Consumption of Prescription Opioids for Pain: A Comparison of Opioid Use in the United States and Other Countries

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Consumption of Prescription Opioids for

Pain: A Comparison of Opioid Use in the

United States and Other Countries

June 2, 2021

Congressional Research Service

https://crsreports.congress.gov

R46805

SUMMARY

Consumption of Prescription Opioids for Pain:

A Comparison of Opioid Use in the United

States and Other Countries

Beginning in the late 1990s, the consumption of medical opioids used to treat pain increased in

many countries worldwide. Since that time, the United States has outpaced every other country in

per capita opioid consumption. Most research suggests that high levels of prescription opioid

consumption in the United States have contributed to the current epidemic of opioid misuse and

overdose deaths.

In response, several states and the U.S. federal government have demonstrated an interest in

reducing opioid misuse and overdose deaths through legislation and executive initiatives.

Understanding why the United States consumes more opioids per capita than other countries may

help Congress construct effective legislation to reduce inappropriate or excess opioid

consumption and mitigate related consequences, such as opioid misuse and overdose deaths. In

addition, lawmakers in the United States could examine policies in peer countries for possible

approaches to curb excessive prescription opioid use.

A review of the scientific literature through February 2020 on international opioid consumption

and prescribing practices pointed to several possible underlying reasons explaining the difference

in opioid consumption per capita in the United States.

R46805

June 2, 2021

Johnathan H. Duff,

Coordinator

Analyst in Health Policy

Sara M. Tharakan

Analyst in Global Health

and International

Development

Carla Y. Davis-Castro

Research Librarian

Ada S. Cornell

Senior Research Librarian

Paul D. Romero

Research Assistant

Prescribing practices and drug potency. At the most basic level, the difference in consumption

of opioids reflects the prescribing practices of health care providers. U.S. health care providers prescribe opioids more

frequently, at higher doses, and throughout more stages of pain treatment—including as a first-line treatment—than their

international counterparts. Use of higher-potency opioids appears particularly high in the United States compared with other

countries. Nearly all published clinical guidelines discourage use of high-potency opioids, and opioids as a first-line

treatment, for managing long-term chronic noncancer pain.

Prevalence of pain and approaches to pain management. It is possible the United States has a greater prevalence of pain,

and that Americans experience—or at least self-report—more intense pain. Americans may receive more opioids at more

points in care at the expense of more comprehensive pain therapies. Higher opioid prescribing practices may be influenced by

insurance reimbursement systems that incentivize opioids over alternative pain treatments, cost structures that promote more

efficient care, or evaluations that conflate patient satisfaction with effective pain management.

Health care system structures. The U.S. health care system and regulatory structure may have had more risk factors—such

as permissive marketing laws and a decentralized oversight system—compared with European or other countries.

Conversely, countries with nationalized health care systems and centralized regulation of health care practices may have had

more protective factors that prevented an increase in overprescribing. Compared with its European counterparts, the U.S.

medical system permits more autonomy for health care providers, imposes fewer national regulations on health care

practices, and allows more direct-to-provider marketing practices. U.S. prescription drug monitoring programs (PDMPs),

which track prescriptions for narcotic drugs such as opioids, are decentralized and generally structured to monitor bad actors;

PMDPs are not always designed to promote best practices aligned with clinical guidance.

Cultural differences and access to care. More broadly, cultural differences, such as expectations about pain relief and

entitlements to opioid treatment, may also explain the greater reliance on pharmacological treatments in the United States. In

addition, health care systems that provide more expansive access to care and broader options for pain management—

including many in Western Europe—may enable greater preventive care and more multimodal approaches to pain, in part

because there may be fewer barriers to accessing these types of treatments. Countries with nationalized health care systems

and centralized regulation of health care practices also may have had protective factors that prevented an increase in

overprescribing.

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Consumption of Prescription Opioids for Pain

This report describes trends in opioids use across industrialized countries and identifies possible factors explaining the

disproportionate use of prescription opioids in the United States. The main findings in this report appear in the “Key

Takeaways” text box.

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Contents

Overview ....................................................................................................................... 1

Global Medical Opioid Use .............................................................................................. 4

Global Trends ........................................................................................................... 6

U.S. Trends............................................................................................................... 8

Factors Influencing Medical Opioid Consumption.............................................................. 10

Physician Behavior and Patient-Related Factors ........................................................... 11

Prescribing Practices........................................................................................... 11

Pain Rates among Select Countries ....................................................................... 14

Medical Treatment of Pain ................................................................................... 19

External Influences on Health Care Practices .......................................................... 20

Attention to Clinical Guidance ............................................................................. 22

Sociocultural Factors................................................................................................ 24

Health Care Systems ........................................................................................... 24

Cost of and Payment for Pain Treatment ................................................................ 26

Government Regulations ..................................................................................... 28

Prescription Drug Monitoring............................................................................... 30

Cultural Factors ................................................................................................. 31

Issues for Congress ....................................................................................................... 32

Policy Options for Congress ...................................................................................... 33

Reducing Opioid Consumption .................................................................................. 33

Prescription Drug-Monitoring Programs and Electronic Medical Records ................... 33

Setting Annual Quotas for Controlled Substances .................................................... 34

Prescription Drug-Marketing Practices .................................................................. 35

Clinical Best Practices......................................................................................... 36

Prescribing Rules ............................................................................................... 37

Access to Other Pain Treatments........................................................................... 37

Comorbid Opioid Use and Mental Health Issues ..................................................... 38

Figures

Figure 1. Total Opioid Consumption for G-7 Countries ......................................................... 5

Figure 2. Oxycodone Consumption in G-7 Countries ............................................................ 8

Figure 3. Opioid Consumption in the United States, by Opioid ............................................... 9

Tables

Table 1. Morphine Milligram Equivalent (MME) Conversion Factors of Commonly Used

Opioid Analgesic Drugs ................................................................................................ 3

Table A-1. Common National Regulatory Systems for Medical Opioid Use in

OECD Countries ........................................................................................................ 40

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Appendixes

Appendix A. International Opioid-Prescribing Regulations .................................................. 40

Appendix B. Methodology and Search Strategy ................................................................. 42

Contacts

Author Information ....................................................................................................... 43

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Overview

Beginning in the late 1990s, many countries saw increases in consumption of medical opioids

used to treat pain. Opioids are substances that act on receptors in the brain, particularly those

involved in pain regulation and emotion. Opioids are used in the medical field as analgesics,

meaning to treat pain. From the mid-1990s through 2019, the United States outpaced every other

country in opioid consumption per capita, including all other Organisation for Economic Cooperation and Development (OECD) and Group of 7 (G-7) member countries. 1 U.S. opioid

consumption peaked in 2012. 2 Since then—and after historic levels of misuse and overdose

deaths—the United States has witnessed a decline in opioid prescribing. Despite this decline, the

United States continues to consume more opioids per capita than any other country in the world,

including its G-7 counterparts.

Policymakers interested in addressing the opioid epidemic may want to understand why the

United States consumes a disproportionate amount of opioids. The scientific evidence suggests

that many factors may influence this disparity between the United States and other economically

advanced countries. This report synthesizes the scientific research to explain relevant factors

regarding the difference between opioid consumption in the United States and other comparable

industrialized countries, such as the G-7 countries.

A review of scientific literature on international and domestic opioid use pointed to several

factors affecting the difference in consumption per capita. 3

Prescribing practices of health care providers appear to be a primary factor affecting

consumption. U.S. health care providers prescribe opioids more frequently, at higher doses, and

throughout more stages of pain treatment—including as a first-line treatment—than their

European counterparts. Use of higher-potency opioids—with greater morphine milligram

equivalents (MMEs) per dose—appears especially high in the United States compared with other

countries. Although there is generally no agreed upon threshold value of what constitutes a “high

potency” opioid, 4 clinical guidelines and research studies often use MMEs per day or per dose to

establish a threshold. 5 The MME metric allows for standardization of dose across different opioid

analgesics. Table 1 lists the MME conversion factors of several commonly used opioid

analgesics, as defined by the U.S. Centers for Disease Control and Prevention (CDC). 6 Clinical

guidelines published by the World Health Organization (WHO) and others discourage using high1 T he Organisation for Economic Co-operation and Development (OECD) and Group of 7 (G7) are international

intergovernmental economic organizations of economically developed countries. T he G-7 consists of Canada, France,

Germany, Italy, Japan, the United Kingdom, and the United States. For a list of the 36 member countries of the OECD,

see https://www.oecd.org/about/members-and-partners/. All G-7 countries are members of the OECD. T his report

compares opioid consumption across the United States and other OECD countries, with an emphasis on the G-7

countries for simplicity.

2 Ensuring Adequate Access for Medical and Scientific Purposes, report published by the United International

Narcotics Control Board, Availability of Internationally Controlled Drugs Nations, New York, NY, January 2016.

3 Literature review reflects scientific literature through February 2020. Data used in the figures reflect the most recent

complete annual data (2019) as obtained August 2020.

4 FDA Briefing Document, Joint Meeting of the Drug Safety and Risk Management (DSaRM) Advisory Committee

and Anesthetic and Analgesic Drug Products Advisory Committee (AADPAC), June 11 -12, 2019, p. 34,

https://www.fda.gov/media/127780/download.

Different research studies define “high potency” or “strong” in varying ways. See the specific journal articles for

details regarding how these terms were defined in the studies.

6 Published MME conversion tables may vary, depending on the source.

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potency opioids and opioids as a first-line treatment for long-term chronic noncancer pain

management. 7

Measuring Opioid Consumption

Opioid consumption on a national scale is measured in a variety of ways. The most common metrics include (1)

total weight (in kilograms) or weight per capita, (2) morphine milligram equivalents (MMEs) per capita, (3) total

number of individual prescriptions, and (4) defined daily doses (DDD). These metrics are used in research on

opioid consumption and are defined below.

Total weight refers to the amount of an opioid consumed by a country in kilograms. Total weight on its own

does not factor in potency of the opioid or per capita rate of use. It is most useful for comparing opioid use within

a country over time rather than between countries in a single year. When comparing opioid use within a single

country over several decades, weight per capita can help account for population change in that country over time.

Morphine milligram equivalents (MMEs) is a value assigned to an opioid to reflect its potency compared

with morphine—one of the first modern opioid analgesics used medically to treat pain.8 MMEs are an opioid’s

dosage equivalency to morphine, measured in milligrams. MMEs are commonly used with a population metric to

create an MME per capita rate.9 Although MMEs are commonly used to standardize the potency of opioid

medications, published MME conversion tables may vary, depending on the source used.10 Table 1 displays the

MME conversion factors of several commonly used opioid analgesics.

Number of prescriptions refers to the amount of individual opioid prescriptions issued in a country. The

number of prescriptions does not always factor in the length of the prescription, specific medication, number of

pills, or potency of the medication, especially since countries differ in average number of pills and potency per

prescription. Number of prescriptions more often serves as an indicator of provider and patient behavior rather

than of opioid consumption.

Defined daily dose (DDD) is “the assumed average maintenance dose per day” for an opioid used for “its main

indication in adults” according to the World Health Organization.11 DDDs are units of measurement used to

provide an estimate of drug consumption. DDDs do not necessarily reflect the prescribed therapeutic dose, which

is based on individual patient characteristics (e.g., age, weight). DDDs are useful as a standard measure of drug use

in national and international comparison studies at the population level because one DDD per day is implied.12

Several additional factors besides higher prescribing practices may explain the higher relative use

of opioids in the United States. It is possible the United States has a greater prevalence of pain,

and that Americans experience, or at least self-report, more intense pain. Americans may receive

more opioids at more frequent points in care rather than more comprehensive approaches to pain

management, such as those that use combinations of pharmaceutical, psychological, and physical

therapies. Higher opioid-prescribing practices may be driven by insurance reimbursement

systems that incentivize opioids over alternative pain treatments, cost structures that promote

more efficient care, or evaluations that prioritize patient satisfaction and conflate it with pain

7 World Health Organization, Web statement on pain management guidance, “Essential medicines and health

products,” June 20, 2019.

Morphine also refers to the molecule isolated from opium that serves as the foundation for natural and semisynthetic

opioid analgesics.

9 Centers for Disease Control and Prevention, CDC Guidelines for Prescribing Opioids for Chronic Pain - United

States, 2016, MMWR vol. 65 no. 1, Atlanta, GA, March 28, 2016, at https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/

rr6501e1.pdf.

FDA Briefing Document, Joint Meeting of the Drug Safety and Risk Management (DSaRM) Advisory Committee

and Anesthetic and Analgesic Drug Products Advisory Committee (AADPAC), June 11 -12, 2019, p. 34,

https://www.fda.gov/media/127780/download.

See World Health Organization, Essential Medicines and Health Products/Defined Daily Doses, at

https://www.who.int/medicines/regulation/medicines-safety/toolkit_ddd/en/.

J. Merlo, A. Wessling, and A. Melander, “Comparison of Dose Standard Units for Drug Utilisation Studies,” Eur J

Clin Pharmacol, vol. 50 (1996), pp. 27-30; and T homas Grimmsman and Wolfgang Himmel, “Discrepancies between

Prescribed and Defined Daily Doses: A Matter of Patients or Drug Classes,” Eur J Clin Pharmacol, vol. 67 (2011), pp.

847-854.

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management. Compared with most of its European counterparts, the U.S. medical system allows

for more autonomy for health care providers, imposes fewer national government regulations on

health care practices, and permits more direct-to-provider marketing practices. In addition,

prescription drug monitoring programs (PDMPs) in the United States are decentralized. PDMPs

in the United States are generally structured to monitor bad actors and generally not designed to

promote best practices aligned with clinical guidance. More broadly, cultural differences, such as

expectations about pain relief and entitlements to opioid treatment, may also explain the greater

reliance on pharmacological treatments in the United States.

Table 1. Morphine Milligram Equivalent (MME) Conversion Factors of Commonly

Used Opioid Analgesic Drugs

Low Equivalency

(MME factor <1)

Equivalent

(MME factor =1)

High Equivalency

(MME factor >1)

Codeine

0.15

Hydrocodone

Fentanyl (patch)

2.4

Dihydrocodeine

0.25

Morphine

Hydromorphone

Tapentadol

0.40

Nalbuphine

Oxycodone

1.5

Tramadol

0.10

Oxymorphone

Source: Based on Michael Von Korff, Kathleen Saunders, G. Thomas Ray, et al., “Defacto Long-term Opioid

Therapy for Non-Cancer Pain,” Clinical Journal of Pain, vol. 24, no. 6 (2008), pp. 521-527 (as cited in Centers for

Disease Control and Prevention, CDC Guidelines for Prescribing Opioids for Chronic Pain - United States, 2016,

MMWR vol. 65 no. 1, Atlanta, GA, March 28, 2016, at https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/

rr6501e1.pdf), and Exhibit 37 in IQVIA Institute for Human Data Science, Medicine Use and Spending in the U.S.: A

Review of 2018 and Outlook to 2023, Parsippany, NJ, May 2019.

Notes: Conversion factors are for oral administration (with the exception of fentanyl). To determine the dose

of an opioid in MMEs, the dose is multiplied by the conversion factor for that opioid. For example, oxycodone 80

mg multiplied by the conversion factor of 1.5 would be equivalent to 120 MME per dose; taken twice a day (160

mg), this would be equal to 240 MME/day.

The MME factor of fentanyl varies depending on the formulation for this drug. The most commonly prescribed

fentanyl formulation (transdermal patch) has an MME factor of 100; however, here the fentanyl conversion to

morphine equivalents is based on the assumption that one patch delivers the dispensed micrograms per hour

over a 24-hour day and remains in place for three days. Other forms of licit fentanyl used to treat pain, including

injectables and oral formulations (spray, buccal, sublingual, lozenges), have MME factors with scale based on

strength from 10 to over 200.

Health care systems that provide more expansive access to care may allow for greater preventive

care and more multimodal approaches to pain, in part because there may be fewer barriers to

using these types of treatments. Moreover, providers operating in highly regulated systems may

be less susceptible to the direct and indirect influences experienced by American providers, such

as profit-driven fee-for-service incentives or direct-to-provider pharmaceutical marketing. The

U.S. federal government leaves the majority of medical practice regulation to individual states.

This decentralized system may impose rules governing prescribing practices (e.g., those instituted

in European countries to prevent adverse outcomes of opioid use) at a slower pace than those

imposed by centrally governed health care systems. 13

13 In general, the decentralized regulation of the practice of medicine may provide several benefits to health care in the

United States. Evaluating the benefits and drawbacks of the federalized structure of the regulation of medicine in the

United States is beyond the scope of this report. Notably, this decentralized structure may contrast with some other

countries and may contribute to differences in opioid consumption overall. T he health care system in the United States

is not exclusively decentralized, however. Some aspects, such as Medicare or the Veteran’s Health Administration,

offer more centralized regulatory controls.

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Taken together, the evidence suggests that numerous factors may influence the relatively

disproportionate amount of opioids consumed by the United States. 14 Opioid use rose

precipitously beginning in the late 1990s, corresponding with the introduction of reformulated

opioid analgesics such as OxyContin15 and intensified marketing of these drugs. Due to several of

the aforementioned factors, the United States may have been more susceptible to petitions from

the pain advocacy community and the aggressive marketing campaigns of the pharmaceutical

industry than other countries. The U.S. health care system and regulatory structure may have had

more risk factors—such as permissive marketing laws and a decentralized oversight system—

compared with European or other countries. Conversely, countries with nationalized health care

systems and centralized regulation of health care practices may have had more protective factors

that prevented an increase in overprescribing.

