Abstract Background Chronic nonmalignant pain (CNMP) is commonly treated with opioids and other analgesics, yet prescribing carries risks and substantial costs. Promotional and financial interactions between clinicians and the pharmaceutical industry may influence analgesic prescribing, but CNMP-relevant evidence has not been systematically synthesized. Methods We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Web of Science from inception to February 2025 (no language restrictions). We included observational studies assessing associations between pharmaceutical industry interactions and analgesic prescribing outcomes relevant to CNMP. Two reviewers independently screened studies, extracted data, assessed risk of bias using ROBINS‑I, and appraised certainty using GRADE. We synthesized findings using SWiM vote counting by direction of effect, and undertook random‑effects meta‑analysis when exposure and outcome definitions were sufficiently similar. Results Ten U.S. observational studies met inclusion criteria. Across 44 outcome contrasts, 38 (86%) were directed towards higher prescribing or higher opioid‑related expenditure among clinicians receiving payments/interactions; 6 contrasts evaluating marketing‑restriction policies were directed towards reduced prescribing. Because prescribing‑volume metrics were heterogeneous (e.g., prescriptions vs. days supplied), we did not pool volume outcomes. For expenditure, meta‑analysis of two studies showed that receipt of opioid‑related payments was associated with higher opioid‑related prescribing expenditure (pooled +$4,785 per physician‑year; 95% CI $2,162 to $7,408; I² = 93.5%). Under ROBINS‑I, studies were at low to moderate overall risk of bias, with residual confounding a key concern. GRADE certainty was moderate for prescribing expenditure and prescribing volume and low for dosage intensity. Conclusions In U.S. real-world prescribing datasets, pharmaceutical industry interactions were consistently associated with higher analgesic prescribing and higher opioid-related expenditures, with repeated evidence of dose–response patterns. Evidence from institutional restriction policies suggests prescribing may be modifiable when promotional access is constrained. However, the evidence is observational and largely does not identify CNMP patients explicitly; residual confounding and indirectness should be considered when interpreting magnitude. Registration PROSPERO CRD42024627184.

BACKGROUND:General practices have been a long-standing focus of pharmaceutical promotion, but their financial relationships with pharmaceutical companies remain understudied. AIM:To examine pharmaceutical company payments to general practices in England from 2015-2022, focusing on changing patterns of payments and what this reveals about companies' marketing. DESIGN & SETTING:Descriptive analysis of pharmaceutical company payments made to practices using data from industry's Disclosure UK database, covering 4430 recipient practices and 54 companies over an 8-year period. METHOD:Annual Disclosure UK data from 2015-2022 were merged, identifying practices using a novel algorithm-based methodology, and categorising payments by type (for example, donations and grants, event sponsorship). Trends were analysed by company and payment type. The Gini coefficient measured payment concentration, and the persistence of relationships was assessed over time. RESULTS:Pharmaceutical payments to general practices rose from £2.5 million in 2015 to £7.5 million in 2022. While 54 companies made payments, just one company, Chiesi - marketing commonly prescribed respiratory inhalers - accounted for more than 50% of the payment value from 2017 onwards. More than 40% of practices received payments from only one company, and 74% of company-practice relationships lasted just 1 study year. A few companies dominated, with a Gini coefficient of 0.86, driven by Chiesi's payments. CONCLUSION:The growing scale and concentration of payments and the dominance of one company raises concerns about bias in general practice. Future research should investigate the impact of payments on clinical decision making, but to do so, payment disclosures need enhanced transparency, particularly through including product-specific payment details.

