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

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URL: https://www.frixlaw.com/law-library/documents/crs%3AR46805

## Record

- **Collection:** Congressional research report
- **Document type:** CRS Report
- **Published:** June 2, 2021
- **Citation:** R46805

## Text

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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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.
5

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.
8

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.
10
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.
11

See World Health Organization, Essential Medicines and Health Products/Defined Daily Doses, at
https://www.who.int/medicines/regulation/medicines-safety/toolkit_ddd/en/.
12
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

1

Fentanyl (patch)

2.4

Dihydrocodeine

0.25

Morphine

1

Hydromorphone

4

Tapentadol

0.40

Nalbuphine

1

Oxycodone

1.5

Tramadol

0.10

Oxymorphone

3

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.
16

17

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).
18

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.
20

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.
25
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).
26

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.
28

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.
31

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.
41
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
43

Ibid.

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

weight.
45

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.
49

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.
54
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
56

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.
61
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.
62

63

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.
64

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.
66

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.
67

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.
77

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.
80
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.
82

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).
95

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.
99

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 Tr

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Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/crs%3AR46805. Public record. Not legal advice.