Although regulating the practice of medicine is mostly left up to the states, Congress may have a

number of options to reduce the overutilization of opioids for pain. For example, the federal

government plays a role in establishing the annual quotas for opioid production, specifying

storage and dispensing rules, defining training requirements for health care providers, and

regulating federal health care programs such as Medicare and Medicaid. Congress might also

consider policies instituted in peer countries for possible approaches to curb excessive

prescription opioid use.

This report discusses these points in further detail. More specifically, it



identifies several factors that may influence the differences between opioid

consumption in the United States and other developed countries;

describes related empirical research and summarizes findings from a literature

review;

provides an overview of opioid use internationally and in the United States, along

with factors that may influence differences between the United States and other

economically advantaged countries; and

discusses issues related to this topic that may interest Congress.

Global Medical Opioid Use

Nearly all countries use opioids as medicines to manage or treat pain, typically under the

supervision of a health care provider. In the United States, for instance, opioids are legally

available only by prescription. Opioids can pose significant dangers, including addiction and

overdose resulting in death. Most research suggests that long-term opioid use, in particular,

increases risks for several adverse events, including gastrointestinal distress, dizziness, fatigue,

14 Given that no consensus exists on an appropriate amount of opioids per capita, it is possible that other countries

consume fewer opioids than the United States because pain is undertreated there. However, most experts believe that

the opioid-related drug overdose epidemic in the United Stat es is due in part to overprescribing practices. See, for

instance, Sameer Imtiaz, Kevin Shield, Benedikt Fischer, et al., “Harms of Prescription Opioid Use in the United

States,” Substance Abuse Treatment, Prevention, and Policy, vol. 9, no. 4 (October 27, 2014), and Organisation for

Economic Co-operation and Development (OECD), Addressing Problematic Opioid Use in OECD Countries, OECD

Health Policy Studies, Paris, France, June 11, 2019, at https://www.oecd.org/health/addressing-problematic-opioid-usein-oecd-countries-a18286f0-en.htm.

15 OxyContin is the brand-name extended-release formulation of oxycodone manufactured by Purdue Pharma L.P. For

more information, see U.S. Food and Drug Administration, OXYCONTIN, Medication Guide (Reference ID 3805894),

August 2015, https://www.fda.gov/media/78453/download.

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addiction, and overdose death. 16 Since the 1990s, opioid misuse and overdose deaths have

increased significantly in many countries, particularly in the United States. In some countries —

including the United States—the increase in adverse outcomes has corresponded with the increase

in opioids prescribed to treat pain. 17 Most data suggest that high levels of prescription opioid

consumption in the United States have contributed to the current epidemic of misuse and

overdose deaths in the country. 18 Several experts have identified overutilization of prescription

opioids in particular as a key contributing factor to the epidemic of opioid overdose deaths. 19

Figure 1. Total Opioid Consumption for G-7 Countries

Defined daily doses per 1 million inhabitants: 1964-2018

Source: International consumption of narcotic drugs, 1964-2018, data provided to CRS by the International

Narcotics Control Board (August 2020).

Notes: The opioids included in the total are hydrocodone, oxycodone, morphine, methadone,

dextropropoxyphene, dihydrocodeine, diphenoxylate, ethylmorphine, pethidine, pholcodine, tilidine,

hydromorphone, and fentanyl. Defined daily doses (DDD) are “the assumed average maintenance dose per day”

for an opioid used for “its main indication in adults,” according to the World Health Organization. DDDs are

commonly used as a standard measure of drug use in national and international comparison studies at the

population level because one DDD per day is implied. DDDs do not necessarily reflect the prescribed

therapeutic dose, which is based on individual patient characteristics (age, weight, etc.). See World Health

Organization, Essential Medicines and Health Products/Defined Daily Doses, at https://www.who.int/medicines/

regulation/medicines-safety/toolkit_ddd/en/.

Roger Chou, Rick Deyo, Beth Devine, et al., “T he Effectiveness and Risks of Long-T erm Opioid T reatment of

Chronic Pain,” Evidence Report/Technology Assessment, vol. 218 (2014), pp. 1-219, and Charl Els, T anya Jackson,

Diane Kunyk, et al., Adverse Events Associated with Medium -and Long-Term Use of Opioids for Chronic Non-Cancer

Pain: An Overview of Cochrane Reviews, Cochrane Database of Systematic Reviews, 2017.

Leonard Paulozzi, Christopher Jones, Karin Mack, et al., Vital Signs: Overdoses of Prescription Opioid Pain

Relievers: United States, 1999-2008, Centers for Disease Control and Prevention, National Center for Injury

Prevention, Morbidity and Mortality Weekly (MMWR) Early Release, Atlanta, GA, November 4, 2011, at

https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm, and OECD, Addressing Problematic Opioid Use,

2019.

For example, see Sameer Imtiaz, Kevin Shield, Benedikt Fischer, et al., “Harms of Prescription Opioid Use in the

United States,” Substance Abuse Treatment, Prevention, and Policy, vol. 9, no. 4 (October 27, 2014).

19 OECD, Addressing Problematic Opioid Use, 2019.

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Despite general acceptance in the medical field that opioids are effective treatments for acute

pain, no medical consensus exists regarding the appropriate amount of opioid consumption per

capita in a country. 20 Medical opioid use (separate from use of illicit opioids, such as heroin21 ) has

increased in many economically developed countries over the past 25 years. 22 However, per

capita opioid consumption differs substantially among countries. The United States has less than

5% of the world’s population but consumed roughly 30% of the world’s opioids in 2009,

including more than 99% of the world’s hydrocodone and 80% of the world’s oxycodone. 23

Figure 1 displays trends in the use of the most common opioids in the G-7 countries over the past

several decades.

Global Trends

Global opioid use has increased over the past 25 years. 24 For instance, from 2001 to 2013,

prescription opioid use for pain more than doubled globally, most significantly in North America,

Europe, and Australia. 25 Opioid consumption rose nearly 40% in the European Union (EU) during

that time. 26 Several individual countries experienced substantial growth in opioid consumption in

the early 2000s. In the decade from 2000 to 2010, for example, the proportion of individuals in

Germany with at least one opioid prescription increased by 37%. 27 During that same period,

prescription opioid sales in Italy and total consumption of opioids in Canada both tripled. 28

In the majority of countries, the largest prescription opioid use increases were among patients

with chronic noncancer pain. 29 One research study found a pronounced trend toward the use of

Laxmaiah Manchikanti, Standiford Helm, a Bert Fellows, et al., “Opioid Epidemic in the United States,” Pain

Physician, vol. 15 (2012), pp. ES9-ES38.

21 T he term “opioid use” in this report refers to medical opioid use only, not illicit opioid use (e.g., heroin or illicit

fentanyl use). Likewise, except where noted, the term “opioids” denotes opioids used medically to treat pain. Statistics

describing the consumption of opioids likewise refer to those used medically —not to illicit opioids.

22 International Narcotics Control Board, Narcotic Drugs – Technical Report, 1972-2019, available at

https://www.incb.org/incb/en/narcotic-drugs/T echnical_Reports/narcotic_drugs_reports.html.

23 Hydrocodone is a long-acting opioid formulation used to treat severe pain for a prolonged duration, and is taken

orally. Oxycodone is a synthetic analgesic drug used to treat moderate to severe pain. International Narcotics Control

Board, Narcotic Drugs: Estimated World Requirements for 2011, Statistics for 2009 , T he United Nations, Vienna,

Austria, 2010, at https://www.incb.org/documents/Narcotic-Drugs/T echnical-Publications/2010/Narcotic_

drugs_publication_2010.pdf.

24 International Narcotics Control Board, Narcotic Drugs: Estimated World Requirements for 2019, Statistics for 2017 ,

T he United Nations, Vienna, Austria, 2018, at https://www.incb.org/incb/en/narcotic-drugs/T echnical_Reports/

narcotic_drugs_reports.html, and Cristina Bosetti, Claudia Santucci, Silvia Radrezza, et al., “T rends in the

Consumption of Opioids for the T reatment of Severe Pain in Europe, 1990 -2016,” European Journal of Pain, vol. 23

(2019), pp. 697-707.

See, for instance, Stefano Berterame, Juliana Erthal, Johny T homas, et al., “Use of and Barriers to Access to Opioid

Analgesics: A Worldwide, Regional, and National Study,” The Lancet, February 3, 2016, and C. Chenaf, J. L. Kabore,

J. Delorme, et al., “Prescription Opioid Analgesic Use in France: T rends and Impact on Morbidity -Mortality,”

European Journal of Pain, vol. 23 (2019).

From 2005 to 2015. Ibid.

27 Jan van Amsterdam and Wim van den Brink, “T he Misuse of Prescription Opioids: A T hreat for Europe?” Current

Drug Abuse Reviews, vol. 8 (2015), pp. 3-14.

See Chenaf et al., “Prescription Opioid Analgesic Use in France,” 2019.

29 S. Mathieson, G. Wertheimer, C.G. Maher, et al., “What Proportion of Patients with Chronic Nonca ncer Pain are

Prescribed an Opioid Medication: Systematic Review and Meta-regression of Observational Studies,” Journal of

Internal Medicine, 2020, pp. 1-17.

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stronger, higher-potency opioids (defined in this study as >50 MME per day). 30 Another study

found that in the United Kingdom (UK) the number of individuals using strong opioids increased

nearly fivefold from 2000 to 2010. 31 The use of oxycodone—considered one of the higherpotency opioids—has increased the most in many countries. 32 In France, oxycodone use jumped

1,950% between 2004 and 2017. 33 By 2010, oxycodone was the most widely prescribed opioid in

the United States, with an increase in consumption of 1,100% between 1997 and 2010.34 Figure 2

illustrates oxycodone use in the United States compared with the other G-7 members over the

past several decades.

Since the early to mid-2010s, European countries and other developed economies have

experienced different trajectories of opioid use. Some continue to see increases in the dose and

quantity of prescriptions, while others have seen level use or declines. 35 In Denmark, Finland,

France, Ireland, Switzerland, and Poland, for instance, opioid consumption has leveled off or

declined in 2014-2016. 36 Israel, Greece, and Portugal, however, experienced increases of more

than 50% between 2011 and 2016. 37 Similar increases have been reported in Australia and New

Zealand. 38 During that time, some countries, such as France and Canada, have experienced a

surge in adverse effects associated with increased opioid prescriptions, such as opioid misuse,

doctor shopping, opioid-related hospitalizations, and overdose deaths. 39

30 Ibid.

C.S. Zin, L.C. Chen, and R.D. Knaggs, “Changes in T rends and Pattern of Strong Opioid P rescribing in Primary

Care,” European Journal of Pain, vol. 18 (2014), pp. 1343-1351.

32 IQVIA Institute for Human Data Science, Medicine Use and Spending in the U.S.: A Review of 2018 and Outlook to

2023, Parsippany, NJ, May 2019; Chenaf et al., “Prescript ion Opioid Analgesic Use in France,” 2019; and van

Amsterdam et al., “T he Misuse of Prescription Opioids,” 2015.

33 Chenaf et al., “Prescription Opioid Analgesic Use in France,” 2019 .

34 International Narcotics Control Board, Narcotic Drugs: Estimated World Requirements for 2011, Statistics for 2009,

T he United Nations, Vienna, Austria, 2010, and International Narcotics Control Board, Narcotic Drugs: Estimated

World Requirements for 2003, Statistics for 2001, T he United Nations, Vienna, Austria, 2002, at https://www.incb.org/

incb/en/narcotic-drugs/T echnical_Reports/narcotic_drugs_reports.html. An exploration of the factors explaining these

different trajectories is beyond the scope of this report.

35 OECD, Addressing Problematic Opioid Use, 2019. A full comparison of the different trajectories of use across

countries and an exploration of the factors contributing to these differing rates are beyond the scope of this report.

36 Cristina Bosetti, Claudia Santucci, Silvia Radrezza, et al., “T rends in the Consumption of Opioids for the T reatment

of Severe Pain in Europe, 1990-2016,” European Journal of Pain, vol. 23 (2019), pp. 697-707.

37 Karima Hider-Mlynarz, Philippe Cavalie, and Patrick Maison, “T rends in Analgesic Co nsumption in France Over the

Last 10 Years and Comparison of Patterns across Europe,” British Journal of Clinical Pharmacology, vol. 84 (2018),

pp. 1324-1334, and OECD, Addressing Problematic Opioid Use, 2019.

38 Bosetti et al., “T rends in the Consumption of Opioids,” 2019.

39 G.T . Helmerhorst, T . T eunis, S.J. Janssen, et al., “An Epidemic of the Use, Misuse, and Overdose of Opioids and

Deaths Due to Overdose, in the United States and Canada,” The Bone and Joint Journal, vol. 99-B (2017), pp. 856-864.

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Figure 2. Oxycodone Consumption in G-7 Countries

Defined daily doses per 1 million inhabitants: 1964-2018

Source: International consumption of narcotic drugs, 1964-2018, data provided to CRS by the International

Narcotics Control Board (August 2020).

Notes: Defined daily doses (DDD) are “the assumed average maintenance dose per day” for an opioid used for

“its main indication in adults” according to the World Health Organization. DDDs are commonly used as a

standard measure of drug use in national and international comparison studies at the population level because

one DDD per day is implied. DDDs do not necessarily reflect the prescribed therapeutic dose, which is based

on individual patient characteristics (age, weight, etc.). See World Health Organization, Essential Medicines and

Health Products/Defined Daily Doses, found at https://www.who.int/medicines/regulation/medicines-safety/

toolkit_ddd/en/.

U.S. Trends

Although opioid consumption has increased in many countries, the United States continues to

outpace its European counterparts in opioid consumption (see Figure 1). Research from CDC

shows that overall opioid sales in the United States quadrupled from 1999 to 2010. 40 In some

years, prescription opioid use in the United States was as much as four times higher than in

Western European countries. 41

Prescription opioid use peaked in the United States in 2012, with decreases in the years that

followed. 42 The overall national opioid prescribing rate declined from 81.3 prescriptions per 100

40 CDC, Vital Signs: Overdoses of Prescription Opioid Pain Relievers—United States, 1999–2008, MMWR

60(43):1487-92, 2011. Of note, studies examining opioid consumption often cover different time periods, making it

difficult to compare certain trends.

Benedikt Fischer, Annette Keates, Gerhard Buhringer, et al., “Non -medical Use of Prescription Opioids and

Prescription Opioid-Related Harms: Why So Markedly Higher in North America Compared to the Rest of the World?,”

Addiction, vol. 109 (2013), pp. 177-181; Chenaf et al., “Prescription Opioid Analgesic Use in France,” 2019; van

Amsterdam et al., “T he Misuse of Prescription Opioids,” 2015; and INCB, Narcotic Drugs – Technical Report, 20112019.

42 Wenjia Zhu, Michael Chernew, T ismarie Sherry, et al., “Initial Opioid Pr escriptions among U.S. Commercially

Insured Patients, 2012-2017,” New England Journal of Medicine, March 14, 2019.

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persons in 2012 to 51.4 prescriptions per 100 persons in 2018 (from 255 million total opioid

prescriptions to 168 million). 43 Data from the International Narcotics Control Board (INCB)

showed a 50% decrease in the consumption of both hydrocodone and oxycodone from 2012 to

2018. Figure 3 displays opioid consumption over time from 1964 to 2018 in the United States.

Figure 3. Opioid Consumption in the United States, by Opioid

Consumption in milligrams per capita: 1964-2018

Source: International consumption of narcotic drugs, 1964-2018, data provided to CRS by the International

Narcotics Control Board (August 2020).

Notes: Consumption in milligrams per capita accounts for population change over time but does not factor in

the potency of the opioid.

Despite the decrease in opioid prescriptions since 2012, the United States remains the top

consumer of prescription opioids globally, followed by Germany, the United Kingdom, and

Canada (see Figure 1). 44 In addition, the rates of lengthy prescriptions (more than three days) for

high-potency opioids have remained high. From 2012 to 2017, prescriptions for more than a

three-day supply or for a dose of 50 MMEs per day or higher persisted in United States, even as

overall consumption declined. 45 CDC has noted that prescribing rates remain especially high in

certain areas of the country. The agency reported annual prescribing rates of over 350

prescriptions per 100 people in some areas, with 11% of U.S. counties having enough opioid

prescriptions for each inhabitant. 46 In 2015, average per capita amounts of opioids prescribed in

the top-prescribing counties were approximately six times the amounts prescribed in the lowest

prescribing counties. 47 Other studies report similar findings, showing that a relatively small

Ibid.

44 Figure 1 refers to opioid consumption per capita. T he United States also leads in total annual opioid consumption by

weight.

Zhu et al., “Initial Opioid Prescriptions among U.S. Commercially Insured Patients,” 2019.

46 Centers for Disease Control and Prevention, Opioid Overdose/Data/U.S. Opioid Prescribing Rate Maps, 2019,

https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html.