Background Prescribing epidemiology in general practice shows gabapentinoid drugs to be independently associated with unexpected, drug-related death. There is an increasing trend of gabapentinoid deaths throughout Europe and North America.Objectives The overall aim of this study was to assess how patient, practice and health system factors might be associated with gabapentinoid prescribing in primary care.Methods Case series following a critical incident of an unexpected death in a patient prescribed a gabapentinoid drug in a single general practice. Unexpected and expected deaths in patients prescribed a gabapentinoid drug deaths over an 11-year period in a single general practice. We examined patient, prescriber and health system factors. Toxicology and post-mortem data were provided by the Coroner.Results There were 36 deaths (four unexpected and 32 expected deaths) during the study period. Of the four patients who suffered an unexpected death, one of these patients’ cause of death could be attributed to drug and alcohol toxicity. Over half of gabapentinoid prescribing (n = 19,53%) was hospital initiated, often ‘off-label’ (n = 6, 17%) and commonly co-prescribed with opiates (n = 15, 42%) and benzodiazepines (n = 11, 31%) to patients with high multi-morbidity.Conclusions Gabapentinoids are often initiated in the outpatient setting in clinically complex patients, often for ‘off label’ indications, with high polypharmacy. Patient, practice and health-system related factors need to be addressed in relation to gabapentinoid associated deaths and reflected in clinical practice guidelines. There is critical value in using toxicology reports from Coroner’s offices in cases of unexplained gabapentinoid death in general practice.

Background Interactive dashboards can support safe prescribing but effectiveness depends on user engagement. The research team developed a prescribing safety dashboard, deployed in 27 Irish general practices. Trend graphs tracked prescribing changes (2019-2025) by practices across key metrics. This study explored how GPs engaged with the dashboard and their perceptions of using routine data for prescribing feedback. Methods Prescribers from participating practices were invited to online interviews (May - August 2025). A think-aloud exercise involved participants verbalising their thoughts while navigating the dashboards, followed by a semi-structured interview exploring views on safe prescribing, feedback and data access. Interviews were recorded, auto-transcribed and manually reviewed for accuracy. Think-aloud data were analysed deductively using a sense-making framework, interviews analysed inductively, and findings triangulated to refine themes. Results Nine general practitioners (GPs) from eight practices participated. Themes were organised into four categories: (1) Perceptions of open data, (2) Perceptions of feedback, (3) Dashboard engagement, and (4) High-quality prescribing. Most were in favour of open data and transparency but some feared misuse. GPs valued feedback but reported workload as a barrier. Engagement with the dashboard was mainly interpretative, focused on data meaning in the context of their practice. GPs showed a strong emotional dimension to engagement and also described intended actions in response to what they saw. Finally, high-quality prescribing was mainly viewed as avoiding harm. Conclusions GPs valued and engaged with dashboard feedback but workload competed with time for reflection and action highlighting the need for practical, streamlined tools and nudges to support engagement. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Protocols ### Funding Statement CMC is funded by a Health Research Board Clinician Scientist Fellowship Award (CSF- 2023-012). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ### 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: Ethical approval was granted by the Irish College of General Practitioner Research Ethics Committee, 7th October 2024, ICGP\_REC\_2024_ 2502. All participants gave fully informed written consent. 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 Transcripts are not available as participants were not asked for consent for sharing them.

Background The World Health Organization recommends each country develop a national essential medicines list (NEML), prioritising a core medicines set aligned with national health needs. Policy in Ireland partly focusses on prescribing costs and quality, which creates opportunities for NEML development. Objective We aimed to explore interest-holders’ perspectives on an Irish NEML. Methods We applied a descriptive qualitative methodology. Using purposive and snowball sampling, we recruited interest-holders from Irish bodies/groups with roles in shaping Ireland’s medicines policy/use with potential for involvement in a NEML. Semi-structured interviews were conducted and analysis involved Braun and Clarke’s six-stage approach to thematic analysis. Results Thirteen participants were interviewed and three themes were generated: 1) the NEML’s purpose, 2) NEML barriers and facilitators and 3) development and implementation processes. For participants, an NEML’s purpose is meeting the population’s priority needs. Participants also outlined roles in ensuring adequate supplies and as a national formulary. Views differed on whether an NEML should involve reduced costs to patients for access. Participants proposed that the national government health department, the state body who run the health service (HSE), and/or the medicines regulator (HPRA) should be responsible for an NEML. Conclusions Participants perceived an NEML in Ireland as beneficial and aligning with the WHO’s vision: medicines that effectively and safely treat the priority healthcare needs of the population. Future work should explore the patients’ and the public’s perspectives on an NEML. Other countries’ NEMLs offer exemplars to inform Ireland’s approach.

