The Doctor’s Prescription Has a Passport

How medical training across countries may shape opioid prescribing in England

Opioids are an important tool for pain management, but their use has become a major public health concern. The experience of the United States has highlighted the risks associated with excessive opioid prescribing, including misuse, dependence and overdose. Similar concerns have increasingly emerged in Europe. England, in particular, experienced a 34% increase in opioid prescriptions between 2008 and 2018, alongside a 49% rise in opioid-related hospitalisations.

What drives doctors’ decisions to prescribe these drugs? Patient characteristics clearly matter, as does the socioeconomic environment in which doctors work. But another factor may also play a role: where doctors received their medical training. This question is particularly relevant for the British National Health Service (NHS), which has long relied on doctors trained outside the UK. In the data analysed here, around one third of GPs obtained their medical degree abroad.

An increasingly international NHS

Foreign-trained GPs are not evenly distributed across England. Even before the Covid-19 pandemic, more than one in five GPs in England had been trained abroad. The geographical variation is substantial: among the 209 Clinical Commissioning Groups (CCGs) considered, 14 had more than half of their GPs trained outside the UK. In Barking and Dagenham, in London, for example, around two thirds of GPs were internationally trained.

This geographical variation makes it possible to investigate whether differences in the composition of the medical workforce are also associated with differences in prescribing behaviour. The analysis combines several administrative datasets containing information on GPs, practice and patient characteristics, disease prevalence and prescriptions. The resulting dataset follows 6,659 GP practices quarterly between 2018 and 2021, generating more than 90,000 observations. On average, general opioid analgesics account for approximately 2% of all prescriptions.

Being trained abroad is not the whole story

The first result is perhaps also the most interesting. Simply comparing practices according to their overall share of foreign-trained GPs reveals no statistically significant association with opioid prescribing.

A very different picture emerges, however, when doctors are distinguished according to the region of the world in which they received their medical training. Compared with UK-trained doctors, practices with larger shares of GPs trained in Africa, South Asia and Australia/Pacific tend to prescribe fewer opioids. By contrast, practices with larger shares of doctors trained in North America and the Middle East show higher opioid prescribing.

The simple distinction between “domestic” and “foreign” doctors may therefore hide important differences. What appears to matter is not foreign training per se, but where that training took place. Opioid prescribing is around 5% lower among GPs trained in Africa and around 2% lower among those trained in South Asia, relative to UK-trained GPs. At the other end of the spectrum, prescribing is approximately 30% higher among North American-trained GPs and 10% higher among those trained in the Middle East.

Importantly, these patterns remain broadly unchanged when the period most affected by the Covid-19 pandemic is excluded, suggesting that they are not simply driven by the exceptional circumstances surrounding the pandemic.

Medical training, clinical culture and prescribing

How can these differences be explained?

One possibility is that medical education and clinical practice differ across countries. Doctors trained in healthcare systems where opioids are used more extensively may develop a different approach to pain management from those trained in countries where opioid prescribing is more restrictive.

This does not necessarily imply that one group of doctors is prescribing “better” or “worse” than another. Rather, clinical practice may retain some of the imprint of the healthcare system in which doctors were originally trained, even after they move to another country. Differences in medical education, clinical norms, healthcare priorities and the epidemiological environment of the country of training may all contribute to the patterns observed.

The socioeconomic environment in which doctors work also appears to matter. In more deprived areas, a higher overall share of foreign-trained GPs is associated with a higher proportion of opioid prescriptions. Once again, however, the pattern differs considerably depending on the region in which doctors received their training.

Integration rather than origin

These results are particularly relevant for a healthcare system such as the NHS, where internationally trained doctors play an essential role in addressing workforce shortages. The policy implication is therefore not to reduce reliance on overseas doctors. Rather, the increasing international mobility of healthcare professionals makes it more important to understand how different medical training systems may shape clinical practice.

Targeted training and professional development could help doctors entering the NHS from different healthcare systems become familiar with UK clinical guidelines and prescribing practices. Such policies could facilitate the integration of internationally trained doctors while promoting greater consistency in patient care.

Some caution is nevertheless needed. The evidence identifies associations rather than causal effects. Doctors are not randomly allocated across practices, and unobserved characteristics of patients or local areas may influence both the composition of the medical workforce and prescribing behaviour. Moreover, grouping countries into broad geographical regions inevitably masks potentially important differences between individual countries and healthcare systems.

Yet the broader message remains relevant for increasingly international healthcare systems: the medical environment in which doctors are trained may continue to shape their clinical decisions after they move abroad. Understanding these differences can help healthcare systems not only attract professionals from around the world, but also integrate different medical backgrounds while ensuring consistent and appropriate standards of care.

References:

• Madia, J., Nicodemo C., Orso, C.E., and Tealdi, C. "Overseas General Practitioners (GPs) and Opioid Prescriptions in England" (2025). Health Policy, Vol. 159, doi: https://doi.org/10.1016/j.healthpol.2025.105362