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America’s huge problem with opioid prescribing, in one quote

You have to double the amount of opioids Japan consumes five times to come close to the US.

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If you want a clear explanation of just how much of an outlier the US is in prescribing the powerful drugs that led to the opioid epidemic, consider this statistic given by drug policy expert Keith Humphreys last week during Stanford Medicine X (emphasis mine):

The biggest misconception is that the US is normal in how it handles prescription opioids. So let’s compare ourselves to another country. Japan, for example. Older population than us; you would think more aches and pains. Universal access to health care, so more opportunities to prescribe.

So consider the amount of standard daily doses of opioids consumed in Japan. And then double it. And then double it again. And then double it again. And then double it again. And then double it a fifth time. That would make Japan No. 2 in the world, behind the United States.

Every other developed country does at least as good or as poor a job as we do managing pain — while not using opioids at anywhere near the same level.

The statistics really do back this up. Japan is one of the lowest prescribers of opioids in the developed world (for reasons outlined in a great piece by my colleague Ella Nilsen). And the US absolutely dwarfs anyone else in terms of opioid prescriptions, with Japan not even showing up in the top 25:

This is the root of the opioid epidemic, which is now the deadliest drug overdose crisis in US history, is killing tens of thousands each year, and is estimated to kill hundreds of thousands more in the coming decade.

The epidemic began when doctors prescribed a huge number of opioids — leading the drugs to proliferate not just among patients but also among teens who rummaged through their parents’ medicine cabinets, friends and family whom patients shared the drugs with, and a black market where patients sold excess pills. Over time, drug users moved to other opioids, including heroin, fentanyl, and fentanyl analogs. And overdose deaths climbed and climbed.

How America became the world’s leading opioid prescriber

So how did the US become the world’s top prescriber of opioid painkillers? There are several reasons.

First, there were the pharmaceutical companies. Wanting to make as much money as possible, these companies marketed their drugs as safe and effective for treating pain — even though the evidence for opioids shows that, particularly for chronic pain, the risks outweigh the benefits in most, but not all, cases. Many doctors and patients were convinced by this campaign. (Purdue Pharma, the maker of OxyContin, and some of its higher-ups later paid more than $600 million in fines for their misleading marketing claims, and opioid makers and distributors are now facing many more lawsuits on similar grounds.)

Then there were doctors. On one hand, doctors were under a lot of pressure from advocacy groups (some pharma-backed), medical associations, and government agencies to treat pain more seriously. On the other hand, doctors faced increasing pressure to see and treat patients quickly and efficiently.

The latter is a result of what Stanford addiction specialist Anna Lembke, author of Drug Dealer, MD, describes as “the Toyotazation of medicine — tremendous pressure on doctors within these large integrated health care centers to practice medicine in a certain way and get patients out in a timely fashion to be able to bill insurers at the highest possible level and to make sure that their patients were satisfied customers.”

Opioids provided an answer to these two problems. Doctors didn’t know how to deal with many of the complex pain problems their patients were dealing with, because in many cases the answers were complicated and simply required too many resources and too much time. So an easy response was to give patients some pills.

In many situations, doctors simply prescribed far too much. With acute pain patients, doctors often gave weeks- or even months-long prescriptions when only a few days’ worth was needed. It was common, for example, to give weeks-long supply for opioids after wisdom teeth removals, even though the procedure usually leads to pain for no more than a week and the pain typically can be treated with milder painkillers like ibuprofen. The prescriptions left patients with a lot of extra pills, all because a doctor wanted to play it safe — and make sure that a patient didn’t come back complaining that a provider gave too few pills the first time around.

And in other cases, the doctors involved were outright malicious — establishing “pill mills” in which they gave away opioids with little scrutiny, often for hard cash.

On the patient side, there were serious medical issues that needed to be addressed. For one, the Institute of Medicine has estimated that about 100 million US adults suffer from chronic pain. Given that the evidence shows opioids pose more risks than benefits in the majority of these cases, patients likely should obtain other treatments for chronic pain, such as non-opioid medications, special physical exercises, alternative medicine approaches (such as acupuncture and meditation), and techniques for how to self-manage and mitigate pain.

But these other options are often out of reach for pain patients. They may not have insurance to cover treatment. Even if they do have insurance, their health plan might not cover comprehensive pain care. And even if they do have insurance and their health plan covers pain treatments, there may not be a nearby pain clinic or doctor who can actually provide the care these patients are seeking. So frequently, the only suitable answer seemed to be opioids.

Opioids may still be a good answer for a few chronic pain patients. When prescribed carefully on a schedule that works to diminish the excessive buildup of tolerance, they can work for some people. But Stanford pain specialist Sean Mackey cautions that opioids should not be a first-line treatment due to the grave risks, and alternatives should be tried first.

With the broader proliferation of opioids, there were so many of these pills — enough prescribed just in 2015 to medicate every American around the clock for three weeks, according to the Centers for Disease Control and Prevention (CDC) — that they were often diverted.

So America got its deadliest drug overdose crisis ever.

For more on the opioid epidemic, read Vox’s explainer.

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