Abstract Background Prescribing cascades, where one medication is used to treat/prevent the adverse effects of another, have been the subject of increased research focus. However, few studies have confirmed potential prescribing cascades identified via administrative or dispensed medicines records with general practice patient record data. This study examined the incidence of ThinkCascades, a list of nine prescribing cascades of clinical relevance in older adults developed via international expert consensus, using general practice data in The Netherlands. Methods A retrospective cohort study examined prescribing records for adults aged ≥ 65 years captured within the FaMe-Net general practice database in The Netherlands for the period 2011–2021. The primary exposures were incident use of Drug A within each ThinkCascades dyad, with the primary outcomes defined as incident use of the corresponding Drug B within 365 days. Independent clinical review of identified potential prescribing cascades was conducted by a general practitioner and pharmacist using an approach consistent with methods applied in earlier prescribing cascade research. Results The eligible cohort comprised 710 incident users of any ThinkCascades Drug A. Their mean age was 75.8 (SD = 6.1) years; 53.5% (n = 380) were female. Overall, 21 ThinkCascades dyads were identified in 18 participants, representing a one-year incidence proportion of 2.5% (N = 710). Only six of nine ThinkCascades were identified amongst study participants, most commonly the calcium channel blocker to diuretic prescribing cascade. Just over one-quarter of identified potential prescribing cascades (6/21; 28.6%) were supported as true prescribing cascades based on independent clinical record review. True cascade likelihood was indeterminable for three cases. Conclusions Prescribing cascades, defined by ThinkCascades, were relatively uncommon over the eight-year study of older people attending Dutch general practice. Three of nine ThinkCascades were not identified. Only one in four identified prescribing cascades had evidence supporting a true prescribing cascade following independent clinical record review. Further research to characterise the prevalence of confirmed prescribing cascades is required. Recent research recommends expanding the number of prescribing cascade dyads which may impact identification rates. Tools to support prescribing cascade awareness, identification and deprescribing need to incorporate shared decision-making with patients and demonstrate clinical utility in supporting medication reviews in primary care.

ObjectivesTo describe the prevalence of sub-optimal monitoring for selected higher-risk medicines in older community-dwelling adults and to evaluate patient characteristics and outcomes associated with sub-optimal monitoring.Study designRetrospective observational study (2011–2015) using historical general practice-based cohort data and linked dispensing data from a national pharmacy claims database.SettingIrish primary care.Participants625 community-dwelling adults aged ≥70 years and prescribed at least one higher-risk medicine during the 5-year study period.Primary and secondary outcome measuresThe primary outcome was the prevalence of sub-optimal laboratory monitoring using a composite measure of published medication monitoring indicators, with a focus on commonly prescribed higher-risk medicines such as diuretics and anticoagulants. Poisson regression was used to assess the patient characteristics associated with sub-optimal monitoring and explanatory variables included the number of medicines, age, sex, deprivation and anxiety/depression symptoms. Logistic regression was used to explore the association between baseline sub-optimal monitoring and the odds of adverse health outcomes (unplanned healthcare utilisation, adverse drug reactions and mortality).ResultsOf 625 participants, the mean age was 77.7 years, 53% were female, the mean number of drugs was 7.3 (SD 3.3) and 499 (79.8%) had ≥1 unmonitored dispensing over 5 years. The number of drugs, deprivation and anxiety/depression symptoms were significantly associated with sub-optimal monitoring, with the strongest association seen for anxiety/depression symptoms (incidence rate ratio: 1.33, 95% CI 1.05 to 1.68). There was a small but significant association between baseline sub-optimal monitoring and emergency department visits at follow-up, but no evidence of an association with unplanned hospital admissions, mortality or adverse drug reactions.ConclusionThe prevalence of sub-optimal medication monitoring was high, and number of drugs, deprivation and anxiety/depression symptoms were significantly associated with sub-optimal monitoring. However, the public health impact of these findings remains uncertain, as there was no clear evidence of an association between sub-optimal monitoring and adverse health outcomes. Further research is needed to evaluate the effect of improved monitoring strategies and the optimal timing for drug monitoring of higher risk medications.

