The United States stands out for the sheer amount of opioids like Vicodin and Oxycontin it consumes, fueling a deadly drug epidemic. With just 4 percent of the world’s population, the US accounts for about 27 percent of the world’s drug overdose deaths. The federal government estimated 8.5 million Americans, about 3 percent of the population, misused opioid painkillers in 2015, and 2.5 million were addicted to either painkillers or heroin. More than 33,000 people died that year from overdoses.
The European Union’s entire population exceeds that of the United States, but it has a fraction of the opioid use. Out of the approximately 507 million people living in the EU in 2014, 1.3 million — or 0.4 percent — were considered high-risk opioid users. That same year, officials recorded 6,800 drug overdose deaths in the EU; opioids were to blame in about 80 percent of those deaths.
Why is the United States such an outlier when it comes to dependence on powerful, addictive painkillers? After all, people in other countries also break bones, have surgery, and suffer from back pain and arthritis.
Part of it is regulatory: In Europe, opioids are much more tightly regulated. The American opioid epidemic is what you get when you pair a culture that values treating pain at all costs with a regulatory environment that makes dangerous and addictive drugs relatively easy to obtain.
When you compare United Nations data on the top 25 countries that consume the most opioids, the United States is far and away at the top of the list. The standard daily dose per million people in the United States is 50,000 doses of opioids. That’s every day. International data shows that despite making up 4.4 percent of the global population, the US gobbles up a disproportionate amount of the world’s opioid supply; about 30 percent of the total. And Americans use almost all of the entire world supply of certain opioids, including a full 99 percent of the world’s hydrocodone supply.
In the United States, doctors started making the case in the late 1990s that pain needed to be treated aggressively. This shift in attitude was fed by drug manufacturers like Purdue Pharma, which were trying to increase sales for extended-release narcotics like OxyContin. Prescription opioid sales nearly quadrupled from 1999 to 2014, even though Americans didn’t report a huge change in the amounts of pain they felt.
Western Europe regulates opioids more tightly. In Europe, the way patients and doctors view pain isn’t that different from attitudes toward pain in North America, according to Canadian researcher Dr. Benedikt Fischer. But Europe still has much lower rates of opioid prescription. Germany, the country that consumes the most opioids in Europe, prescribes pills at about half the rate of the US.
A few years ago, Fischer and a team of researchers at the University of Toronto set to explain the difference between opioid prescribing in North America and Western Europe. They found that pharmaceutical regulation (or lack thereof) plays a large role in how opioids are advertised, sold and prescribed in the US and Europe.
“In North America, health is much more of an industry than in Europe,” Fischer said. “Europe is generally much more regulated. That’s not universally the case, but in regards to medicine and health care, that’s probably more often the case than not.”
Western Europe is actually starting to catch up to the United States for rates of opioid prescribing, Fischer said. (Europe’s opioid problem has largely been restricted to heroin, although there are signs of prescription painkillers and synthetic fentanyl becoming a problem.)
But the two are very different when it comes to how the government regulates opioids, controlling where and how pharmaceutical companies are able to advertise, and also the setting where doctors can prescribe opioids.
One of the biggest differences is how centralized this regulation is across Europe, including limitations on how much doctors can prescribe and cost coverage. Comparatively, regulation in the United States usually happens on a case-by-case basis, with individual states running prescription drug monitoring programs where individual doctors upload information.
In Europe, opioids are generally dispensed by specialists, not primary care doctors. They are also prescribed mostly in hospital settings, rather than in community-based clinics. There is also a strict ban on pharmaceutical companies advertising directly to patients in Europe.
Contrast that to the United States, where primary doctors write half of the nationwide prescriptions for opioid pain relievers, according to the CDC. At the root of these differences in prescribing practices are even bigger differences among health care systems. For instance, nearly all European countries have national health systems where doctors are salaried, and don’t get paid depending on how much medical care they give, or how many pharmaceutical drugs they prescribe. There’s much more private competition and fee-for-service medicine in the US.
Pain is complex and multi-faceted, and it can be cause by different things, including an injury, chronic pain due to nerve damage, or maybe even psychological pain from a traumatic event. If doctors had more time, they could spend time talking to patients, getting to the root of the problem, and refer patients to physical therapy for back pain that won’t go away, or to a mental health therapist to work through anxiety and post-traumatic stress disorder. But often, there’s not enough.