“We should take it very seriously,” Bob Anderson, chief of the Mortality Statistics Branch at the National Center for Health Statistics, told my colleagues Lenny Bernstein and Christopher Ingraham. “If you look at the other developed countries in the world, they’re not seeing this kind of thing. Life expectancy is going up.”
In other words: In no other developed country are people taking and dying from opioids at the rates they are in the United States. We have about 4 percent of the world's population but about 27 percent of the world's drug-overdose deaths.
What explains the discrepancy?
Americans are prescribed opioids significantly more often than their counterparts in other countries. In the United States, 50,000 opioid doses are taken daily per every million residents. That is nearly 40 percent higher than the rate in Germany and Canada, and double the rate in Austria and Denmark. It is four times higher than in Britain, and six times higher than in France and Portugal. As the BBC put it, “American doctors prescribe — a lot.”
That is in large part a result of our health insurance structure. Unlike countries that provide universal health care funded by state taxes, the United States has a mostly privatized system of care. And experts say insurers are much more likely to pay for a pill than physical therapy or repeat treatments. “Most insurance, especially for poor people, won't pay for anything but a pill,” Judith Feinberg of the West Virginia University School of Medicine told the BBC. “Say you have a patient that's 45 years old. They have lower back pain, you examine them, they have a muscle spasm. Really the best thing is physical therapy, but no one will pay for that. So doctors get very ready to pull out the prescription pad. Even if the insurance covers physical therapy, you probably need prior authorization which is a lot of time and paperwork.”
As a result, Americans were being prescribed opioids. Often, they were given several more pills than they could be expected to use, to avoid repeat visits. “Other countries deal with pain in much healthier ways,” said Feinberg, a professor in the Department of Behavioral Medicine and Psychiatry at the WVU School of Medicine.
The U.S. health-care system is different from other countries' in other ways, too. There is pressure to address pain, and a pervasive attitude that everything is fixable. As a result, doctors in the United States are much more likely to provide painkillers than are doctors in other countries. One comparative study found that Japanese doctors treated acute pain with opioids about half the time. In the United States, the number was 97 percent of the time.
“I'm 51,” Professor Keith Humphreys of Stanford University told the BBC. “If I go to an American doctor and say, 'Hey, I ran the marathon I used to run when I was 30, now I'm all sore, fix me,' my doctor will probably try to fix me. If you do that in France the doctor would say, 'It's life, have a glass of wine, what do you want from me?'”
There are other culprits, too. The United States is one of only two countries that allow prescription drug companies to advertise on television. (The other is New Zealand.) The companies do advertise, a lot. In 2016, pharmaceutical companies spent $6.4 billion on advertising. Experts say, too, that U.S. medical schools have not done enough to educate students on pain management, addiction and opioid use and abuse.
Drug companies also try to woo physicians with gifts. Some companies host fancy dinners, and others sponsor conferences and junkets. In 2016, for example, OxyContin maker Purdue Pharma spent $7 million on gifts to doctors and teaching hospitals. From 1996 to 2001, the company sponsored 40 national “pain management symposia” in attractive destinations. In the same period, the company doubled its sales force, distributing coupons so doctors could offer patients 30-day supplies of OxyContin and other highly addictive drugs. In those six years, prescriptions for OxyContin jumped from 670,000 to more than 6 million.
That alarmed at least one public-health group, which ran a 2009 bulletin titled, “The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy.”
By then, it was too late.