Background The third WHO Global patient safety challenge, “Medication Without Harm” aims to reduce severe avoidable medication related ham by 50% globally. One approach to reducing medication related harm is to develop interventions that improve prescribing. Audit and feedback is one such intervention that has been shown to have an effect on professional behaviour. With advancements in the data infrastructure of primary care it is now possible to harness routine prescribing data for ongoing and up-to-date comparative benchmarking. The aim of this study was to assess the usability and usefulness of a prescribing safety dashboard developed in Irish general practice. Methods Practices utilising the data analytics platform, MedVault opted in to share anonymous prescription data to enable the development of the prescribing safety dashboard. Participants from these practices who had previously expressed an interest in taking part in this qualitative study will be formally invited to take part. Recruited prescribers will take part in an online interview with a think aloud process where they will share their screen as they navigate the dashboard and verbalise their thoughts. This will be followed by a semi-structured interview where their views on prescribing safety and receiving feedback on prescribing will be explored. For the think aloud process, screen recordings will be reviewed alongside the transcripts, and analysed using Nielsen’s five quality components of usability: learnability, efficiency, memorability, error recovery and satisfaction as a framework. An inductive thematic approach will be used to analyse GPs’ perspectives on prescribing safety and feedback. Discussion This study will explore the usability and acceptability of a prescribing quality and safety dashboard. To design future interventions, policies, and quality improvement initiatives that make use of routine data, it is essential to understand how GPs engage with and use these tools. This understanding can help ensure such initiatives are developed in ways that maximise relevance, usability, and engagement.

AIMS:Analgesic medicines are an important component of pain management, with different medicines carrying different risks and benefits. The aim of this study was to examine trends in analgesic prescribing in Ireland and England between 2014 and 2022. METHODS:Monthly data on medicines prescribed and dispensed in primary care were used. For Ireland, data comprised medicines prescribed through the means-tested General Medical Services (GMS), covering approximately 32% of the population, while for England, data consisted of medicines prescribed through all general practices. Outcomes included rates of dispensings, costs and standard doses (including oral morphine equivalents [OMEs] for opioids) per 1000 population, summarized per year for each drug class and drug. RESULTS:In Ireland, the rate of analgesia dispensings increased between 2014 and 2022 for most drugs. Opioid dispensings increased from 979 to 1220 per 1000 population (+25%), while paracetamol increased from 1295 to 1824 (+41%). Systemic NSAIDs decreased from 781 to 734 (-6%). In England, most analgesia dispensing rates decreased, with opioids decreasing from 721 to 585 per 1000 population (-19%), paracetamol from 734 to 484 (-34%) and systemic NSAIDs from 259 to 167 (-35%). CONCLUSIONS:Substantially different dispensing patterns were found in Ireland and England, with dispensing rates in Ireland generally higher and increasing between 2014 and 2022 and rates in England generally lower and decreasing. This discrepancy is likely largely driven by the older age and lower socioeconomic status of GMS patients; however, further research to understand the drivers for this high volume of use is required.