47 Gery Guy, Kun Zhang, and Michele Bohm, Vital Signs: Changes in Opioid Prescribing in the United States: 2006-

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percentage of U.S. providers prescribe a disproportionate amount of opioid prescriptions to U.S.

patients. 48

Factors Influencing Medical Opioid Consumption

Several factors may influence differences in opioid-prescribing practices among developed

countries. 49 Comparing global opioid consumption is a challenge. Economic, social, and health

care systems in G-7 and other economically developed countries vary. Excluding these broader

discussions, public health experts have identified three key factors shaping opioid consumption:50



physician behavior (e.g., influence by pharmaceutical marketing, inadequate

training on opioid pharmacology and risks, lack of access to multimodal pain

treatments, and the ease of prescribing opioids compared with other pain

therapies);



patient-related factors (e.g., awareness of pain management options, attitudes

toward pain, an emphasis on pain relief in treatment as opposed to underlying

mental health, more value placed on pain relief than on functional improvement,

and susceptibility to direct-to-consumer advertising); and



sociocultural factors (e.g., beliefs about pain and the right to pain treatments,

such as opioid therapy; health care coverage for opioid medications and

alternative therapies; direct-to-provider and direct-to-consumer marketing rules;

and opioid-prescribing regulations). 51

This section describes how these key factors might explain the differences in opioid consumption

between the United States and other developed countries. These factors are organized into two

general categories: (1) physician behavior and patient-related factors, and (2) sociocultural

factors. 52

2015, Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report (MMWR) vol. 66, no.26,

July 7, 2017, pp. 697-704, https://www.cdc.gov/mmwr/volumes/66/wr/mm6626a4. htm#contribAff.

48 See, for example, Zhu et al., “Initial Opioid Prescriptions among U.S. Commercially Insured Patients,” 2019.

Medical treatment and the use of certain health care services such as prescription opioids are complex. A

combination of many factors likely influences use. T he goal of this report is to provide as many possible reasons as are

supported by the scientific literature. It is possible that other factors exist but are not identified in this report.

50 Mark Sullivan and Catherine Howe, “Opioid T herapy for Chronic Pain in the U.S: Promises and Perils,” Pain, vol.

154, no. 01 (December 2013).

51 See Winfried Hauser, Frank Petzke, Lukas Radbruch, et al., “T he Opioid Epidemic and the Long-term Opioid

T herapy for Chronic Noncancer Pain Revisited: A T ransatlantic Perspective,” Pain Management, vol. 6, no. 3 (2016),

pp. 249-263.

52 Factors are grouped generally, though many of the factors are interrelated and some categories may overlap.

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Key Takeaways

Key findings from this section are as follows:



Research consistently shows that U.S. health care providers prescribe a greater number of opioids per capit a,

at higher doses, throughout more stages of treatment of various conditions compared with providers in

other countries.



A few studies suggest that U.S. citizens may self-report higher levels of pain than citizens in other countries,

which may increase demand for and subsequent use of opioids. International reviews of pain prevalence are

incomplete, though possible explanations for a greater prevalence of pain in the United States may include

more frequent assessments of pain during medical care or more risk factors for pain, such as undertreated

mental illness, greater income inequality, or higher rates of other socio-economic stressors.



The United States uses opioids for pain management more frequently than other economically advanced

countries, which frequently offer a wider variety of pharmacological and nonpharmacological interventions for

pain.



Increases in opioid use for chronic noncancer pain in some countries—such as the United States—were

parallel to an emergent pain advocacy movement and the intensified marketing campaigns of the

pharmaceutical industry. While much of this activity originated in the United States—and may have been

concentrated there due to factors such as market share—some evidence suggests that U.S. prescribing

practices may have been more susceptible to these outside influences than in other countries.



Clinical guidance for opioid use in the United States is nonbinding for health care providers. Some other

countries tie clinical guidelines more closely to their national policies.



Differences in health care systems may influence rates of opioid use in medical care. The historical

predominance of a fee-for-service model in the United States may incentivize the use of opioids. In addition,

the federalized regulatory model in the United States (which leaves many regulations to the states) may result

in a slower, less direct ability to govern the use of opioids compared with the more centralized systems in

many European countries and elsewhere.



Payment systems for opioid and nonopioid pain interventions, and their respective costs, may influence the

frequency of opioid use—particularly in the United States, where not all pain management treatments are

reimbursed equally.



The ability of oversight or regulatory bodies to monitor opioid use may affect consumption.



Cultural differences surrounding experiences of pain, expectations of pain remediation, and the use of

medical care may explain higher rates of opioid use in the United States compared with other countries.

Physician Behavior and Patient-Related Factors

Prescribing Practices

Prescribing practices influence opioid use, and research consistently shows that U.S. health care

providers prescribe more opioids, at higher doses, more frequently during more stages of care for

acute and chronic pain conditions than health care providers in other countries. 53 Most

governments regulate medical opioid use, often requiring permission for use—such as a

prescription—from a health care provider. 54 From 1995 through 2019, the United States

53 Laxmaiah Manchikanti, Standiford Helm, Bert Fellows, et al., “ Opioid Epidemic in the United States,” Pain

Physician, vol. 15 (2012), pp. ES9-ES38; Luca Miceli, Rym Bednarova, Alessandro Rizzardo, et al., “Opioids

Prescriptions in Pain T herapy and Risk of Addiction: A One-Year Survey in Italy. Analysis of National Opioids

Database,” Ann Ist Super Sanita,vol. 54, no. 4 (2018), pp. 370-374; and Heather T ick, Arya Nielson, and Kenneth

Pelletier, “Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: T he Consortium Pain T ask

Force White Paper,” Explore, vol. 14, no. 3 (May/June 2018), pp. 177-211.

Some countries, such as Canada, allow a select few opioids with low morphine equivalent levels such as codeine, to

be available over the counter without a prescription. See, for example, Jesse MacKinnon, “T ighter Regulations Needed

for Over-the-Counter Codeine in Canada,” Canadian Pharmacists Journal, vol. 149, no. 6, (November 2016), pp. 322 -

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prescribed more opioids than any other country in the world. 55 Research shows that U.S.

providers generally use higher doses of opioids, 56 higher-potency opioids (meaning higher MMEs

per dose or per day), 57 and opioids at more stages of treatment than health care providers in other

countries. 58

Attitudes toward opioids may affect prescribing practices. According to several studies, U.S.

providers are more likely to report being “very comfortable” prescribing opioids, compared with

non-U.S. prescribers. 59

Use of higher-potency opioids may explain relatively higher national consumption of opioids in

the United States. Multiple studies have found that long-term use of more potent opioids—such

as oxycodone and hydromorphone—increased substantially in the United States from the mid1990s through 2011, while the use of codeine—an opioid with comparatively low potency—

decreased (see Figure 3).60 A CDC study found that the percentage of adults in the United States

324.

55 Manchikanti et al., “Opioid Epidemic in the United States,” 2012, and INCB, Narcotic Drugs – Technical Report,

2011-2020, available at https://www.incb.org/incb/en/narcotic-drugs/T echnical_Reports/narcotic_drugs_reports.html.

T his includes opioid use per capita, total weight, and number of prescriptions

For example, one study found that the average MME for a postoperative opioid prescription was higher in the United

States compared with Canada and Sweden. See Karim Ladha, Mark Neuman, Gabriella Broms, et al., “Opioid

Prescribing After Surgery in the United States, Canada, and Sweden,” JAMA Network Open, vol. 2, no. 9 (September 4,

2019). Opioid users in the United States are also more likely to use immediate-release opioid medications—as opposed

to extended release opioids—which may require more frequent dosing (e.g., every 4-6 hours instead of every 12 hours)

and a greater overall number of pills. See Catherine Hwang, Elizabeth Kang, Yulan Ding, et al., “Patterns of

Immediate-Release and Extended-Release Opioid Analgesic Use in the Management of Chronic Pain, 2003 -2014,”

JAMA Network Open, vol. 1, no. 2 (June 1, 2018).

57 For example, one study found that American patients were more likely to receive opioids the day after surgery than

European patients. Another study examining opioid-prescribing practices among providers treating sickle cell disease

in the United States and internationally found that U.S. providers tend to prescribe more tablets of stronger opioids per

patient than non-U.S. physicians. Another study comparing opioid-prescribing practices between dentists in the United

States and England during calendar year 2016 found that U.S. dentists prescribed opioids at a rate 37 times higher than

dentists in England. T his study also found that U.S. dentists prescribed a wider variety of opioids, including

hydrocodone-based opioids and oxycodone, compared with England, where the only opioid prescribed by dentists was

dihydrocodeine, a codeine derivative and less potent opioid. See C. Richard Chapman, Duncan Stevens, and Arthur

Lipman, “ Quality of Postoperative Pain Management in America versus European Institutions,” J Pain Palliat Care

Pharmacother, vol. 27, no. 4 (December 2013); Nadirah El-Amin, Paul Nietart, and Julie Kanter, “International

Differences in Outpatient Pain Management: A Survey of Sickle Cell Disease,” Journal of Clinical Medicine, vol. 8,

no. 2136 (December 2019); and Katie Suda, Michael Durkin, Gregory Calip, et al., “Comparison of Opioid Prescribing

by Dentists in the United States and England,” JAMA Network Open, vol. 2, no. 5 (May 24, 2019).

58 For example, one study comparing the United States with 13 European countries found that U.S. patients received

opioids more frequently at every treatment phase (except for during an operation), including before admission to the

hospital and after discharge. See R. Zaslansky, W. Meissner, and C.R. Chapman, “Pain After Orthopaedic Surgery:

Differences in Patient Reported Outcomes in the United States vs Internationally. An Observational Study from the

PAIN OUT Dataset,” British Journal of Anaesthesia, vol. 120, no. 4 (2018), pp. 790-797. Another study found that

most American patients attending a pain management clinic had been receiving opioids prior to specialized pain care,

suggesting that opioids may be frequently used as first -line pain treatments. See L. Manchikanti, K.S. Damron, C.D.

McManus, et al., “Patterns of Illicit Drug Use and Opioid Abuse in Patients with Chronic Pain at Initial Evaluatio n: A

Prospective, Observational Study,” Pain Physician, vol. 7, no. 4 (September 30, 2004), pp. 431 -437.

59 El-Amin et al., “International Differences in Outpatient Pain Management,” 2019.

60 See, for instance, Sairam Atluri, Gururau Sudarshan, and Laxmaiah Manchikanti, “Assessment of the T rends in

Medical Use and Misuse of Opioid Analgesics from 2004 to 2011,” Pain Physician, vol. 17 (2014), pp. E119-E128;

and Denise Boudreau, Michael Von Korff, Carolyn Rutter, et al., “T rends in De-Facto Long-T erm Opioid T herapy for

Chronic Non-Cancer Pain,” Pharmacoepidemiol Drug Saf., vol. 18, no. 12 (December 2009), pp. 116-175. In the latter

study, “high potency” opioids were defined as schedule II opioids. For more information on scheduling opioid

medications, see U.S. Drug Enforcement Administration (DEA), Drug Scheduling, available at https://www.dea.gov/

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who used only a weaker-than-morphine opioid in the past 30 days declined from 42.4% in 1999–

2002 to 20.0% in 2011–2012, while the percentage who used a stronger-than-morphine opioid

increased from 17.0% to 37.0%. 61 This finding suggests that increases in opioid consumption

rates may be partially due to higher-potency opioids replacing those of lower potency, resulting in

more MMEs per capita in the United States. 62

Patient attitudes toward opioids may also affect opioid consumption rates. Some studies indicate

that American patients are more likely to fill and use prescriptions compared with their European

counterparts.63 In addition, American patients may be more likely to use opioids in long-term

treatment for pain (the majority of which is chronic noncancer pain), which can lead to tolerance,

leading in turn to use of more opioids. 64 Long-term use can also result in hyperalgesia—a

heightened sensitivity to pain that can result in more opioid use. 65 In this way, opioid

consumption often begets more opioid consumption. 66

Several countries demonstrate high rates of opioid consumption, including long-term use for

chronic noncancer pain, yet most do not experience comparable adverse outcomes (e.g., high

overdose deaths). 67 Germany, for instance, is a top global consumer of opioids but has low rates

of opioid-related overdose deaths compared with the United States. 68 This difference may be

partially due to the amount of opioids that are used in institutional settings, compared with

outpatient settings away from provider supervision, where most U.S. use occurs.69 As one study

drug-scheduling; DEA, The Controlled Substances Act, available at https://www.dea.gov/controlled-substances-act;

and European Union, European Monitoring Centre for Drugs and Drug Addiction, Classification of Controlled Drugs,

available at http://www.emcdda.europa.eu/publications/topic-overviews/classification-of-controlled-drugs/html_en.

Steven Frenk, Kathryn Porter, and Leonard Paulozzi, Prescription Opioid Analgesic Use Among Adults: United

States, 1999-2012, CDC, National Center for Health Statistics, NCHS Data Brief No. 189, Hyattsville, MD, February

2015, at https://www.cdc.gov/nchs/data/databriefs/db189.pdf.

Laxmaiah Manchikanti, Bert Fellows, Hary Ailinani, et al., “T herapeutic Use, Abuse, and Nonmedical Use of

Opioids: A T en Year Perspective,” Pain Physician, vol. 13 (2010), pp. 401-435.

In one study, for example, roughly 10% of Swedish patients filled an opioid prescription within the first seven days

after discharge for any procedure, compared with over 75% of U.S. and Canadian patients. Ladha et al., “Opioid

Prescribing After Surgery in the United States, Canada, and Sweden,” 2019. Canadian patients in the study filled

prescriptions at similar rates as Americans, though the average dose of opioids was higher in the United States.

Deborah Dowell, T amara Haegerich, and Roger Chou, CDC Guidelines for Prescribing Opioids for Chronic Pain United States, 2016, Centers for Disease Control and Prevention, Recommendations and Reports, Atlanta, GA, March

18, 2016. See also, Manchikanti et al., “T herapeutic Use, Abuse, and Nonmedical Use of Opioids,” 2010; Okie, “A

Flood of Opioids,” 2010; and Anuj Shah, Corey Hayes, and Bradley Martin, “Factors Influencing Long-T erm Opioid

use Among Opioid Naïve Patients: An Examination of Initial Prescription Characteristics and Pain Etiologies,” The

Journal of Pain, vol. 18, no. 11 (November 2017), pp. 1374 -1383.

65 L. Chen, M. Sein, T . Vo, et al., “Clinical Interpretation of Opioid T olerance versus Opioid-Induced Hyperalgesia,”

Journal of Opioid Management, vol. 10, no. 6 (2014), pp. 383-393.

See, for example, Sebastiano Mercadante, Edoardo Arcuri, and Angela Santoni, “Opioid-Induced T olerance and

Hyperalgesia,” CNS Drugs, vol. 33 (2019), pp. 943-955; and Lesley Colvin, Fiona Bull, and T im Hales, “Perioperative

Opioid Analgesia-When is Enough T oo Much: A Review of Opioid-Induced T olerance and Hyperalgesia,” Lancet, vol.

393 (2019), pp. 1558-1568.

Bastian Rosner, Jessica Neicun, Justin Christopher Yang, et al., “Opioid Prescription Patterns in Germany and the

Opioid Epidemic: Systematic Review of Available Evidence,” PLoS ONE, vol. 14, no. 8 (2019).

68 U. Marschall, H. L’hoest, L. Radbruch, et al., “Long-term Opioid T herapy for Chronic Non-Cancer Pain in

Germany,” European Journal of Pain, 2015.

69 Keith Humphreys, Jonathan P. Caulkins, and Vanda Felbab-Brown, What the U.S. and Canada Can Learn From

Other Countries to Combat the Opioid Crisis, the Brookings Institution, Order from Chaos Blog, Washington, DC,

January 13, 2020, at https://www.brookings.edu/blog/order-from-chaos/2020/01/13/what-the-us-and-canada-can-learnfrom-other-countries-to-combat-the-opioid-crisis/.

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noted, “The international data thus suggest that it’s not just the volume of opioid prescribing that

matters, but where and how opioids are prescribed and used.”70 The higher rate of opioid

prescribing by health care providers in the United States may not be limited to opioids. Other

studies have shown that U.S. providers rely more heavily on pharmacotherapy in medical

treatment compared with other countries.71

Pain Rates among Select Countries

International reviews of pain prevalence are sparse and often incomparable, though a few studies

suggest that U.S. citizens may experience higher levels of pain (or higher subjective self-reported

pain) than citizens in some other countries, which may increase demand and subsequent use of

opioids. 72

In 2016, CDC estimated that 20.4% of U.S. adults experienced chronic pain. 73 Estimates of

chronic pain in Europe typically range from 11% to 20% of the population (though some research

has estimated that in some European countries as much as 50% of the population experienced

chronic pain). 74 One study comparing the prevalence of common chronic pain conditions across a

number of countries found that the United States has a similar prevalence as some developed

countries—such as France and Italy (44% prevalence in the U.S. population versus 50% and 43%

in France and Italy, respectively)—but has a higher prevalence than others, such as Germany

(32%) and Japan (28%). 75

Pain is one of the most common reasons for seeking medical care in the United States. 76

Population-level studies of U.S. citizens indicate that pain prevalence may have increased during

70 Ibid.

71 T he use of psychotropic medications for mental disorders, for example, is substantially higher in North America

compared to most other regions. See, for instance, Benedikt Fischer, Annette Keates, and Gerhard Buhringer, et al.,

“Non-medical Use of Prescription Opioids and Prescription Opioid-Related Harms: Why So Markedly Higher in North

America Compared to the Rest of the World?,” Addiction, vol. 109 (2013), pp. 177-181. A comparison of use across

classes of medications is beyond the scope of this report, though it is notable that higher rates of prescription

medication use by the United States is not solely confined to opioids.

72 See, for instance, N. T orrance, R. Mansoor, and H. Wang, et al., “Association of Opioid Prescribing Practices with

Chronic Pain and Benzodiazepine Co-Prescription: A Primary Care Data Linkage Study ,” British Journal of

Anaesthesia, vol. 120, no. 6 (June 2018), pp. 1345-1355; and Geana Paula Kurita, Per Sjogren, and Knud Juel, et al.,

“ T he Burden of Chronic Pain: A Cross-Sectional Survey Focusing on Disease, Immigration, and Opioid Use,” Pain,

vol. 153, no. 12 (December 2012), pp. 2332 -2338.

