef PubMed 36. ↵ iSympathy Consortium . iSimpathy Evaluation Report . 2023 . 37. ↵ Kinahan C , Kirke C , O’Hagan L , et al. Evaluating the impact of general practice pharmacist-led person-centred medicines reviews on medicines appropriateness and patient-reported outcome measures . British Journal of Clinical Pharmacology . n/a(n/a) doi: 10.1111/bcp.16372 OpenUrl CrossRef 38. ↵ Cooper JA , Moriarty F , Ryan C , et al. Potentially inappropriate prescribing in two populations with differing socio-economic profiles: a cross-sectional database study using the PROMPT criteria . Eur J Clin Pharmacol . May 2016 ; 72 ( 5 ): 583 – 91 . doi: 10.1007/s00228-015-2003-z OpenUrl CrossRef PubMed 39. ↵ Byrne CJ , Cahir C , Curran C , Bennett K. High-risk prescribing in an Irish primary care population: trends and variation . Br J Clin Pharmacol . Dec 2017 ; 83 ( 12 ): 2821 – 2830 . doi: 10.1111/bcp.13373 OpenUrl CrossRef PubMed 40. ↵ HSE . Summary of PCRS AMRIC GP Green Red Reports 2019/2020 for AMRIC Oversight Group & Antimicrobial Stewardship Advisory Group . 2020 . 41. ↵ Nowakowska M , Zghebi S , Perisi R , Chen L , Ashcroft D , Kontopantelis E. Association of socioeconomic deprivation with opioid prescribing in primary care in England: a spatial analysis . Journal of Epidemiology and Community Health . 2021 ; 75 ( 2 ): 128 . doi: 10.1136/jech-2020-214676 OpenUrl Abstract / FREE Full Text 42. ↵ Barnett K , Mercer SW , Norbury M , Watt G , Wyke S , Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study . Lancet . Jul 7 2012 ; 380 ( 9836 ): 37 – 43 . doi: 10.1016/s0140-6736(12)60240-2 OpenUrl CrossRef PubMed Web of Science 43. ↵ Jennings AA , Doherty AS , Clyne B , et al. Stakeholder perceptions of and attitudes towards problematic polypharmacy and prescribing cascades: a qualitative study . Age Ageing . Jun 1 2024 ; 53 ( 6 ) doi: 10.1093/ageing/afae116 OpenUrl CrossRef 44. ↵ The National Treatment Purchase Fund. Detailed Visuals - Specialities https://www.ntpf.ie/home/nwld.htm 45. ↵ National Guideline C . National Institute for Health and Care Excellence: Guidelines. Low Back Pain and Sciatica in Over 16s: Assessment and Management . National Institute for Health and Care Excellence (NICE) Copyright © NICE , 2016 .; 2016. 46. Allen A , Carville S , McKenna F. Diagnosis and management of rheumatoid arthritis in adults: summary of updated NICE guidance . Bmj . Aug 3 2018 ; 362 : k3015 . doi: 10.1136/bmj.k3015 OpenUrl FREE Full Text 47. ↵ Wood G , Neilson J , Cottrell E , Hoole SP . Osteoarthritis in people over 16: diagnosis and management-updated summary of NICE guidance . Bmj . Jan 24 2023 ; 380 : 24 . doi: 10.1136/bmj.p24 OpenUrl CrossRef PubMed 48. ↵ NICE . Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. NICE guideline [NG193] 2021 . 49. ↵ Eccleston C , Aldington D , Moore A , de CWAC. Pragmatic but flawed: the NICE guideline on chronic pain . Lancet . May 29 2021 ; 397 ( 10289 ): 2029 – 2031 . doi: 10.1016/s0140-6736(21)01058-8 OpenUrl CrossRef PubMed View the discussion thread. Back to top Previous Next Posted April 10, 2025. Download PDF Supplementary Material Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. You are going to email the following Patterns of analgesic prescribing and high-risk prescribing in primary care in Ireland 2014-2022 – a repeated cross-sectional study Message Subject (Your Name) has forwarded a page to you from medRxiv Message Body (Your Name) thought you would like to see this page from the medRxiv website. Your Personal Message CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Share Patterns of analgesic prescribing and high-risk prescribing in primary care in Ireland 2014-2022 – a repeated cross-sectional study Molly Mattsson , Ahmed Hassan Ali , Fiona Boland , Michelle Flood , Ciara Kirke , Emma Wallace , Derek Corrigan , Mary E Walsh , Tom Fahey , Brian MacKenna , Frank Moriarty medRxiv 2025.04.08.25325447; doi: https://doi.org/10.1101/2025.04.08.25325447 Share This Article: Copy Citation Tools Patterns of analgesic prescribing and high-risk prescribing in primary care in Ireland 2014-2022 – a repeated cross-sectional study Molly Mattsson , Ahmed Hassan Ali , Fiona Boland , Michelle Flood , Ciara Kirke , Emma Wallace , Derek Corrigan , Mary E Walsh , Tom Fahey , Brian MacKenna , Frank Moriarty medRxiv 2025.04.08.25325447; doi: https://doi.org/10.1101/2025.04.08.25325447 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Tweet Widget Facebook Like Google Plus One Subject Area Primary Care Research Subject Areas All Articles Addiction Medicine (568) Allergy and Immunology (863) Anesthesia (300) Cardiovascular Medicine (4435) Dentistry and Oral Medicine (444) Dermatology (382) Emergency Medicine (608) Endocrinology (including Diabetes Mellitus and Metabolic Disease) (1509) Epidemiology (15229) Forensic Medicine (30) Gastroenterology (1124) Genetic and Genomic Medicine (6600) Geriatric Medicine (668) Health Economics (997) Health Informatics (4536) Health Policy (1368) Health Systems and Quality Improvement (1613) Hematology (541) HIV/AIDS (1264) Infectious Diseases (except HIV/AIDS) (15916) Intensive Care and Critical Care Medicine (1103) Medical Education (623) Medical Ethics (146) Nephrology (667) Neurology (6599) Nursing (346) Nutrition (998) Obstetrics and Gynecology (1144) Occupational and Environmental Health (957) Oncology (3332) Ophthalmology (974) Orthopedics (369) Otolaryngology (420) Pain Medicine (436) Palliative Medicine (130) Pathology (663) Pediatrics (1693) Pharmacology and Therapeutics (691) Primary Care Research (711) Psychiatry and Clinical Psychology (5447) Public and Global Health (9232) Radiology and Imaging (2198) Rehabilitation Medicine and Physical Therapy (1370) Respiratory Medicine (1196) Rheumatology (593) Sexual and Reproductive Health (712) Sports Medicine (530) Surgery (712) Toxicology (99) Transplantation (289) Urology (265) (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'a00b19debe8806f7',t:'MTc3OTYxMzEzMg=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();