BACKGROUND:The trends in sedative use have varied in recent years. Benzodiazepines and z-drugs are indicated for anxiety and/or sleep disorders but should be limited to short-term use. The aim of this study is to examine trends and patterns in sedative prescribing in Ireland between 2014 and 2022, as well as comparing trends between Ireland and England within the same period. METHODS:Monthly data on medicines prescribed and dispensed in primary care on the means-tested General Medical Services (GMS) scheme in Ireland were used. Volumes of prescribed benzodiazepine and z-drug use and patterns of prescribing, including initiations, discontinuations, chronic use, and high-risk prescribing were summarized per year. Other sedating agents (sedating antihistamines, antidepressants, and antipsychotics) were also analysed. Volume of use outcomes were compared with NHS data from England for the same period. RESULTS:The rate of benzodiazepine and z-drug dispensings per 1000 GMS population decreased by 5%, from 1531 in 2014 to 1474 in 2022. By comparison in England, there was a steeper decrease of 27% in the dispensing rate and the level of use was substantially lower, falling from 288 dispensings per 1000 population in 2014 to 210 in 2022. In Ireland, dispensing rates were highest amongst women and older age groups. High-risk dispensings of benzodiazepines and z-drugs decreased over the study period. DISCUSSION:Despite decreases in benzodiazepine and z-drug dispensings, rates remain high in Ireland and may suggest a need for enhanced availability of non-pharmacological interventions, and improved education and deprescribing support for healthcare professionals.

PURPOSE:Prescribing cascades occur when one medication is used to treat adverse effects of another medication. Older adults with polypharmacy are at higher risk for this phenomenon. We examined the prevalence, magnitude, and effect modification of 9 prescribing cascades (ThinkCascades) among older community-dwelling adults in a national prescription database. METHODS:We used prescription sequence symmetry analysis to examine prescriptions for ThinkCascades medications dispensed in primary care under the General Medical Services scheme in Ireland. Analyses were based on prescriptions dispensed between 2017 and 2020 among 533,464 adults aged 65 years or older. Incident users of both medications in each ThinkCascades dyad were included. We used an observation window of 365 days and examined other windows in sensitivity analyses. Adjusted sequence ratios (aSRs) took into account secular prescribing trends. We also conducted analyses stratified by sex, age, and individual index medication. RESULTS:Five prescribing cascades had significant positive aSRs, indicating that the patient was more likely to receive the index medication before the marker medication. The largest signal was identified for the calcium channel blocker to diuretic cascade (prevalence, 2.6%; aSR = 1.93; 95% CI, 1.79-2.09). Positive signals were also identified for the α 1-receptor blocker to vestibular sedative cascade (prevalence, 3.0%; aSR = 1.63; 95% CI, 1.46-1.81); the selective serotonin reuptake inhibitor/selective norepinephrine reuptake inhibitor to sleep medication cascade (prevalence, 2.5%; aSR = 1.54; 95% CI, 1.40-1.69); the antipsychotic to antiparkinsonian cascade (prevalence, 0.4%; aSR = 1.20; 95% CI, 1.00-1.43); and the benzodiazepine to antipsychotic cascade (prevalence, 3.2%; aSR = 1.15; 95% CI, 1.08-1.21). CONCLUSIONS:To our knowledge, this study is the first to describe the prevalence of an expert consensus-based list of prescribing cascades, ThinkCascades, in a national population of older adults, and it identified 5 clinically relevant prescribing cascades. These findings highlight prescribing cascades as an important underresearched area contributing to complex polypharmacy among older people living with multimorbidity.

Background: The number of prescription medicines prescribed to older adults is increasing in Ireland and other countries. This is leading to higher out-of-pocket prescription medicine expenditure for older adults, which has several negative consequences including cost-related non-adherence. This study aimed to characterise out-ofpocket prescription medicine payments, and examine their relationship with entitlements, multimorbidity and adherence. Methods: This cross-sectional study used 2016 data from a nationally-representative sample of adults in Ireland aged >= 50 years. Descriptive statistics and regression models were used to describe out-of-pocket prescription medicine payments and assess the association between out-of-pocket prescription medicine payments and the following variables: healthcare entitlements, multimorbidity, and cost-related non-adherence. Results: There were 5,668 eligible participants. Median annual out-of-pocket prescription medicine expenditure was 144 (IQR: 0-312). A generalised linear model showed that, amongst those with out-of-pocket prescription medicine expenditure, having fewer healthcare entitlements was associated with 4.74 (95%CI: 4.37-5.15) times higher out-of-pocket prescription medicine expenditure. Overall, 1.7% (n = 89) of participants reported cost-related non-adherence in the previous year. A multivariable model examining cost-related non-adherence found a significant association only for those prescribed 4-5 regular medications (compared to 3 medications) (OR: 1.87, 95%CI: 1.02-3.42). Conclusions: Those with entitlements to subsidised prescription medicines had much lower out-of-pocket prescription medicine expenditure. This highlights the benefits of expanding healthcare entitlements and ensuring uptake of entitlements by those with eligibility.