73 James Dahlhamer, Jacqueline Lucas, and Carla Zelaya, et al., Prevalence of Chronic Pain and High-Impact Chronic

Pain Among Adults—United States, 2016, Centers for Disease Control and Prevention, Morbidity and Mortality

Weekly Report (MMWR), Atlanta, GA, September 14, 2018. Other surveys of the U.S. population have estimated

anywhere from a tenth of the U.S. adult population, to a third, to over half report experiencing pain. See Jochen Hardt,

Clemma Jacobsen, and Jack Goldberg, et al., “Prevalence of Chronic Pain in a Representative Sample in the United

States,” Pain Medicine, vol. 9, no. 7 (2008); Russell Portenoy, Carlos Ugarte, and Ivonne Fuller, et al., “Population based Survey of Pain in the United States: Differences among White, African American, and Hispanic Subjects,” The

Journal of Pain, vol. 5, no. 6 (August 2004), pp. 317-328; and Committee on Advancing Pain Research, Care, and

Education, Relieving Pain in America, Institute of Medicine of the National Academies, A Blueprint for T ransforming

Prevention, Care, Education, and Research, Washington, DC, 2011, at https://www.ncbi.nlm.nih.gov/books/

NBK91497/pdf/Bookshelf_NBK91497.pdf.

74 O. van Hecke, N. T orrance , and B.H. Smith, “Chronic Pain Epidemiology and Its Clinical Relevance,” British

Journal of Anaesthesia, vol. 111, no. 1 (2013), pp. 13-18; P. Croft, A.S. Rigby, and R. Boswell, et al., “T he Prevalence

of Chronic Widespread Pain in the General Population,” The Journal of Rheumatology, vol. 20, no. 4 (March 31,

1993), pp. 710-713; and Bosetti et al., “T rends in the Consumption of Opioids,” 2019.

75 T sang et al., “Chronic Pain Conditions in Developed and Developing Countries,” 2008.

76 See, for instance, Jennifer St. Stauver, David Warner, Barbara Yawn, et al., “Why Do Patients Visit T heir Doctors?

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the past several decades. 77 Although this jump may have contributed to an increase in opioid use

for pain, it may not fully explain international differences; other studies suggest that pain

conditions may have increased in other countries as well. 78 Some research suggests that

Americans may experience pain at more intense levels than residents of other countries. 79

Possible explanations for a greater prevalence (or intensity) of pain in the United States may

include more frequent assessments of pain during medical care or more risk factors for pain, such

as undertreated mental illness, greater income inequality, or higher rates of other socio-economic

stressors.

American patients receive more frequent assessments of pain compared with patients in other

countries. 80 A body of research suggests that these assessments do not necessarily result in more

effective pain management, and may even increase self-reported pain levels. 81 For example,

repeated assessments may heighten patient awareness of pain, making patients hypervigilant and

increasing their perceptions of pain severity. 82 Conversely, infrequent assessments of pain may

lead to worse pain management for certain patient populations. 83

Different experiences of pain between individuals in the United States and other countries may be

genuine, perhaps the product of increased risk factors for pain conditions. One report attributed

the rise in chronic pain prevalence in the United States to several factors, including greater patient

expectations for pain relief, musculoskeletal disorders of an aging population, obesity, increased

Assessing the Most Prevalent Conditions in a Defined US Population,” Mayo Clinic Proceedings, vol. 88, no. 1

(January 2013), pp. 56-67.

One study found that the proportion of adults in the United States reporting painful health conditions increased from

32.9% (120 million adults) in 1998 to 41.0% (178 million adults) in 2014. See R.L. Nahin, B. Sayer, B.J. Stussman, et

al., “Eighteen-Year T rends in the Prevalence of, and Health Care Use for, Noncancer Pain in the United States: Data

from the Medical Expenditure Panel Survey,” Journal of Pain, vol. 20, no. 7 (January 15, 2019).

78 See E.F. Harkness, G.J. Macfarlane, A.J. Silman, et al., “ Is Musculoskeletal Pain More Common Now T han 40

Years Ago?: T wo Population-Based Cross-Sectional Studies,” Rheumatology, vol. 44, no. 7 (2005), and J.K. Freburger,

G.M. Holmes, R.P. Agans, et al., “ T he Rising Prevalence of Chronic Low Back Pain,” Arch Intern Med, vol. 169

(2009), pp. 251- 258. There is a dearth of research monitoring global prevalence of pain over time, which may impede

making accurate comparisons of international trends or identifying how the United States compares to other countries.

See, for example, Fischer et al., “Non-medical Use of Prescription Opioids and Prescription Opioid-Related Harms,”

2013.

79 For example, in one st udy comparing patients’ preoperative pain scores across countries, researchers found that ,

U.S. patients reporting chronic pain before hospital admission reported higher “ worst pain” scores. See Zaslansky et al.,

“Pain After Orthopaedic Surgery,” 2018.

Ibid. In U.S. health care institutions, patient pain is assessed routinely and these assessments factor in to hospital

accreditation. T he Joint Commission, Pain Assessment and Management Standards, Oakbrook T errance, IL, 2019, at

https://www.jointcommission.org/en/resources/patient-safety-topics/pain-management-standards-for-accreditedorganizations/.

81 See, for example, Richard Mularski, Foy White-Chu, Deborah Overbay, et al., “Measuring Pain as the 5 th Vital Sign

Does Not Improve Quality of Pain Management,” Journal of General Internal Medicine, vol. 21 (June 2006); Charles

E. Lucas, Angie L. Vlahos, and Anna M. Ledgerwood, “Kindness Kills: T he Negative Impact of Pain as the Fifth Vital

Sign,” Journal of the American College of Surgeons, vol. 205, no. 1 (July 2007), pp. 101-107; Jane C. Ballantyne and

Mark D. Sullivan, “Intensity of Chronic Pain - T he Wrong Metric,” The New England Journal of Medicine, vol. 373,

no. 22 (November 26, 2015); and Clara Scher, Lauren Meador, and Janet H. Van Cleave, “Moving Beyond Pain as the

Fifth Vital Sign and Patient Satisfaction Scores to Improve Pain Care in the 21 st Century,” Pain Management Nursing,

vol. 19, no. 2 (April 2018), pp. 125-129.

Arnoud Arntz, Laura Dreessen, and Harald Merckelbach, “Attention, Not Anxiety, Influences Pain,” Behaviour

Research and Therapy, vol. 29, no. 1 (1991), pp. 41-50.

83 Sarah Spilman, Lisa Baumhover, Cheryl Lillegraven, et al., “Infrequent Assessment of Pain in Elderly T rauma

Patients,” Journal of Trauma Nursing, vol. 21, no. 5 (September/October 2014), pp. 229 -235.

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survivorship after injury and cancer, and increasing frequency and complexity of surgery.84 These

factors may explain only some of the differences between countries, however, as other developed

countries have experienced similar increases in life expectancy, use comparable advanced

treatments, and, in some cases, perform more surgeries per capita than the United States. 85

Other risk factors may contribute to, or exacerbate, the experience of pain. These include

sociodemographic, clinical, psychological, and biological determinants. 86 For example, largescale national surveys indicate that pain is more common among people who report a history of

abuse and interpersonal violence. 87 CDC has reported that chronic pain is more prevalent among

adults living in poverty, adults with less than a high school education, and adults with public

health insurance. 88 Some research suggests that economic insecurity might increase physical pain

sensations. 89 In the United States, certain sociodemographic factors, such as socioeconomic status

and race/ethnicity, may result in disparities in chronic pain across subgroups.90 Similarly,

sociodemographic factors may predict opioid-prescribing rates, with higher prescribing found in

lower-income counties in the United States, for example. 91 U.S. providers may assess a patient’s

pain differently based on sociodemographic characteristics such as race, which can lead to

systematic undertreatment of pain and other adverse outcomes. 92

Socioeconomic disparities may partially explain higher opioid consumption in the United States.

The United States is a high-income nation overall, but disparities in income within the U.S.

population may explain, in part, higher levels of pain in certain subpopulations. Some research

has identified economic stress as a contributor to pain. 93 Of the G-7 countries, the United States

84 Nabarun Dasgupta, Leo Beletsky, and Daniel Ciccarone, “Opioid Crisis; No Easy Fix to Its Social and Economic

Determinants,” American Journal of Public Health, vol. 108, no. 2 (2018), pp. 182-186.

85 T homas Weisner, Alex Haynes, and George Molina, et al., Size and Distribution of the Global Volume of Surgery in

2012, World Health Organization, Bulletin of the World Health Organization Vol. 94, No.3, Geneva, Switzerland,

March 2016, at https://www.who.int/bulletin/volumes/94/3/BLT -15-159293-table-T 3.html.

86 van Hecke, “Chronic Pain Epidemiology and Its Clinical Relevance,” 2013. Physical health conditions and health

behaviors may also influence opioid consumption for example. See Anne Nitter, Are Pripp, and Karin Forseth, “Are

Sleep Problems and Non-specific Health Complaints Risk Factors for Chronic Pain? A Prospective Population -based

Study with 17 year Follow-Up”,” Scandinavian Journal of Pain, vol. 3, no. 4 (October 1, 2012); and Dasgupta et al.,

“Opioid Crisis: No Easy Fix,” 2018. One UK study found that people who reported “very bad” or “bad” health status

used opioids 14% and 6% more, respectively, compared with those who reported “ very good” health status. T his

suggests that the burden of certain chronic diseases and other health behaviors may affect rates of opioid use. See

Adam T odd, Nasima Akhter, and Joanne-Marie Cairns, et al., “T he Pain Divide: A Cross-sectional Analysis of Chronic

Pain Prevalence, Pain Intensity, and Opioid Utilisation in England,” BMJ Open, vol. 8, no. 7 (2018).

87 Ibid., and Clare Dominick, Fiona Blyth, and Michael Nicholas, “Unpacking the Burden: Understanding the

Relationships between Chronic Pain and Comorbidity in the General Population,” Pain, vol. 153 (2012), pp. 293-304.

88 CDC, “Prevalence of Chronic Pain,” 2018.

89 Eileen Chou, Bidhan Parmar, and Adam Galinsky, “Economic Insecurity Increases Physical Pain,” Psychological

Science, vol. 27, no. 4 (2016), pp. 443-454.

90 See, for instance, Molly Fuentes, T amera Hart -Johnson, and Carmen Green, “T he Association Among Neighborhood

Socioeconomic Status, Race, and Chronic Pain in Black and White Older Adults,” Journal of the National Medical

Association, vol. 99, no. 10 (October 2007); and Joseph Riley, James Wade, and Cynthia Myers, et al., “Racial/Ethnic

Differences in the Experience of Chronic Pain,” Pain, vol. 100 (2002), pp. 291-298.

91 Douglas McDonald, Kenneth Carlson, and David Izrael, “Geographic Variation in Opioid Prescribing in the U.S.,”

The Journal of Pain, vol. 13, no. 10 (October 2012).

92 Kelly M. Hoffman, Sophie T rawalter, and Jordan R. Axt, et al., “Racial Bias in Pain Assessment and T reatment

Recommendations, and False Beliefs About Biological Differences Between Blacks and Whites,” PNAS, vol. 113, no.

16 (April 19, 2016), p. 4296=4301.

93 Rebeca Rios and Alex Zautra, “Socioeconomic Disparities in Pain: T he Role of Economic Hardship and Daily

Financial Worry,” Health Psychology, vol. 30, no. 1 (2011), pp. 58-66.

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has the highest level of income inequality. 94 Some economics researchers have labelled the

increase in opioid-related overdose deaths in the United States “deaths of despair” due to

declining economic conditions and poor economic prospects for certain populations. Income

inequality and poor economic prosperity for some groups in the United States may equate to a

greater experience of pain across the population, and a higher demand for opioids.

Mental health issues, such as anxiety and depression, have been associated with higher levels of

physical pain. 95 In the United States, individuals with a mental health condition are twice as likely

to be prescribed opioids. 96 Mental illness rates do not differ substantially between the United

States and other G-7 countries. 97 However, in a study comparing the prevalence of chronic pain

conditions and comorbid depression and anxiety, the United States ranked first (23%) in the

percentage of people with depression or anxiety who also reported a pain condition. This

percentage was higher than other G-7 countries, which ranged from 6% to 15%. 98

Although research has shown that mental health disorders are undertreated globally, European

countries tend to treat mental illness at higher rates—something WHO has primarily attributed to

wider availability of health care in Western Europe. 99 Widespread focus in the United States on

treating pain rather than underlying psychological distress may contribute to higher opioid

demand and consumption rates. 100 Placing a greater value on pain relief than on functional

improvement may not effectively address the underlying conditions—such as mental health

issues—that influence pain. 101 In addition, poor physical health and certain health behaviors may

be associated with higher rates of pain and opioid use. 102

94 As measured by the Gini coefficient , an economic index of income inequality. By OECD country, the United States

is ranked seventh globally, above all of Europe and other G-7 countries. See https://data.oecd.org/inequality/incomeinequality.htm.

See, for example, Oye Gureje, Michael Von Korff, and Gregory Simon, et al., “ Persistent Pain and Well-Being: A

World Health Organization Study in Primary Care,” JAMA, vol. 280, no. 2 (July 8, 1998); D. von der Windt, T .

Kuijpers, and P. Jellema, et al., “Do Psychological Factors Predict Outcome in Both L ow-Back Pain and Shoulder

Pain?,” Annals of Rheumatic Diseases, vol. 66 (2007), pp. 313-319; and Ramune Jacobsen, Claus Moldrup, and Lona

Christrup, “Psychological and Behavioural Predictors of Pain Management Outcomes in Patients with Cancer,”

Scandinavian Journal of Caring Sciences, vol. 24 (November 9, 2010).

96 OECD, Addressing Problematic Opioid Use, 2019; and Kern, et al., “ T reatment Patterns, Healthcare Utilization, and

Costs of Chronic Opioid T reatment,” 2015. One study found that 18.7% of all patients with mental health conditions

receive 51.4% of the total opioid prescriptions distributed each year.96 See Matthew Davis, Lewei Lin, and Haiyin Liu,

et al., “Prescription Opioid Use among Adults with Mental Health Disorders in the United States,” Journal of the

American Board of Family Medicine, vol. 30, no. 4 (July 2017), pp. 407-417. Another study found that patients with

mental health disorders were more likely to continue opioid use after a surgery than individuals without a mental health

diagnosis. See Chad Brummet, Jennifer Waljee, and Jenna Goesling, et al., “New Persistent Opioid Use after Minor

and Major Survey in U.S. Adults,” JAMA Surgery, vol. 152, no. 6 (June 21, 2017).

97 Institute for Health Metrics and Evaluation, Global Health Data Exchange, Seattle, WA, 2019, at

http://ghdx.healthdata.org/.

98 T sang et al., “Common Chronic Pain Conditions in Developed and Developing Countries,” 2008. Prevalence was

compared across 18 countries.

Robert Kohn, Shekhar Saxena, and Itzhak Levav, et al., The Treatment Gap in Mental Health Care, World Health

Organization, Bulletin of the World Health Organization Vol.82 Ref No. 03 -005736, Geneva, Switzerland, 2003, pp.

858-866, at https://www.who.int/bulletin/volumes/82/11/en/858.pdf.

100 Winfried Hauser, Stephan Schug, and Andrea Furlan, “T he Opioid Epidemic and National Guidelines for Opioid

T herapy for Chronic Noncancer Pain: A Perspective from Different Continents,” Pain Around the World, vol. 2, no.

e599 (2017).

101 Ibid.

102 Anne Nitter, Are Pripp, and Karin Forseth, “Are Sleep Problems and Non -specific Health Complaints Risk Factors

for Chronic Pain? A Prospective Population-based Study with 17 year Follow-Up”,” Scandinavian Journal of Pain,

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Opioid Use in Japan

Japan consistently has some of the lowest annual per capita opioid consumption in the developed world.103 The

Japanese population is aging faster than any other nation, and 26% of Japan’s population is over the age of 65.

Some reports indicate that demand for opioids in Japan is growing, as Japanese baby boomers deal with diseases

and ailments of aging, such as arthritis, diabetic nerve damage, and cancer.

Most research on opioid use and chronic pain in Japan has found that medical practice norms influence opioid

prescribing and therefore opioid use:



The Japanese national insurance system does not provide coverage for most opioids for nonchronic cancer

pain, which is perhaps a leading factor contributing to Japan’s low-prescription and use rates. 104



Per-capita use of opioids is 26 times higher in the United States, compared with Japan. 105



Japanese providers generally prescribe opioids for chronic noncancer pain at a much lower rate than their

American counterparts.106



In 2019, approximately 45.2% of Japanese adults suffered from chronic pain. 107

Low opioid-use rates in Japan may stem from certain sociocultural factors:



“Opioids are frowned on both culturally and socially.” 108



“Japanese patients may be less likely to complain about pain because of strong cultural mores regarding selfattention, a dynamic far less pervasive in the United States.” 109

Recently, opioid indications in Japan were expanded to include chronic noncancer pain.110 Experts in Japan have

predicted that yearly opioid consumption will begin to increase due to this expansion.111

vol. 3, no. 4 (October 1, 2012); and Dasgupta et al., “Opioid Crisis: No Easy Fix,” 2018. One UK study found that

people who reported “very bad” or “bad” health status used opioids 14% and 6% more, respectively, compared with

those who reported “ very good” health status. T his suggests that the burden of certain chronic diseases and other health

behaviors may affect rates of opioid use. See Adam T odd, Nasima Akhter, and Joanne-Marie Cairns, et al., “T he Pain

Divide: A Cross-sectional Analysis of Chronic Pain Prevalence, Pain Intensity, and Opioid Utilisation in England,”

BMJ Open, vol. 8, no. 7 (2018).

