The number of opioid prescriptions has decreased in the past few years, after more than a decade of explosive growth. This reflects new practice guidelines underscoring opioids’ generally poor effectiveness at reducing chronic pain, increased monitoring of prescribers by government and health-care organizations, and widespread horror within and without medicine over the epidemic of opioid-related deaths.
Although reducing the number of prescriptions will decrease the number of people who become addicted to opioids, too many prescribing restrictions could deny opioids to patients who need and benefit from them. How can we know if and when prescribing controls have gone overboard and the population has insufficient access to prescription opioids? In short, how will we know if the effort to restrict opioids has gone too far?
United Nations data provide one important benchmark against which to judge how much more or less opioid consumption might be appropriate for a given country. And what it finds about the United States is jaw-dropping: Even when the list is restricted to the top 25 heaviest consuming countries, the United States outpaces them all in opioid use.
For example, Americans are prescribed about six times as many opioids per capita as are citizens of Portugal and France, even though those countries offer far easier access to health care. The largest disparity noted in the U.N. report concerns hydrocodone: Americans consume more than 99 percent of the world’s supply of this opioid.
One might think that Americans consume more opioids because as an aging population, they have objectively more aches and pains. But the U.S. population ranks only 42nd in the world in its proportion of people aged 65 or older. Countries with a much higher proportion of senior citizens than the United States, such as Australia and Italy, consume only a fraction of the prescription opioids of Americans.
If objective need doesn’t explain the relatively enormous prescription opioid consumption in the United States, what does? Economics, politics and culture are all likely at play.
Unlike most of the developed world, the United States puts minimal constraints on aggressive marketing by pharmaceutical companies, whether the target is patients, prescribers, or medical and scientific societies. U.S. pharmaceutical manufacturers have been highly successful at promoting prescription opioids in this lightly regulated, profit-driven health-care environment.
The huge profits of opioid manufacturers and distributors translate into significant political clout, further supporting expanding U.S. opioid consumption. For example, as previously reported in The Washington Post, when federal drug agents began holding opioid distribution companies accountable for shipping massive numbers of opioids to pill mills, lobbyists from the industry successfully pressured the Justice Department’s leadership to curtail the investigation.
Cultural factors may augment U.S. opioid consumption, as well. Relative to Europeans, Americans have more faith that life is perfectible (e.g., all pain can be avoided). Consider, for example, a 55-year-old who feels acute back and leg pain after doing the workout that was easy when he was 25. A European in this situation might reflect sadly that aging and physical decay must be accepted as part of life, but an achy American might demand that his doctor fix what he sees as an avoidable problem by prescribing him opioids.
None of this means that some Americans don’t have a legitimate need for opioids, nor that U.S. doctors sometimes don’t prescribe opioids when they should. But it does suggest that before launching into hysteria that the recent, small drops in opioid prescribing reflect a “war on pain patients,” we should recognize that U.S. consumption dwarfs that of other developed countries that have older populations with better access to prescribing health-care providers.
Keith Humphreys is a professor of psychiatry at Stanford University.