BACKGROUND AND OBJECTIVES:Multi-center randomized controlled trials (RCTs) provide vital information about healthcare interventions. Reporting on country-level participation is important for understanding the context of multicenter RCTs. This study aimed to examine multicenter RCT reporting of country-level participation, using Ireland as a case study. STUDY DESIGN AND SETTING:This meta-research study included RCTs identified in a previous study of Irish RCTs. The previous study involved searching six databases (inception-2018) for RCTs with participants recruited in Ireland: PubMed, Embase, Scopus, CINAHL, PsychINFO, and the Cochrane Register of Controlled Trials. This current study focuses on multicenter RCTs conducted on humans in healthcare settings with <80% of participants recruited in Ireland. Outcome variables were trial characteristics and reporting rates for several variables, including the number of Irish centers, number of participants recruited in Ireland, and reporting the use of relevant reporting guidelines. Descriptive statistics were used for analysis. RESULTS:Overall, 239 RCTs were included. The most common intervention was a drug (74.9% of RCTs). The most common clinical domain was the cardiovascular system (18.0%). The number of Irish centers was reported in 75.3% of RCTs and the number of participants recruited in Ireland in 27.2%. Among RCTs that were published after the Consolidated Standards of Reporting in Trials (CONSORT) reporting guideline was published, 8.3% reported using a relevant reporting guideline. CONCLUSION:Our findings show deficits in reporting for multicenter RCTs, particularly in reporting the number of participants in Ireland and reporting the use of relevant reporting guidelines. The development of a multicenter trial extension to existing reporting guidelines may partly address country-level reporting issues. PLAIN LANGUAGE SUMMARY:A randomized controlled trial is a way of assessing the benefits of a medical intervention (like a treatment for a health issue). Randomized trials have at least two different treatment groups. The people taking part are put into one of the groups at random. This process is called "randomization" and is usually done by a computer. These trials are often conducted with people recruited from multiple countries, and Ireland is a country that sometimes plays a role. The key details about trials, such as the number of participants from each country, are often missing from publications related to trials. Information about the number of participants from each country is important, because it shows how applicable the results are to that country or similar countries. We want to find out if trials involving Ireland provide details of how many people from Ireland or how many healthcare centers in Ireland took part in the trial. We did this by looking through the researchers' main publication about the trials and seeing what information they reported. We found 239 trials published between 1968 and 2019, and among those, only 27% detailed the number of participants in Ireland. Three-quarters (75%) of the trials detailed the number of Irish healthcare centers involved. Some researchers are developing a checklist for how to report details of trials conducted across multiple countries; this may help address the shortcomings in the reporting discussed above. In general, those who fund research, publish research, regulate research, and employ researchers need to ensure there are adequate rules and incentives in place so that all relevant information about a trial is published.

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 versus 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. CONCLUSION:There was an overall reduction of analgesic use in Ireland, driven by decreasing systemic NSAID use. Although 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. This study suggests analgesic use is falling in Ireland, particularly for systemic NSAIDs, especially in older adults where adverse effects may be most harmful. The increasing prevalence of other analgesics may largely be explained by an ageing population. Analgesic use, and high-risk prescribing, remains high, suggesting a need for enhanced access to non-pharmacological services and interventions and also improved education and deprescribing support for healthcare professionals to address high-risk prescribing.