103 Kanoko and Matsuyama, “Japan Is Discovering the Power of Painkillers,” September 21, 2017; and International

Narcotics Control Board, Narcotic Drugs: Estimated World Requirements for 2019, Statistics for 2017 , T able XIV.1.a,

T he United Nations, Vienna, Austria, 2018, at https://www.incb.org/incb/en/narcotic-drugs/T echnical_Reports/

narcotic_drugs_reports.html.

104

Committee for the Guidelines for Prescribing Opioid Analgesics for Chronic Noncancer Pain of Japanese Society of

Pain Clinicians, Guidelines for Prescribing Opioid Analgesics for Chronic Noncancer Pain, Japan Society of Pain

Clinicians, 2012.

105 Richard A. Deyo, Michael Von Korff, and David Duhrkoop, “Opioids for Low Back Pain,” British Medical Journal,

vol. 350 (January 5, 2015).

106

Yukari Shindo, Soushi Iwasaki, and Michiaki Yamak age, “Efficacy and Practicality of Opioid T herapy in Japanese

Chronic Noncancer Pain Patients,” Pain Management Nursing, vol. 20, no. 3 (June 2019).

107 Ibid.

108 Eriko Onishi, T adashi Kobayash, Miguel Marino, et al., “Comparison of Opioid Prescribing Patterns in the United

States and Japan: Primary Care Physicians’ Attitudes and Perceptions,” Journal of the American Board of Family

Medicine, vol. 30, no. 2 (March 2017), pp. 248-54.

109 Ibid.

Yukio Suga, Mayako Uchida, Shunya Suzuki, et al., “Current Status of Adverse Events Related with Opioid

Analgesics in Japan: Assessment Based on Japanese Adverse Drug Event Report Database,” Biol. Pharm. Bull., vol.

42, no. 5 (2019), pp. 801-809.

110

111 Ibid.

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Medical Treatment of Pain

Variance in pain management practices may contribute to differences in prescribed opioid use

worldwide. Pain treatment in the United States frequently includes opioids, whereas other

countries may embrace a wider variety of pharmacological and nonpharmacological interventions

for pain.

The medical field continues to identify the most effective treatments for various chronic pain

conditions (e.g., neuropathic versus musculoskeletal), and a consensus on how to best treat

chronic pain conditions has not been reached. 112 Current medical research reveals that a chronic

pain treatment regimen involving nonopioid medications, such as nonsteroidal anti-inflammatory

drugs (NSAIDs), physical therapy, and psychotherapeutic interventions like cognitive-behavioral

therapy and meditation, can often be used effectively to treat pain. 113 According to some research,

using opioids to treat chronic pain over the long term results in limited effectiveness. 114

Much of the scientific literature appears to indicate that European countries tend to use nonopioid

treatment regimens more frequently than the United States does. 115 For instance, in Europe, about

two-thirds of patients with persistent pain take a prescription medication, but only a third of those

medications are opioids. 116

As demonstrated by the higher per capita opioid consumption rates, the medical field in the

United States tends to use opioids as a standard, and often first-line, treatment for both acute and

chronic noncancer pain. 117 Some experts have observed that before the recent rise of U.S. opioid

use, chronic pain was managed largely with nonopioid pain medications, psychotherapies such as

cognitive behavioral therapy, and alternative therapies like hypnosis. 118 Other evidence shows that

when opioid prescription rates were rising in the early 2000s, referrals to alternative treatments

for pain, such as physical therapy, remained stagnant. 119

112 Jacob Gross and Debra Gordon, “T he Strengths and Weaknesses of Current US Policy to Address Pain,” American

Journal of Public Health, vol. 109, no. 1 (January 2019).

113 Hauser et al., “T he Opioid Epidemic and National Guidelin es,” 2017, National Academies of Sciences, Engineering,

and Medicine, The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop ,

Washington, DC, 2019.

114 See, for instance, Andrea T rescot, Scott Glaser, Hans Hansen, et al., “Ef fectiveness of Opioids in the T reatment of

Chronic Non-Cancer Pain,” Pain Physician, vol. 11 (2008), pp. S181-S200.

115 International pat ients appear to receive more nonopioids during and after surgery than American patients (see

Zaslansky et al., “Pain After Orthopaedic Surgery,” 2018). In studies in Norway and Germany, the prevalence of longterm opioid treatment for chronic noncancer pain was found to be less than 1.5%. See Olav Magnus Fredheim, Milada

Mahic, Svetlana Skurtveit, et al., “Chronic Pain and Use of Opioids: A Population-Based Pharmacoepidemiological

Study from the Norwegian Prescription Database and the Nord-T røndelag Health Study,” Pain, vol. 155, no. 7 (July

2014), pp. 1213-1221. Other studies had similar findings, showing that European patients were most frequently treated

with NSAIDs and other nonopioid medications. See Kim Reid, Julie Harker, Malgorzata Bala, et al., “Epidemiology of

Chronic Non-Cancer Pain in Europe: Narrative Review of Prevalence, Pain T reatments, and Pain Impact,” Current

Medical Research and Opinion, vol. 27, no. 2 (2011).

Harald Breivik, Beverly Collett, and Vittorio Ventafridda, “Survey of Chronic Pain in Europe: Prevalence, Impact

on Daily Life, and T reatment,” European Journal of Pain, vol. 10 (2006), pp. 287-333. Of note, CRS identified few

studies that examined the use of interdisciplinary approaches to pain treatment in Europe.

117 Fred Finney, T imothy Gossett, Hsou Mei Hu, et al., “Rate of Opioid Prescriptions for Patients with Acute Ankle,”

Annals of Internal Medicine, vol. 171, no. 6 (2019), pp. 441-443. See the “ Prescribing Practices” section in this report.

116

118 Dasgupta et al., “Opioid Crisis: No Easy Fix,” 2018. Currently, in some U.S. health care institutions, as many as

90% of patients receive opioids for chronic pain management. See Manchikanti et al., “Patterns of Illicit Drug use and

Opioid Abuse,” 2004.

119 Patricia Zheng, Ming-Chih Kao, Nicholas Karayannis, et al., “Stagnant Physical T herapy Referral Rates Alongside

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Few studies directly compare nonopioid treatments between the United States and European

countries. However, some literature seems to indicate that European countries use a wider range

of nonpharmacologic treatments to address pain conditions in patients, whereas U.S. health

providers more commonly use opioids to treat chronic noncancer pain conditions. 120 Some

experts have suggested that this usage may be partially due to more expansive health care

coverage of such treatments in European countries.121

Optimal Pain Treatment

Although clinical practice guidelines provide best practices for opioid use in pain management,

no consensus exists in the global medical community regarding the appropriate amount of per

capita opioid consumption. The international differences in opioid consumption, however, may be

due to the undertreatment of pain in some places. 122

Some experts have argued that pain remains undertreated, even in G-7 or other countries with

adequate access to opioid analgesics. 123 Many believe that the movement to increase the use of

opioid medications worldwide by WHO and others began as a compassionate effort to reduce

undertreated pain. 124 However, a specific figure for safe and effective opioid consumption per

capita may not exist. Instead, countries may have to find a balance between use of opioids for

pain treatment and a reduction in their misuse and abuse. Few analyses of need and availability

for opioids exist; however, according to some estimates, the United States distributes more than

enough opioids in total to meet palliative pain needs, for example. 125

External Influences on Health Care Practices

U.S. prescribing practices may have been more susceptible to outside influences—such as the

pain advocacy movement and marketing campaigns of the pharmaceutical industry—than

prescribing practices in other countries, resulting in higher rates of opioid use. For example, the

OECD, U.S. Government Accountability Office, U.S. Surgeon General, and other experts believe

that differences in drug advertising regulations have had a direct effect on opioid prescription

practices and opioid use. 126 In the United States, advertisers are allowed to market directly to

Rising Opioid Prescription Rates in Patients With Low Back Pain in the United States 1997 -2010,” [JD: Missing

journal/periodical title?] vol. 42, no. 9 (May 1, 2017), pp. 670 -674.

120

Hauser et al., “T he Opioid Epidemic and Long-T erm Opioid T herapy,” 2016.

121 See, for example, Miceli et al., “Opioids Prescription in Pain T herapy,” 2018. See the “ Health Care Systems”

section below.

122 See, for instance, World Health Organization, The Pursuit of Responsible Use of Medicines: Sharing and Learning

from Country Experiences, T echnical Report prepared for the Ministers Summit, Geneva, Switzerland, 2012.

123 See, for instance, Michael Zenz, T horsten Zenz, Michael T ryba, et al., “Severe Undertreatment of Cancer Pain: A 3 -

year Survey of the German Situation,” Journal of Pain and Symptom Management, vol. 10, no. 3 (April 1995), pp. 187191.

124 World Health Organization, Ensuring Balance in National Policies on Controlled Substances: Guidance for

Availability and Accessibility of Controlled Medicines, Geneva, Switzerland, 2011, at https://apps.who.int/iris/handle/

10665/44519.

125 Felicia Marie Knaul, Paul Farmer, and Erik Krakauer, “Alleviating the Access Abyss in Palliative Care and Pain

Relief—An Imperative of Universal Health Coverage: the Lancet Commission Report,” Lancet, vol. 391 (2018), pp.

1391-1454.

126 See, for instance, Art Van Zee, “T he Promotion and Marketing of OxyContin: Commercial T riumph, Public Health

T ragedy,” American Journal of Public Health, vol. 99, no. 2 (2009); OECD, Addressing Problematic Opioid Use in

OECD Countries, 2019; U.S. Government Accountability Office, Prescription Drugs: OxyContin Abuse and Diversion

and Efforts to Address the Problem , GAO-04-110, December 19, 2003, https://www.gao.gov/products/gao-04-110;

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providers. 127 In the European Union, direct-to-provider marketing is discouraged, with

enforcement of national and international policies delegated to professional groups and selfregulatory bodies. 128 The European Union bans direct-to-consumer marketing explicitly, 129 while

the United States allows such practices—one of two countries in the world to do so. 130

Beginning in the 1990s, several pharmaceutical companies downplayed the addictiveness of

opioids and promoted them as low-risk medications in marketing campaigns. 131 Several studies

have shown that these practices directly influenced prescribing patterns and provider behavior,

subsequently increasing U.S. opioid use. 132 The pharmaceutical industry encouraged opioid use

through direct funding to private hospital systems (see the text box below). 133 Moreover, these

marketing and lobbying campaigns seem to have relegated alternative or complementary pain

interventions to the sidelines. 134

Substance Abuse and Mental Health Services Administration, Office of the Surgeon General, U.S. Department of

Health and Human Services, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and

Health, Washington, DC, November 2016; and Scott Hadland, Magdelena Cerda, Yu Li, et al., “Association of

Pharmaceutical Industry Marketing of Opioid Products to Physicians With Subsequent Opioid Prescribing,” JAMA

Internal Medicine, vol. 178, no. 6 (June 2018).

127

Section 502(n) of the Federal Food, Drug and Cosmetic Act (21 U.S.C. 352(n)) and U.S. Food & Drug

Administration (FDA) regulations at 21 C.F.R. 202.1 address prescription drug advertising. When advertising to the

public, drug companies must comply with various requirements in st atute and FDA regulations; however, no federal

law has ever banned direct -to-consumer advertising. For more information, see t he FDA webpage Background on Drug

Advertising: https://www.fda.gov/drugs/prescription-drug-advertising/background-drug-advertising.

128

T he requirements and procedures for marketing authorization are primarily laid down in Directive 2001/83/EC and

in Regulation (EC) No 726/2004. For more information, see European Commission, Legal Framework for Governing

Medicinal Products for Human Use in the EU, available at https://ec.europa.eu/health/human-use/legal-framework_en.

129

Publications Office of the European Union, Council Directive 89/552/EEC of 3 October 1989 on the Coordination

of Certain Provisions Laid Down by Law, Regulation, or Administrative Action in Me mber States concerning the

Pursuit of Television Broadcasting Activities, https://op.europa.eu/en/publication-detail/-/publication/63084a3f-be4a4415-bf02-ac5f76524348/language-en. See also, World Health Organization, Direct -to-Consumer Advertising Under

Fire, Bulletin of the World Health Organization, vol. 87, no. 8, Geneva, August 2009, https://www.who.int/bulletin/

volumes/87/8/09-040809/en/.

130 New Zealand is the only other country to allow such marketing practices. T im Reed, Ancel la Santos, et al., “What

Healthcare Professionals Need to Know About EU Pharmaceutical Marketing,” Health Ac tion International and

Universities Allied for Essential Medicines, Galway, Ireland, September 2016; and Mareen Poser, “DT CA of

Prescription Medicines in the European Union: Is T here Still a Need for a Ban?,” European Journal of Health Law,

vol. 17, no. 5 (December 2010), pp. 471-484.

131

OECD, Addressing Problematic Opioid Use in OECD Countries, 2019, p. 20, and Art Van Zee, “T he Promotion

and Marketing of OxyContin: Commercial T riumph, Public Health T ragedy,” American Journal of Public Health,

September 20, 2011.

132 T he increases in opioid consumption differ by opioid type, suggesting that the marketing campaigns for specific

drugs may be at least partially responsible. T he timing of the precipitous rise in opioid use—especially in the United

States—aligns with the introduction of new opioid formulations such as OxyContin and the corresponding upsurge in

marketing practices by Purdue Pharma and other pharmaceutical manufacturers. See, for example, Substance Abuse

and Mental Health Services Administration, Office of the Surgeon General, U.S. Department of Health and Human

Services, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, Washington,

DC, November 2016; and U.S. Senate Homeland Security & Governmental Affairs Committee, Fueling an Epidemic,

Exposing the Financial Ties between Opioid Manufacturers and Third -Party Advocacy Groups: Minority Staff Report,

2018.

Andrew Joseph, “‘A Blizzard of Prescriptions’: Documents Reveal New Details about Purdue’s Marketing of

OxyContin,” STAT News, January 15, 2019.

133

134 Dasgupta et al., “Opioid Crisis: No Easy Fix,” 2018, and Fischer et al., “Non -medical Use of Prescription Opioids,”

2013.

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Effectiveness of Pain Advocacy and Pharmaceutical Marketing

Some researchers posit that the pain treatment campaign and pharmaceutical marketing practices of the 1980s and

1990s may have had a greater effect on U.S. health care providers when compared with their European

counterparts. Multinational opioid manufacturers, such as Purdue Pharma and Janssen Pharmaceuticals, funded pain

advocacy organizations, medical societies, clinical practice guideline development efforts, and medical education in

the United States. In turn, advocacy groups, including the American Academy of Pain Management and the

Academy of Integrative Pain Management, issued guidelines recommending opioid use for pain management, and

opposed efforts to monitor and regulate opioid overprescription.135 One report found that opioid manufacturers

contributed $9 million to 14 third-party advocacy organizations between 2012 and 2017, and allocated $1.6 million

in payment to physicians affiliated with these advocacy groups.136 A U.S. Surgeon General report found that

physicians who received any opioid-related payments from industry had 9.3% more opioid prescription claims

compared with physicians who received no such payments.137

Many experts contend that the international opioid promotion campaign was more effective in the United Sta tes

because of cultural and systemic factors. For example, European countries may have had protective factors against

some of the influence of these campaigns, such as cultural stigma and stricter prescribing regulations that kept

opioid use low.138 The United States may have had risk factors that made health care system and providers more

vulnerable to the influence of such campaigns.139 Of note, recent reports indicate that as opioid-prescribing rates

in the United States decline, opioid manufacturers and distributors—such as Purdue Pharma—are promoting

broader use of painkillers in low- and middle-income countries using similar marketing tactics.140

Attention to Clinical Guidance

Adherence to clinical guidance for opioid use for chronic pain varies, potentially resulting in the

contrasting use of opioids across countries. Several professional, national, and international health

organizations have issued guidance on best practices for effective and safe management of

pain. 141 However, adherence to this guidance appears to differ by country, with European

Liz Whyte, Geoff Mulvihill, and Ben Wieder, “Politics of Pain: Drugmakers Fought State Opioid Limits Amid

Crisis,” Center for Public Integrity, September 18, 2016, and U.S. Senate Homeland Security & Governmental Affairs

Committee, Fueling an Epidemic, Exposing the Financial Ties between Opioid Manufacturers and Third -Party

Advocacy Groups: Minority Staff Report, 2018.

135

136

Ibid.

137 HHS, Facing Addiction in America, 2016. See also footnote 132 and footnote 126.

138

Bosetti et al., “T rends in the Consumption of Opioids,” 2019.

139

For example, research shows that U.S. health providers may be more responsive to expectations for treatment or

patient demands than providers in other countries. Survey data have shown that because patients’ satisfaction ratings of

hospitals decreased when they were not prescribed opioids, opioids were prescribed for minor procedures. In addition,

licensing requirements by state medical boards include criteria for supportive and appropriate pain control, which

experts believe have likewise influenced prescribing practices. Prescribing opioids or other drugs for many ailments

may be the feasible or incentivized intervention for care providers, but it is also viewed by many patients as an

expected, satisfactory form of medical care. See, for instance, Koichiro Otani, Neale R. Chumbler, Patrick A.

Herrmann, et al., “Impact of Pain on Patient Satisfaction Integration Process,” Health Services Research and

Managerial Epidemiology, November 3, 2015, and B.M. Kuehn, “Major disparities in opioid prescribing among states:

some states crack down on excess prescribing,” Journal of the American Medical Association, vol. 312 (2014).

140 See, for example, Keith Humphreys, Jonathan Caulkins, and Vanda Felbab-Brown, “Opioids of the Masses:

Stopping an American Epidemic from Going Global,” Foreign Affairs, May/June 2018; and Harriet Ryan, Lisa Girion,

and Scott Glover, “OxyContin goes global—“We’re only just getting started,” Los Angeles Times, December 18, 2016.

141 According to the WHO’s three-step pain ladder, pain analgesics should be prescribed in the following order: first,

nonopioids (e.g., acetaminophen and NSAIDs); then, if necessary, weak opioids (e.g., tramadol and codeine); and then

strong opioids (e.g., oxycodone and morphine). See World Health Organization, WHO’s Cancer Pain Ladder for

Adults, 1986, at https://www.who.int/cancer/palliative/painladder/en/; T . O’Brien, L.L. Christup, A.M. Drewes, et al.,

“European Pain Federation Position Paper on Appropriate Opioid Use in Chronic Pain Management,” European

Journal of Pain, vol. 21 (2017), pp. 3-19; World Health Organization, Ensuring Balance in National Policies on

Controlled Substances: Guidance for Availability and Accessibility of Controlled Medicines, Geneva, Switzerland,

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countries more apt to follow the guidance closely compared with the United States. 142 In

European countries with high levels of prescription opioid use, such as Germany, clinical

guidelines and practice appear to impose greater restrictions on the use of opioids (especially of

higher-potency opioids), limiting their use compared with North American countries.143 Many

other OECD member countries have implemented clinical practice guidelines at the national

level. 144 Some research suggests that national clinical guideline implementation is associated with

fewer adverse outcomes.145 In addition, many European countries use national stewardship

programs to train medical practitioners, review prescribing practices, and provide feedback to

health care professionals. The United States relies primarily on states to institute these

programs. 146

In the United States, national clinical guidance for opioid use was published by CDC in 2016 and

is nonbinding for health care providers. The decision to enact laws consistent with CDC

guidelines is left to the discretion of individual states. 147 Several states have opted to institute

policies that align with the recommendations, and research suggests that compliance with CDC

guidelines has helped curb overprescribing practices. 148 Overall, U.S. opioid use patterns through

2011, at https://apps.who.int/iris/handle/10665/44519; INCB, Narcotic Drugs: Estimated World Requirements for

2019, Statistics for 2017, 2018; and Helmerhorst et al., “An Epidemic of the Use, Misuse, and Overdose,” 2017. T he

WHO recommendations were primarily designed for treating pain in palliative cancer care, but they provide a

framework for treating other pain conditions. See also T eryl Nuckols, Laura Anderson, Ioana Popescu, et al., “Opioid

Prescribing: A Systematic Review and Critical Appraisal of Guidelines for Chronic Pain,” Annals of Internal Medicine,

vol. 160 (2014), pp. 38-47.

142 See for instance, OECD, Addressing Problematic Opioid Use, 2019; and Fischer et al., “Non-medical Use of

Prescription Opioids,” 2013. World Health Organization, WHO’s Cancer Pain Ladder for Adults, 1986, at

https://www.who.int/cancer/palliative/painladder/en/; T . O’Brien, L.L. Christup, A.M. Drewes, et al., “European Pain

Federation Position Paper on Appropriate Opioid Use in Chronic Pain Management,” European Journal of Pain, vol.

21 (2017), pp. 3-19; World Health Organization, Ensuring Balance in National Policies on Controlled Substances:

Guidance for Availability and Accessibility of Controlled Medicines, Geneva, Switzerland, 2011, at

https://apps.who.int/iris/handle/10665/44519; INCB, Narcotic Drugs: Estimated World Requirements for 2019,

Statistics for 2017, 2018; and Helmerhorst et al., “An Epidemic of the Use, Misuse, and Overdose,” 2017. Most of the

world currently adheres to this step ladder in some form, and several countries(e.g., Italy) have enacted national

regulations that align with the WHO recommendations for pain management. Bosetti et al., “Trends in the

Consumption of Opioids,” 2019.

143 See, for instance, Ingrid Schubert, Peter Ihle, and Rainer Sabatows, “Increase in Opiate Prescription in Germany

Between 2000 and 2010,” Deutsches Ärzteblatt International, vol. 110, no. 4 (January 25, 2013), pp. 45-51, and Fischer

et al., “Non-medical Use of Prescription Opioids,” 2013.

144 In addition to the WHO guidelines, 15 other Organization for Economic Co -operation and Development (OECD)

member countries have produced their own opioid clinical practice guidelines. Most of these guidelines agree on

several opioid risk-mitigation strategies, such as upper dosing thresholds, cautions with certain medications, attention

to potential drug interactions, and use of risk assessment tools such as urine drug testing. See T eryl Nuckols, Laura

Anderson, Ioana Popescu, et al., “Opioid Prescribing: A Systematic Review and Critical Appraisal of Guidelines for

Chronic Pain,” Annals of Interal Medicine, vol. 160, no. 1 (January 7, 2014). OECD, Addressing Problematic Opioid

Use, 2019. In some countries, such as Germany, national prescribing laws are closely tied to clinical guidelines. See

Rosner et al., “Opioid Prescription Patterns in Germany,” 2019.

145 OECD, Addressing Problematic Opioid Use, 2019. T his study points to smaller percentages of patients taking high-

dose opioids, more providers avoiding long-acting opioids, fewer co-prescriptions with other potentially dangerous

drugs such as benzodiazepines, and physicians more likely to use drug screens in patients with substance use disorders.

146

OECD, Addressing Problematic Opioid Use, 2019.

147 Some experts have observed that slow adoption of the CDC guidelines may be attributed to opposition to the

recommendations by some patient advocacy and industry groups, particularly those with a financial stake in continued

opioid use. See, for example, Dora Lin, Eleanor Lucas, and Irene Murimi, “Financial Conflicts of Interest and the

Centers for Disease Control and Prevention’s 2016 Guideline for Prescribing Opioids for Chronic Pain,” JAMA

Internal Medicine, vol. 177, no. 3 (2017), pp. 427-428.

148 CDC reported that opioid prescribing decreased at a faster rate after the agency released the guidelines in 2016, for

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the mid-2010s suggest that health care providers have not adhered to international guidelines such

as those released by WHO. 149

Sociocultural Factors

Health Care Systems

Differences in the structure and financing mechanisms of health care systems may influence rates

of opioid use in medical care. 150 The United States uses a number of payers for health care, both

public and private. The historical predominance of a retrospective cost-based, fee-for-service

(FFS) model in the United States (in which providers are paid [reimbursed] according to the

amount of activities they conduct or number of patients they treat) may incentivize the use of

opioids. Without other parallel constraints on services or costs, an FFS model (and other profitdriven forces in the private sector) may create financial incentives for more care and more

profitable procedures, such as surgeries.151 Treating pain with opioids may lead to shorter visits

with patients and, as a consequence, enable heath providers to treat more patients and bill for

more services. 152 In addition, time constraints may drive providers to prescribe opioids for pain

management rather than provide comprehensive pain care, which is more time- and resourceintensive and may be considered less efficient. Medical care in European systems is often funded

before the point of service (e.g., through taxes) and is less likely to rely exclusively on FFS

models in favor of other funding structures, such as pay-for-performance or diagnostic-related

group payments. 153

In addition, the federalized regulatory model in the United States (which leaves many regulations

to the states) may result in a slower, less direct ability to govern the use of opioids compared with

the more centralized systems in many European countries and elsewhere. A centralized, publicly

instance. See Amy Bohnert, Gery Guy, and Jan Losby, “Opioid Prescribing in the United States Before and After the

Centers for Disease Control and Prevention’s 2016 Opioid Guideline,” Annals of Internal Medicine, vol. 169, no. 16

(September 18, 2018), pp. 367-375.

149

For instance, one study found that one-third of all patients who visited an emergency department in the United

States had opioids prescribed at discharge. See Maryann Mazer-Amirshahi, Peter Mullins, Irit Rasooly, et al., “Rising

Opioid Prescribing in Adult U.S. Emergency Department Visits: 2001 -2010,” Academic Emergency Medicine, vol. 21,

no. 3 (March 13, 2014), pp. 236-243. Another study found that 80% of patients undergoing relatively minor surgery in

the United States received a prescription for an opioid. See Hannah Wunsch, Duminda Wijeysundera, Molly Passarella,

et al., “Opioid Prescribed After Low-Risk Surgical Procedures in the United States, 2004-2012,” Journal of the

American Medical Association, vol. 315, no. 15 (April 19, 2016), pp. 1654 -1656.

150 A full discussion of the many differences between the health care systems of the United States and other countries is

beyond the scope of this report. However, as described in this report, research suggests that a few notable differences

may particularly affect opioid use.

151 See Steven A. Schroeder and William Frist, “Phasing Out Fee-for-Service Payment,” New England Journal of

Medicine, vol. 368, no. 21 (May 23, 2013), pp. 2029-2032; Miriam J. Laugesen and Sherry Glied, “Higher Fees Paid

T o US Physicians Drive Higher Spending For Physician Services Compared T o Other Countries,” Health Affairs, vol.

30, no. 9 (September 2011); and U.S. Congress, Office of T echnology Assessment, Medicare’s Prospective Payment

System: Strategies for Evaluating Cost, Quality, and Medical Technology, OT A-H-262, Washington, DC, October

1985.

152 DR Oyler, KS Deep, and PK Chang, “Opioid Use in the Acute Setting: A Survey of Providers at an Academic

Medical Setting,” Journal of Opioid Management, vol. 14, no. 3 (May/June 2018), pp. 203-210.

153 Naoki Ikegami, “Fee-for-Service Payment—An Evil Practice T hat Must Be Stamped Out?” International Journal of

Health Policy Management, vol. 4, no. 2 (February 2015), and Jacqueline O’Reilly, Reinhard Busse, Unto Hakkinen, et

al., “Paying for Hospital Care: T he Experience With Implementing Activity-Based Funding in Five European

Countries,” Health Economics, Policy and Law, vol. 7, no. 1 (January 2012).

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administered health care system may permit greater control over medical practices and facilitate a

faster response to problematic trends—such as the overprescribing of opioids—compared with

the U.S. system.

In the United States, health care is regulated on multiple governmental levels. 154 The majority of

European countries, including those in the G-7, operate various nationalized health care system

models. According to research, many of the regulatory responses that mitigated prescription

opioid misuse were implemented in Europe sooner than in the United States (see Appendix A for

more information on government regulations affecting opioid use). 155 Centralized health care may

pose other tradeoffs, such as less efficiency in other areas, reduced innovation, less regional

flexibilities, and less responsiveness to patient needs. 156

The specialization of medicine in the United States—and the lack of coordination among medical

specialties—may have also influenced high opioid prescription rates. Patients frequently access

care through a specialist, visiting multiple providers for a variety of health issues, which can

make coordinating care difficult. 157 Siloed specializations may contribute to fragmented care and

create obstacles for streamlined provider communication (such as through synchronized

Electronic Health Records). By contrast, in the UK’s National Health System (NHS), for

example, patients receive coordinated care through their general practitioner (GP). 158 When

patients are referred to a specialist, their GP continues to coordinate their care, and related

information (e.g., prescriptions) is centralized and accessible to other providers. 159 Such

coordinated care reduces duplicative services (or prescriptions) and may lead to more effective,

efficient medical care.

Some research suggests that U.S. patients often delay seeking care due to cost, and will frequently

wait until a health condition (such as chronic pain) becomes severe.160 More widespread and

coordinated health care coverage may lead to more preventive treatments, reducing the amount or

severity of health complications and thus reducing subsequent demand for opioid medications. 161

154

Many European countries have vertically integrated health care regulatory systems that have imposed restrictions on

the prescribing and accessibility of prescription opioids. A vertically integrated health care system is an arrangement

whereby a health care organization offers, either directly or through others, a broad range of patient care and support

services. Evidence suggests that some European health systems are shifting toward more decentralization. See, for

example, Federalism and Decentralization in European Health and Social Care, ed. Joan Costa-Font and Scott L.

Greer (Palgrave Macmillan, 2013). In the United States, medical practice regulations differ by state.

155

One study noted that the consumption of opioids has leveled off in recent years in many Western and Northern

European countries, suggesting “ that the measures being implemented by governments may prevent the development of

an opioid crisis.” See Bosetti et al., “T rends in the Consumption of Opioids,” 2019, and van Amsterdam et al., “T he

Misuse of Prescription Opioids,” 2015. Notably, the U.S. Veteran’s Health Administration —a vertically integrated

health system for military veterans—achieved a significant reduction in opioid prescribing after instituting several

system-wide safety and pain management initiatives, such as the Opioid Safety Initiative. See U.S. Department of

Veterans Affairs, VHA Pain Management/Opioid Safety Initiative, available at https://www.va.gov/

PAINMANAGEMENT /Opioid_Safety_Initiative_OSI.asp.

156 See, for instance, Richard B. Saltman and Joseph Figueras, “Analyzing the Evidence on European Health Care

Reforms,” Health Affairs, vol. 17, no. 2 (March/April 1998).

157 Gross et al., “T he Strengths and Weaknesses of Current U.S. Policy to Address Pain,” 2019.

158 Martin Roland, Bruce Guthrie, and David Colin T home, “Primary Medical Care in the United Kingdom,” Journal of

the American Board of Family Medicine, vol. 25 (March 2012), pp. 6-11.

159 Ibid.

160 Sora Al Rowas, Michael Rothberg, and T ara Lagu, “T he Association between Insurance T ype and Cost -Related

Delay in Care: A Survey,” The American Journal of Managed Care, vol. 23, no. 7 (July 2017), pp. 435-442.

161 Institute of Medicine Committee on the Consequences of Uninsurance, “Effects of Health Insurance on Health,” in

Care Without Coverage: Too Little, Too Late (Washington, DC: National Academies Press, 2002), and Substance

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Cost of and Payment for Pain Treatment

Cost structures and payment systems for pain treatments may explain international differences in

prescription opioid use. How various pain therapies are paid for—and whether they are

reimbursed under health insurance systems—likely affects how frequently patients and providers

use them, especially compared with other possible approaches (see, for example, the text box on

Japan above). 162

According to some research, payment structures for health care in the United States often

incentivize the use of prescription opioids over other pain management alternatives. 163 Evidence

suggests that policies adopted by some payers, such as Medicaid, have encouraged providers to

prescribe opioids due, in part, to their comparatively low cost. 164 Although coverage of opioid

pain medications by commercial insurers—including those participating in the Medicare and

Medicaid programs—is common, reimbursement for nonopioid pain interventions is less

consistent. 165

Some effective nonopioid treatments for chronic pain management have been identified, though

they may remain underutilized in the United States due in part to insurance coverage policies. 166

Utilization of nonopioid interventions has decreased in the United States since the early 2000s,

primarily due to inconsistent coverage by insurers.167 Some nonpharmacological treatments for

pain, such as physical therapy, are frequently covered by commercial and Medicare insurers. 168

Other treatments, like steroidal injections, are sometimes covered, while treatments such as

acupuncture do not appear to be covered often, if at all. 169

Abuse and Mental Health Services Administration, Office of the Surgeon General, U.S. Department of Health and

Human Services, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health,

Washington, DC, November 2016.

162

T oby Gosden, Frode Forland, Ivar Kristiansen, et al., Capitation, Salary, Fee-for-Service and Mixed Systems of

Payment: Effects on the Behaviour of Primary Care Physicians, Cochrane Database of Systematic Reviews, Cochrane

Systematic Review - Intervention, July 24, 2000, at https://www.cochranelibrary.com/cdsr/doi/10.1002/

14651858.CD002215/abstract. One study revealed that oxycodone consumption in Poland, for instance, was negligible

until 2011 when it gained reimbursement status by the National Health Fund. In the years following, oxycodone use

grew substantially: by 2015, oxycodone ranked fourth among opioids used in the country. Another study found a

similar pattern in Italy, with the increase in use of specific opioids corresponding to change s in reimbursement

structures. See T omasz Dzierzanowski and Aleksandra Cialkowska-Rysz, “Accessibility of Opioid Analgesics and

Barriers to Optimal Chronic,” Support Care Cancer, vol. 25 (2017); and Umberto Maria Musazzi, Paolo Rocco, Cinzia

Brunelli, et al., “Do Laws Impact Opioid Consumption? A Breakpoint Analysis Based on Italian Sales Data,” Journal

of Pain Research, vol. 11 (2018), pp. 1665-1672.

163 Nicoleta Stoicea, Andrew Costa, Luis Periel, et al., “Current Perspectives on the Opioid Crisis in the US Healthcare

System: A Comprehensive Literature Review,” Medicine, vol. 98, no. 20 (2019).

164 Lynn Webster, Susan Cochella, Naburan Dasgupta, et al., “An Analysis of the Root Causes for Opioid-Related

Overdose Death in the United States,” Pain Medicine, vol. 12, suppl_2 (June 13, 2011), and OECD, Addressing

Problematic Opioid Use, 2019.