Introduction Chronic non-malignant pain (CNMP) represents a major global health issue and is a primary reason for disability worldwide. Managing CNMP often involves prescribing analgesics which carry risks such as dependency and adverse outcomes. Interactions between healthcare professionals (HCPs) and the pharmaceutical industry, including financial incentives, gifts, and sponsored education, may influence analgesic prescribing practices. Understanding these dynamics is essential for promoting ethical, evidence-based prescribing and ensuring patient safety. Therefore, the aim is to assess how pharmaceutical industry interactions with HCPs affect the prescribing of analgesics, specifically in the context of CNMP management. Methods This is a protocol for a systematic review, which is also prospectively registered on PROSPERO (Registration Number: CRD42024627184) and is reported according to PRISMA-P guidelines. A systematic search will be performed across MEDLINE, EMBASE, CINAHL, PsycINFO, and Web of Science. Observational studies (e.g., cross-sectional, cohort) evaluating the association between pharmaceutical industry interactions and HCPs’ prescribing patterns for CNMP management will be included. Primary outcomes include analgesic prescribing patterns, such as rate, volume, and cost. Secondary outcomes involve patient safety measures and HCP attitudes towards prescribing. Titles, abstracts, and full texts will be screened according to the inclusion criteria. Data extraction will utilize a standardized form, and the methodological quality will be evaluated using the ROBINS-I tool. Screening, data extraction and quality appraisal will be conducted by two reviewers, independently, resolving any discrepancies with the help of a third reviewer. Should there be sufficient homogeneity in the results data, a meta-analysis will be conducted; if not, the findings will be presented in a narrative synthesis. The strength of evidence will be assessed using the GRADE approach. Discussion The findings could inform strategies to enhance unbiased and evidence-based prescribing in CNMP management, promoting better patient care.

Prescribing cascades occur when medication is prescribed to prevent/treat the adverse effects of another medication and may be intentional/unintentional. This study examines the prevalence of nine prescribing cascades (ThinkCascades) in The Irish Longitudinal StuDy on Ageing (TILDA). A prospective cohort study examined those aged ≥50 years with three consecutive data collection waves (N = 6118) recorded between Wave 1 (2009/2011) and Wave 5 (2018). Nine separate analysis sets were created, representing each ThinkCascade. Exposure was the incident use of Drug A at wave x. A prescribing cascade was defined as the incident use of Drug B at wave x + 1, with continued use of Drug A. Five out of nine ThinkCascades were identified over 9 years of follow-up. Overall, 24 participants experienced at least one ThinkCascade, representing a 2.1% prevalence (n = 1153 eligible). This low prevalence may indicate prescribers' awareness of prescribing cascades. Higher event rates are required to examine any association with adverse health outcomes.

Background The Health Service Executive (HSE) in Ireland releases monthly reports on prescription dispensing claims and payments relating to community drug schemes. This paper describes the implementation of an R-based Shiny application that facilitates interactive visualisation and analysis of trends in medication prescribing and improves the data’s practical value, and presents use cases focused on drug utilisation and medication policy questions. Methods Using Primary Care Reimbursement Service (PCRS) data provided by the HSE relating to the means-tested General Medical Services (GMS) scheme covering approximately one-third of the population, an R-based Shiny application was developed. This application uses monthly prescribing and cost data from 2016 up to the most recent data available (currently October 2024) relating to the 100 most commonly prescribed medications (by frequency and cost) and all therapeutic groups. The application leverages a range of R packages to enable users to select medications, therapeutic groups, and physiological systems to explore and compare prescribing and cost trends over time. Results The RxTrends Shiny application effectively integrates PCRS data, providing multiple functionalities that allow for visualisation of dispensing trends of multiple medications, therapeutic groups and physiological systems. Graphs are available across multiple prescribing frequency and cost metrics and can be restricted to a selected time period. The ‘compare’ function visualises the proportion of prescribing/cost a selected medication or therapeutic group accounts for within a therapeutic group or physiological system. Use cases relating to Ireland’s Preferred Drug Initiative, availability of generic products and reference pricing, and seasonality of drug utilisation are presented. Conclusion The application provides an interactive interface for stakeholders to visualise and monitor prescribing patterns using data from monthly PCRS reports. The application increases access to and usability of PCRS data for various audiences for whom it may be of interest, including researchers, healthcare professionals, policymakers and the general public.