165 Haiden Huskamp, Lauren Riedel, Colleen Barry, et al., “Coverage of Medications that T reat Opioid Use Disorder

and Opioids for Pain Management in Marketplace Plans, 2017,” Med Care, vol. 56, no. 6 (June 2018).

166

Agency for Healthcare Research and Quality, Noninvasive Nonpharmacological Treatment for Chronic Pain: A

Systematic Review, Comparative Effectiveness Review Number 209, Rockville, MD, June 2018.

167 Michael Schatman and Lynn Webster, “T he Health Insurance Industry: Perpetuation the Opioid Crisis through

Policies of Cost -Containment and Profitability,” Journal of Pain Research, vol. 8 (March 18, 2015), pp. 153-158, and

Stoicea et al., “Current Perspectives on the Opioid Crisis in the US Healthcare System,” 2019.

168 James Heyward, Christopher Jones, and Wilson Compton, “Coverage of Nonpharmacologic T reatments for Low

Back Pain Among US Public and Private Insurers,” JAMA Network Open, vol. 1, no. 6 (October 5, 2018).

169 Ibid. One commentary on pain treatment in the United States proposed that the displacement of nonpharmacological

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Some experts have suggested that the limited insurance coverage of alternative pain treatments —

primarily for “cost-containment and profitability” reasons—has contributed to overuse of opioids

for chronic pain management. 170 The disproportionate coverage for some treatments, such as

opioids, but not others, such as acupuncture, may have a trickledown effect on chronic pain

management. 171 The absence of financial incentives to treat pain in a comprehensive manner may

in turn produce a health care system with fewer providers learning about and using these

therapies effectively. 172

Recent changes in health care coverage suggest that more insurers—both public and private—

may be limiting payments based on the dosage in opioid prescriptions. 173 In addition, more

insurers may be moving to offer comprehensive pain treatments. For example, the Centers for

Medicare & Medicaid Services announced in 2019 that Medicare would cover some (but not all)

possible nonopioid interventions as part of a comprehensive pain treatment regimen. 174

Other characteristics of health care systems, such as provider and patient knowledge of insurance

coverage, may affect opioid use. Insurance coverage may not be obvious to providers

coordinating care, and the system may be challenging for patients to navigate. 175 If coverage of

opioid medications is common and well-known, providers may default to pharmacological

treatment over nonpharmaceutical interventions.

Medication costs may also play a role. One study examining opioid purchases and expenditures

across Europe found that the same drug costs different amounts in different countries. 176 The

researchers noted that costs to purchasers—such as hospitals and patients—differed between

countries, and that pricing may factor into differential opioid use. 177 The reasons behind different

costs for identical opioid medications are complex and beyond the scope of this report. What is

notable is that the costs of opioids differ across countries, and it is possible that these disparities

affect use.

treatments in favor of greater opioid use was not coincidental, noting that “ as insurers limited coverage of behavioral

pain therapy, biopharmaceutical manufacturers sensed an opportunity. Pharmaceutical innovation propagated extendedrelease formulations, transdermal patches, nasal sprays, and oral dissolving strips. Medical device manufacturers drove

a proliferation of novel pain modulating implants.”

170

See, for example, Michael Schatman, “T he Role of the Health Insurance Industry in Perpetuating Suboptimal Pain

Management,” Pain Medicine, vol. 12 (2011), pp. 415-426.

171 T he lack of coverage for nondrug and nonmedical treatments may contribute to a dearth of providers who are

knowledgeable and willing to provide these services for people with chronic pain, particularly in the rural United States

(including in some areas disproportionately affected by the opioid crisis). See Gross et al., “T he Strengt hs and

Weaknesses of Current US Policy to Address Pain,” 2019, and Schatman, “Role of Health Insurance Industry,” 2011.

172

Gross et al., “T he Strengths and Weaknesses of Current US Policy to Address Pain,” 2019.

173 Stephen Bernard, Paul Chelminski, and T imothy Ives, “Management of Pain in the United States—A Brief History

and Implications for the Opioid Epidemic,” Health Services Insights, vol. 11 (2018), pp. 1-6, and Dora H. Lin,

Christopher M. Jones, Wilson M. Compton, et al., “Prescription Drug Coverage for T reatment of Low Back Pain

Among US Medicaid, Medicare Advantage, and Commercial Insurers,” JAMA Network Open, vol. 1, no. 2 (2018).

174 Centers for Medicare and Medicaid Services, Medicare Coverable Services for Integrative and Non -

pharmacological Chronic Pain Management, MLN Matters Number: SE19008, August 19, 2019. For more

information on Medicare and Medicaid, see CRS Report R40425, Medicare Primer, and CRS Report R43357,

Medicaid: An Overview.

175 Gross et al., “T he Strengths and Weaknesses of Current US Policy to Address Pain,” 2019.

Franco De Conno, Carla Ripamonti, and Cinzia Brunelli, “Opioid Purchases and Expenditures in Nine Western

European Countries: ‘Are We Killing Off Morphine?’” Palliative Medicine, vol. 19 (2005), pp. 179-184.

176

177 De Conno et al., “Opioid Purchases and Expenditures in Nine Western European Countries,” 2005, p. 184.

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Government Regulations

National policies likely influence prescribing practices for opioids, particularly in Europe, where

many governments have instituted national-level regulations on opioid prescribing. Many

European regulations are more stringent than those in the United States; possibly because many

European countries have public health care systems that, generally speaking, can be regulated

more uniformly. 178 European governments use a variety of regulatory restrictions, including179



the requirement for permission to prescribe or receive opioids;



limitations on the amount to be prescribed;

restrictions regarding dispensing privileges;180

national formularies to regulate which opioids can be prescribed under what

conditions;181



requirements for a permit or license to prescribe; and

restrictions regarding the authorization to prescribe, administrative provisions,

and requirements for the storage of controlled medicines or prescription forms.182

Dispensing rules include



stipulations for the pharmacies authorized to dispense,



limitations on the dispensing of controlled medicines, and

administrative requirements, storage requirements, and delivery restrictions. 183

For example, several countries restrict opioid prescriptions to less than three weeks’ supply.

Germany and other countries specify dose limits and require that opioids be prescribed in

duplicate or triplicate using special forms (see the text box below). 184

Global health experts have noted that several European countries introduced stricter control

measures in response to the increase in deaths due to oxycodone overdose reported in North

America. 185 Recent observations indicate that, in some countries, regulations on opioid

prescribing may becoming more permissive. 186

Christopher Adolph, Scott L. Greer, and Elize Massard da Fonseca, “Allocation of Authority in European Health

Policy,” Social Science & Medicine, vol. 75, no. 9 (2012), pp. 1595-1603; and U.S. Congress, Office of T echnology

Assessment, Medicare’s Prospective Payment System , 1985.

178

179 Van Amsterdam et al., “T he Misuse of Prescription Opioids,” 2015.

Marjolein Vranken, John Lisman, and Aukje Mantel-T eeuwisse, “Barriers to Access to Opioid Medicines: Results

of a Review of National Legislation and Regulations of 11 Central and Eastern European Countries,” The Lancet

Oncology, vol. 17, no. 1 (2016), pp. e13-e22.

180

181 Aiden Meyer, Cheryl LeClair, and James McDonald, “Opioid Prescribing in Western Europe and the United States,”

Rhode Island Journal of Medicine, March 2020.

182 Vranken et al., “Barriers to Access to Opioid Medicines,” 2016.

183 Ibid.

N.I. Cherny, J. Baselga, F. de Conno, et al., “Formulary Availability and Regulatory Barriers to Accessibility of

Opioids for Cancer Pain in Europe: A Report from the ESMO/EAPC Opioid Policy Initiative,” Annals of Oncology,

vol. 21 (2010), pp. 615-626.

184

185 Bosetti et al., “T rends in the Consumption of Opioids,” 2019.

186 Humphreys et al., “What the US and Canada Can Learn,” 2020.

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Opioid-Prescribing Regulations in Germany

Germany has the largest population and the largest economy in the EU, and it has the second-highest opioid

consumption rate in the world.187 Opioid prescription in Germany is strictly regulated by the Narcotic Drugs

Prescription Ordinance (Betäubungsmittel-Verschreibungsverordnung, BtMVV) and by the German Narcotic

Drugs Act (Betäubungsmittelgesetz, BtMG), which entered into force in 1992.188 The BtMVV established detailed

prescription guidelines, which, among other things, regulate



the maximum quantities of opioids that can be prescribed within a certain timeframe, and



the maximum amount of different opioids prescribed during one visit to a health care provider/prescriber.

In Germany, every opioid dispensed requires a prescription by a physician. Under the BtMG, all opioids classified

as “strong” and “intermediate”—except Tramadol and Codeine, which are classified as “weak” opioids and do not

need a special prescription—require a specific narcotic prescription known as a “BtM” prescription.

The majority of opioid prescription regimens in Germany are based on the WHO guidelines for cancer pain

treatments published in 1986 (and updated in 2019) and follow the WHO’s pain treatment ladder.189 These

guidelines also apply to acute pain conditions. In 2008, a separate guideline for long-term treatment of chronic

noncancer pain (CNCP) was published. The guideline established rules for long-term use of opioids (four weeks or

longer) and treatment methodology.190 Some observers have noted that having multiple guidelines governing

opioid prescribing practices in different health care settings may have myriad unintentional outcomes, such as

increasing opioid prescription rates and sowing confusion among providers. 191 Though German guidelines do not

recommend opioids as the first-line treatment for CNCP, since the early 2000s Germany has seen an increase in

the prevalence of “strong” opioid prescriptions.192 Although prescription opioid use in Germany has increased

significantly since 2000, the prescription opioid overdose death rate has not increased at a comparable rate.193 In

comparison, in the United States, adverse events such as opioid overdose deaths paralleled increased prescription

opioid use from 1996 to 2010.

Table A-1 identifies several common legal or regulatory provisions regarding opioid distribution

and prescribing practices in G-7 and other economically advanced countries.

Public policies governing opioid use in the United States differ from most European countries in

a number of ways. At the federal level, the United States does not impose limits on the daily dose

of opioids a person can receive, place caps on long-term use, or restrict who can receive opioids,

among other regulations commonly seen abroad. Federal programs such as the FDA’s Risk

Evaluation and Mitigation Strategies (REMS) 194 institute risk-mitigation procedures to promote

the safe use of medications, although questions remain about the effectiveness of these policies. 195

187 Bastian Rosner, Jessica Neicun, Justin Yang, et al., “Opioid Prescription Patterns in Germany and the Global Opioid

Epidemic: Systematic Review of Available Evidence,” Plos One, August 28, 2019; and International Narcotics Control

Board, Narcotic Drugs: Estimated World Requirements for 2019, Statistics for 2017 , T he United Nations, Vienna,

Austria, 2018, at https://www.incb.org/incb/en/narcotic-drugs/T echnical_Reports/narcotic_drugs_reports.html.

188 Ibid.

189

World Health Organization, WHO Guidelines for the Pharmacological and Radiotherapeutic Management of

Cancer Pain in Adults and Adolescents, January 2019.

190

Rosner et al., “Opioid Prescription Patterns in Germany,” 2019.

191 Ibid.

I. Schubert, P. Ihle, and R. Sabatowski, “Increase in Opiate Prescription in Germany between 2000 and 2010,”

Dtsch Arztebl International, vol. 110, no. 4 (2013), pp. 45-51. A. Werber, U. Marschall, H. L’hoest, et al., “Opioid

T herapy in the T reatment Of Chronic Pain Conditions in Germany,” Pain Physician, vol. 18, no. 3 (May-June 2015).

193 European Monitoring Centre for Drugs and Drug Addiction, Germany, Country Drug Report, 2019.

192

194

For more information on REMS, see CRS Report R44810, FDA Risk Evaluation and Mitigation Strategies (REMS):

Description and Effect on Generic Drug Development.

195

Suzanne Murrin, FDA’s Risk Evaluation and Mitigation Strategies: Uncertain Effectiveness in Addressing the

Opioid Crisis, U.S. Department of Healt h and Human Services Office of Inspector General, OEI-01-17-00510,

Washington, DC, September 2020; and James Heyward, Lily Olsen, Joshua Sharfstein, et al., “Evaluation of the

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Although other restrictions, such as medication storage and frequency of patient visits to receive

prescriptions are imposed on the national level, 196 most prescribing practices are regulated at the

state level. At the national level, the U.S. system governing opioid prescriptions appears to allow

for more provider autonomy than in many European countries. Several states have instituted

opioid-prescribing regulations similar to those in Western Europe, though there is substantial

variation between states. This decentralized system may create oversight challenges, making it

more difficult to consistently monitor safe prescribing, enforce laws, and identify bad actors. 197

Prescription Drug Monitoring

The ability of national governments and other oversight or regulatory bodies to monitor the use of

controlled substances used in medicine—such as opioids—may affect national consumption rates.

Prescription drug-monitoring programs consist of electronic databases that track prescriptions for

controlled medicines such as opioids. 198 PDMPs are designed to provide health authorities with

timely information about prescribing patterns and patient behaviors. Evaluations suggest that such

programs have a positive impact in controlling problematic drug use by influencing both health

care and law enforcement systems.199 Recent studies in the United States have shown that

prescription opioid misuse increased more slowly in states with PDMPs than in states without

them, 200 and that states with more robust PDMPs have fewer prescription opioid overdose

deaths. 201

Most economically advanced countries use PDMPs to monitor opioid prescribing, but to varying

degrees. 202 Compared with PDMPs in the United States and Canada, most European countries use

PDMPs to assert more control over prescribing practices. The North American PDMPs appear

primarily designed to detect individual instances of inappropriate prescribing rather than to

promote safe and effective prescribing practices.203 In addition, the United States lacks a

systematic post-dispensing control mechanism. Although the Drug Enforcement Administration

Extended-Release/Long-Acting Opioid Prescribing Risk Evaluation and Mitigation Strategies by the US Food and

Drug Administration,” JAMA Internal Medicine, December 30, 2019, pp. E1-E9.

196 See, for example, T itle II of P.L.91-513, T he Controlled Substances Act, as amended; 21 C.F.R. §1301.71 et seq.;

and 21 U.S.C. §823.

197 Sara Imhof and Brian Kaskie, “How Can We Make the Pain Go Away? Public Policies to Manage Pain at the End

of Life,” The Gerontologist, vol. 48, no. 4 (2008), pp. 423-431.

198 OECD, Addressing Problematic Opioid Use, 2019.

199 U.S. Government Accountability Office, State Monitoring Programs Provide Useful Tool to Prevent Diversion ,

GAO-02-634, May 2002, at https://www.gao.gov/new.items/d02634.pdf. One review noted that PDMPs effectively

reduced “doctor shopping” strategies, curbed prescription misuse, and improved physicians’ prescribing practices. See

Julie Worley, “Prescription Drug Monitoring Programs, a Response to Doctor Shopping: Purpose, Effe ctiveness, and

Directions for Future Research,” Issues in Mental Health Nursing, vol. 33, no. 5 (2012), pp. 319-328.

200 See, for example, Liza Reifler, Danna Droz, and J. Elise Bailey, “Do Prescription Monitoring Programs Improve

State T rends in Opioid Abuse/Misuse?” Pain Medicine, vol. 13, no. 3 (March 2012), pp. 434-442.

201 Bryce Pardo, “Do More Robust Prescription Drug Monitoring Programs Reduce Prescription Opioid Overdose?”

Addiction, vol. 112, no. 10 (October 2017), pp. 1773 -1783.

Australia and the Netherlands appear to have robust national systems, for instance, while France’s program is

limited in its ability to identify and monitor national trends over time. See OECD, Addressing Problematic Opioid Use,

2019, and Chenaf et al., “Prescription Opioid Analgesic Use in France,” 2019.

202

203 Ibid., and Cherny et al., “Formulary Availability and Regulatory Barriers,” 2010.

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(DEA) oversees one-day prescription drug take-back events biannually (with the first occurring in

2010), no coordinated system exists to manage prescription opioid supply after dispensing. 204

The absence of a mandated centralized PDMP may contribute to higher rates of opioid use in the

United States. Although states are not required to operate PDMPs, all 50 states, the Distric t of

Columbia, and two territories (Guam and Puerto Rico) have operational PDMPs. 205 How PDMPs

are organized and operated varies among states, which can slow interoperability and

coordination. 206 The decentralized nature of PDMPs in the United States may explain some of the

differences in opioid consumption compared with European countries that have uniform national

programs designed to promote, or ensure, safe prescribing practices.

Cultural Factors 207

Cultural differences surrounding experiences of pain, expectations of pain remediation, and the

use of medical care may explain higher rates of opioid use in the United States compared with

other countries. A full exploration of all of the cultural factors that may explain differences in

opioid consumption is beyond the scope of this report. Instead, this section identifies certain

cultural factors commonly highlighted in existing research that may affect opioid consumption

rates. 208

Social, cultural, and educational factors “influence illness behaviour in a number of ways

including defining what is regarded as ‘normal’ and ‘abnormal,’ determining the cause of illness,

influencing the decision-making control in healthcare settings and impacting on health-seeking

behaviour.”209

Research indicates that culture likely influences



communication about pain between patients and physicians;210

Okie, “A Flood of Opioids,” 2010. Section 3032(a) of the SUPPORT Act (P.L. 115-271) allows the HHS Secretary

to require, as part of a REMS for a drug that has a serious risk of abuse or overdose, that the drug be dispensed with a

safe disposal packaging or safe disposal system. T his provision did not require such packaging or disposal system,

however, and it is unclear whether the provision has had any effect on drug disposal practices.

204

205 T he state of Missouri does not have a state-wide system. It is operated on the county level, with some counties

opting to collaborate with one another.

206

Each state determines which agency houses the PDMP; which controlled substances must be reported; which types

of dispensers (e.g., pharmacies) are required to submit data; how often data are collected; who may access informa tion

in the PDMP database (e.g., prescribers, dispensers, or law enforcement); the circumstances under which the

information may (or must) be accessed; and what enforcement mechanisms are in place for noncompliance. For more

information on prescription drug-monitoring programs in the United States, see CRS Report R42593, Prescription

Drug Monitoring Programs, by Lisa N. Sacco, Johnathan H. Duff, and Amanda K. Sarata. See also, Office of National

Drug Control Policy, Prescription Drug Monitoring Programs, Fact Sheet, Washington, DC, April 2011, at

https://www.ncjrs.gov/pdffiles1/ondcp/pdmp.pdf; and Dianne Goede and Scott Joy, “It Is Past T ime for A National

Prescription Drug Monitoring Program,” SGIM Forum , vol. 41, no. 7 (July 2018). T here may be benefits to having

different state PDMPs; however, evaluating the benefits and drawbacks is beyond the scope of this report. What is

notable is that the partitioned structure of the PDMP system in the United States may explain some differences in

opioid consumption compared with other countries.

207 For the purposes of this report, “culture” refers to the customary beliefs and social norms of a particular racial,

religious, or social group, and the set of shared attitudes, values, and practices that characterizes a group of people.

208 Bosetti et al., “T rends in the Consumption of Opioids,” 2019.

209 Sue Peacock and Shilpa Patel, “Cultural Influences on Pain,” British Journal of Pain, vol. 1, no. 2 (2008).

210

For example, one study of pain in minority populations found that if clinicians and patients were of different ethnic

backgrounds, the patient s were less likely to be fully honest about the intensity of their physical pain . Shaurab Sharma,

J. Abbott, and Mark Jensen, “Why clinicians should consider the role of culture in chronic pain,” Brazilian Journal of

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

beliefs about the cause of physical pain, and a focus on physical pain as opposed

to psychological distress caused by the pain; 211



expectations and acceptance of pain (e.g., as a normal part of life or as a medical

problem that needs clinical intervention);

displays of emotion or verbal expression in response to pain or injury; 212 and



pain intensity and tolerance.

Other research demonstrates that established attitudes and beliefs about pain are important

predictors in identifying who is likely to develop long-term and disabling pain. 213 For example,

some researchers note that Americans believe pain can be controlled, and thus they may have

lower pain tolerance and more permissive attitudes toward pain treatment and human intervention

in the treatment of pain, compared with some of their European counterparts.214

Further research highlights the way national laws and regulations may influence cultural beliefs

about pain and an individual’s expectations of pain management. For example, U.S. health care

providers can be held personally liable for pain control; patients can sue a practitioner if they

perceive pain control to be inadequate. 215 One study found that as medical care has increasingly

been viewed as a consumer good (including, in this case, advertisements that contain subjective

information about pain relief), more individuals believe there should be a quick solution to pain—

ideas that may have permeated American culture. 216

Issues for Congress

Congress has demonstrated continued interest in addressing the opioid epidemic in the United

States. The 114th and 115th Congresses enacted several laws addressing opioid use, such as the

Comprehensive Addiction and Recovery Act of 2016 (CARA, P.L. 114-198), the 21st Century

Cures Act (P.L. 114-255), and the Substance Use-Disorder Prevention that Promotes Opioid

Recovery and Treatment for Patients and Communities Act (SUPPORT Act, P.L. 115-271). These

laws included provisions specifically designed to address widespread overprescribing and abuse

of opioids in the United States. 217 Future efforts by Congress could continue to address the United

States’ comparatively high use of prescription opioids through oversight, hearings, or legislation

on this topic. As described below, Congress could consider several options when addressing

opioid consumption in the United States.

Physical Therapy, vol. 22, no. 5 (Sept.-Oct. 2018).

211 Hauser et al., “T he Opioid Epidemic and Long-T erm Opioid T herapy,” 2016.

212 Ibid.

213 See, for example, Van Hecke, “Chronic Pain Epidemiology and Its Clinical Relevance,” 2013.

214 Ibid., and R. Zaslansky, W. Meissner, and C.R. Chapman, “Pain After Orthopaedic Surgery: Differences In Patient

Reported Outcomes In T he United States Versus Internationally,” British Journal of Anaesthesiology, vol. 120, no. 4

(February 2, 2018). Prodita Sabarini, “How Different Cultures Experience and T alk About Pain,” The Conversation,

2015.

215 Van Amsterdam et al., “T he Misuse of Prescription Opioids,” 2015.

216

Ibid.

217 For more information on the SUPPORT Act, see CRS Report R45405, The SUPPORT for Patients and

Communities Act (P.L. 115-271): Food and Drug Administration and Controlled Substance Provisions.

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Policy Options for Congress

Congress may have a number of options in seeking to reduce the overutilization of opioids for

pain. Although regulating the practice of medicine is mostly left up to the states, Congress has

several policy levers at its disposal to influence opioid-prescribing practices. The federal

government is involved in multiple aspects of regulating the use of scheduled drugs in medicine,

for example, such as establishing annual quotas for production, 218 specifying storage and

dispensing rules, 219 requiring certain training for health care providers, 220 and regulating federal

health care programs such as Medicare and Medicaid. The federal government—often through the

annual appropriations process—provides substantial funding to states specifically for opioidrelated activities. Congress has sometimes linked states’ receipt of discretionary funding with

their employment of certain policies or practices aimed at reducing prescription opioid use.

Congress could consider using mandatory or discretionary funding for innovative activities

designed to promote best clinical practices. For example, research has shown that default settings

in electronic medical record systems can influence lower opioid utilization for pain without

compromising the quality of pain care. 221 Sometimes referred to as “nudges” in the scientific

literature, these default settings could promote alignment with clinical guidelines without any

additional burdens to health care providers or additional costs to the system. 222

Reducing Opioid Consumption

Congress could also consider other policy or program strategies to reduce consumption of

opioids. For example, lawmakers in the United States could look to policies in peer countries for

possible approaches to curb excessive prescription opioid use. Congress could consider broadly

applying some strategies from the Veterans Health Administration’s Opioid Safety Initiative, 223

which, according to the VA, reduced prescription opioid use in patients within the VA health care

system by 64%. 224 Possible strategies for reducing prescription opioid use are discussed further

below.

Prescription Drug-Monitoring Programs and Electronic Medical Records

Congress funds state prescription drug-monitoring programs (PDMPs) through initiatives such as

the Harold Rogers grant program. 225 Although the current authorizing statute outlines best

practices for PDMPs, states must meet few requirements—none of which mandate state PDMPs

to interact with other electronic medical record (EMR) systems. Congress could use the PDMP

218 21 U.S.C. §826.

219 21 U.S.C. §826 and 21 C.F.R. §1301.71 et seq.

220

See, for example, 21 U.S.C. §823.

221 Alexander Chiu, Raymond Jean, Jessica Hoag, et al., “Association of Lowering Default Pill Counts in Electronic

Medical Record Systems With Postoperative Opioid Prescribing,” JAMA Surgery, vol. 153, no. 11 (July 18, 2018).

222 Mitesh Patel, Kevin Volpp, David Asch, et al., “Nudge Units to Improve the Delivery of Health Care,” New

England Journal of Medicine, vol. 378, no. 3 (January 18, 2018).

223 U.S. Department of Veterans Affairs, VHA Pain Management/Opioid Safety Initiative (OSI), https://www.va.gov/

PAINMANAGEMENT /Opioid_Safety_Initiative_OSI.asp.

U.S. Department of Veterans Affairs, Office of Public and Intergovernmental Affairs, “VA Reduces Prescription

Opioid Use by 64% during the Past Eight Years,” press release, July 30, 2020, https://www.va.gov/opa/pressrel/

pressrelease.cfm?id=5492#:~.

224

225 42 U.S.C. 280g-3.

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grant program to encourage states to integrate their PDMPs with EMRs , for example. Congress

could also revise the grant stipulations for PDMPs to encourage, or require, use of PDMPs in

promoting best clinical practices, rather than primarily for diversion enforcement. In its toolkit

outlining state strategies to improve PDMPs, the National Governors Association recommended

integrating PDMPs with EMRs, using PDMPs to support clinical decision-making, and providing

PDMP data access to health care institution leadership to facilitate oversight and best practices. 226

Integrating PDMPs with EMRs may be challenging and burdensome. EMRs have substantial

financial costs and are often not interoperable across systems, among other possible drawbacks.227

Further federal regulation on EMRs could actually restrict operability and curb innovation,

having a counterproductive effect on opioid-related clinical practices.

As mentioned above, opioid-prescribing rates are not equally distributed across geographic areas

in the United States. A relatively small percentage of health care providers are responsible for a

disproportionate amount of opioid prescriptions. 228 Congress could encourage the use of PDMPs

to target regions or providers for education campaigns, training programs, or other PDMP-related

interventions shown to curb excessive opioid use. 229

Setting Annual Quotas for Controlled Substances

The Controlled Substances Act (CSA) includes a production quota system that requires the DEA

to establish the total amount of each basic class of Schedule I and II controlled substances and

listed chemicals 230 that may be manufactured in a given calendar year “to provide for the

estimated medical, scientific, research, and industrial needs of the United States for lawful export

requirements, and for the establishment and maintenance of reserve stocks.”231 Many prescription

opioids are Schedule II controlled substances under the CSA. 232 The DEA establishes aggregate

production quotas (APQs) and then assigns individual production quotas to manufacturers that

226 National Governors Association, State Strategies to Improve the Use of Prescription Drug Monitoring Programs to

Address Opioid and other Substance Use Disorders, Washington, DC, July 2020, https://www.nga.org/wp-content/

uploads/2020/07/NGA_PDMP_T oolkit-July-2020.pdf.

227 For more detailed information on health information technology and EMRs, see, for example, Comm ittee on Patient

Safety and Health Information T echnology, Institute of Medicine, Health IT and Patient Safety: Building Safer Systems

for Better Care, Washington, DC, November 10, 2011, https://www.ncbi.nlm.nih.gov/books/NBK189661/.

228

Guy et al., Vital Signs: Changes in Opioid Prescribing in the United States: 2006 -2015, 2017; and Zhu et al.,

“Initial Opioid Prescriptions among U.S. Commercially Insured Patients,” 2019.

229 Centers for Disease Control and Prevention, CDC/Opioid Information/State Information/State Successes, 2019,

https://www.cdc.gov/drugoverdose/policy/successes.html.

230 T hese listed chemicals are ephedrine, pseudoephedrine, and phenylprop anolamine, which are ingredients commonly

found in over-the-counter cold medicines that may be used in the production of methamphetamine and amphetamine.

See Drug Enforcement Administration, CMEA (Combat Methamphetamine Epidemic Act) Questions & Answers,

https://www.deadiversion.usdoj.gov/meth/q_a_cmea.htm.

231

21 U.S.C. §826(a).

232 For more information on the CSA, see CRS Report R45948, The Controlled Substances Act (CSA): A Legal

Overview for the 117th Congress.

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prevent the APQ from being exceeded. 233 Registrants 234 may not manufacture a Schedule I or II

controlled substance that is (1) not expressly authorized by their registration and by the individual

quota assigned to them by the DEA, or (2) in excess of that quota. 235

For any year in which the approved APQ for a covered controlled substance is higher than in the

previous year, the Attorney General, in consultation with the HHS Secretary, includes in the final

order an explanation of why the public health benefits of increasing the quota clearly outweigh

the consequences of having an increased volume of the covered controlled substance available for

sale, and potential diversion, in the United States.

In trying to control the opioid supply and reduce opioid abuse, Congress has imposed tighter

oversight of opioid production and distribution, including through oversight of annual APQs for

opioids quotas. For example, Section 3282 of the SUPPORT Act strengthened considerations for

DEA’s opioid quotas. 236 Congress may consider further amending the quota process to control the

nation’s opioid supply. For instance, Congress could amend data considerations for the DEA in its

annual APQ determinations. In the annual APQ notices, the DEA has stated that it has difficulty

relying on overdose death data provided by CDC because the data do not distinguish between, for

instance, licit fentanyl and illicit fentanyl. 237 Congress could diversify the quota process and

involve other federal agencies, such as the FDA, in the decisionmaking process. The DEA has

often stated that the quota decision is a careful balance between providing an adequate supply to

those who need such substances for medical care and limiting the supply to prevent diversion to

unlawful users.

Prescription Drug-Marketing Practices

Congress could look to peer countries for examples of national policies that appear to reduce

opioid prescribing. The United States, for example, is the only country in the world besides New

Zealand that allows direct-to-consumer marketing for prescription drugs, including opioids. 238

233 Statement for the record of Joseph T . Rannazzisi, Deputy Assistant Administrator, Office of Diversion Control,

Drug Enforcement Administration, before the U.S. Congress, United States Senate Caucus on International Narcotics

Control, Improving Management of the Controlled Substances Quota Process, 114 th Cong. 1 st sess., May 5, 2015; and

21 U.S.C. §826(b). By regulation, the DEA Administrator must consider specific factors in making APQ

determinations. See 21 C.F.R. §§1303.11(b)(1)-(5). In establishing quotas for fentanyl, oxycodone, hydrocodone,

oxymorphone, or hydromorphone, the Attorney General estimates the amount of diversion that occurs in the United

States. In estimating such diversion, the Attorney General must consider, in consultation with the HHS Secretary,

information they determine to be reliable on rates of overdose deaths and abuse and overall public health impact related

to the substance, along with whatever other sources of information the Attorney General determines reliable. After

estimating the amount of diversion, the Attorney General makes appropriate reductions from the quota that would have

otherwise been established had such diversion not been considered.

234 Under the CSA, every person who manufactures, distributes, or dispenses any controlled substance, or who proposes

to engage in any of those activities, must register with DEA, unless an exemption applies. See 21 U.S.C. §822 and 21

C.F.R. Part 1301.

235 21 U.S.C. §§842(b). T he CSA allows registrants to apply for an increase in individual manufacturing quota if it is

necessary “to meet … estimated disposal, inventory, and other requirements during the remainder of that year.” See 21

U.S.C. §826(b) and (e).

236

21 U.S.C. §826.

237 See Drug Enforcement Administration, “Proposed Aggregate Production Quotas for Schedule I and II Controlled

Substances and Assessment of Annual Needs for the List I Chemicals Ephedrine, Pseudoephedrine, and

Phenylpropanolamine for 2021,” 85 Federal Register 54407-54414, September 1, 2020; and Drug Enforcement

Administration, “Proposed Aggregate Production Quotas for Schedule I and II Controlled Substances and Assessment

of Annual Needs for the List I Chemicals Ephedrine, Pseudoephedrin e, and Phenylpropanolamine for 2020,” 84

Federal Register 48170-48177, September 12, 2019.

238 For more information, see Lisa Schwartz and Steven Woloshin, “Medical Marketing in the United States, 1997 -

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The pharmaceutical industry in the United States spends over $20 billion annually on marketing

to health care professionals. 239 These expenditures are generally tax deductible as business

expenses. 240 Many other countries either prohibit direct-to-provider marketing or place limitations

on such practices. As examples, Congress might consider



imposing a moratorium on advertising of certain prescriptions drugs;



expanding FDA’s authority to review advertisements for drugs with high risk of

abuse;

eliminating tax deductions for the costs of advertising of certain prescription

drugs;241 or



limiting certain types of marketing practices, such as gifts to providers.242

Reducing direct-to-provider marketing could have drawbacks, such as practitioners being less

informed about available medications or the proper use of certain formulations. In addition, a

complete ban on direct-to-consumer (or health care provider) advertising may raise First

Amendment issues. 243

Clinical Best Practices

National-level policies do not need to be purely restrictive to effectively reduce unnecessary

opioid prescribing. Several other countries—such as Japan—operate national provider training

curriculums or stewardship programs designed to help practitioners learn and employ best clinical

practices. In the United States, such programs are primarily instituted by states, if at all. FDA’s

opioids REMS requires pharmaceutical companies that market opioids to make training available

to prescribers. Prescribers are encouraged to participate in training, but they are not required to do

so as a condition of prescribing. 244 Congress could consider instituting national training programs

similar to those of other countries, or international training and mentorship exchange programs,

such as international twinning programs, where U.S. providers and public health professionals

shadow counterparts in other countries to learn certain best practices.245

2016,” JAMA, vol. 321, no. 1 (2019), pp. 80-96.

239 Lisa M. Schwartz and Steven Woloshin, “Medical Marketing in the United States, 1997 -2016,” JAMA, vol. 321, no.

1 (January 2019).

240 Richard Frank, Keith Humphreys, and Harold Pollack, “Policy Responses to the Addiction Crisis,” Journal of

Health Politics, Policy, and Law, vol. 8970796 (January 22, 2021). See §162 and Rev. Rul. 92 -80, 1992-2 C.B. 57,

September 11, 1992, and 26 U.S.C. §162.

241 For more information on this issue, see CRS Report R40590, Direct-to-Consumer Advertising of Prescription

Drugs.

242 Matthew D. Eisenberg, Elizabeth M. Stone, Harlan Pittell, et al., “The Impact of Academic Medical Center Policies

Restricting Direct -T o-Physican Marketing on Opioid Prescribing,” Health Affairs, vol. 39, no. 6 (June 2020).

243

CRS Report R40590, Direct-to-Consumer Advertising of Prescription Drugs.

For a list of FDA REMS opioid-related continuing education resources, see https:

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