Balance, Pain

Does the USA have a greater need of opioid analgesics?


In the discussion on “Back to School,” film # 12 in the LIFE before Death series, the recent BMJ articles quoting Dr Volkow, the Director of the USA National Institute for Drug Abuse (NIDA) were referenced. This question in particular stands out.

“I think it poses the question, why do we have much greater need of opioid analgesics than other countries, and it’s tricky because you don’t want patients not to be able to get access to their medications because there’s not sufficient quantities but at the same time, the greater the amount of drugs out there available, the greater the likelihood that they are being diverted, the greater the likelihood that people become addicted or overdosed.”

So does the USA have a greater need of opioid analgesics than other countries?
It may be worthwhile looking at USA opioid consumption provided to PPSG from the International Narcotic Control Board and displayed at our web site (http://www.painpolicy.wisc.edu) using Gapminder software. I have created some charts below comparing the USA, Australia, Ireland and Austria below.

Comments:

  1. Much of the world’s population have access to little or no opioids for pain relief
  2. Country with lines: USA (Blue), Australia (Orange), Ireland and Austria (Green)
  3. Units are years on the X-axis and mg/person/year on the Y-axis
  4. Morphine equivalents are calculated for 6 opioids: morphine, oxycodone, hydromorphone, fentanyl, pethidine (demerol) and methadone.
  5. Morphine equivalents are calculated from a WHO formula
  6. Methadone is used for the treatment of opioid dependency syndrome and pain in the USA. It is primarily used for opioid dependency syndrome in most other countries.
  7. The United Kingdom uses significant quantities of diacetomorphine for pain control which is not reflected in this data
  8. Austria uses morphine for the treatment of opioid dependency syndrome.
  9. Canada is the smaller blue circle seen in the vicinity of the USA (reflective of population not size)
Let me suggest a number of possible answers to the question. “Does the USA have a greater need of opioid analgesics than other countries?”
a) Yes
b) No
c) I don’t have enough information to answer the question (not just from this data)
d) I don’t know.
Appreciate your thoughts on this, the factors that influence the variability between countries, and the influence the US statistics may have on the 5/6 of the world who lack access for established medical purposes!
Addendum:
I have included Slide 10 here for readers convenience as per the Comment by Dr Kolodny.
Does this slide does answer the question?

About Pain policy & palliative care

Improving global pain relief by achieving balanced access to opioids worldwide

Discussion

4 thoughts on “Does the USA have a greater need of opioid analgesics?

  1. I think the answer to this question can be found on slide 10 of the following presentaion:
    http://www.cdc.gov/about/grand-rounds/archives/2011/pdfs/PHGRRx17Feb2011.pdf

    Posted by Andrew Kolodny | August 8, 2011, 11:50 AM
  2. So does the USA have a greater need of opioid analgesics than other countries?

    Posted by morphine side effects | August 24, 2011, 4:45 PM
  3. No, the U.S. does not have a greater need for opioids.

    What we have is greater consumption because of the influence of pharmaceutical companies. Industry-funded medical education led docs to believe that opioids are a safe and effective treatment for chronic non-cancer pain. And industry-funded advocacy groups (including the Wisconsin Pain and Policy Study Group’s domestic arm) convinced state and federal agencies to de-regulate opioid prescribing.

    The result has been an epidemic of addiction and overdose deaths. Chronic pain patients have been harmed rather than helped by all of this.

    The U.S. is as unbalanced (but in the opposite direction) as nations who allow palliative care patients to suffer needlessly because of overly restrictive prescribing regs.

    Here’s a link to a great article published in BMJ this week on this topic: http://www.responsibleopioidprescribing.org/index_10_3360311107.pdf

    Jim- Any chance you’ll post a blog entry on the BMJ article?

    Posted by Andrew Kolodny | August 24, 2011, 8:23 PM
  4. Andrew,
    Appreciate the link to the BMJ article. I will blog on it.
    It does address the level of evidence of opioid use in a meaningful way but raises some questions (which a good paper always should).

    I would agree with you that “free market forces” are a major problem within US health care generally, and have contributed to higher uses of opioids in this country. THe Federal government has taken what it has deemed appropriate action for breeches of its rules (discussed in the BMJ article). While the University of WIsconsin has confirmed that it had received unrestricted gifts from the pharmaceutical industry to support the work of the Pain and Policy Studies Group throughout the world, I would ask you to clarify the statement
    “convinced state and federal agencies to de-regulate opioid prescribing.”

    To quote from the Model Policy for the Use of Controlled Substances for the Treatment of Pain adopted by the Federation of State Medical Boards of the United States, Inc in May, 2004.

    “Since adoption in April 1998, the Model Guidelines for the Use of Controlled Substances for the Treatment of Pain have been widely distributed to state medical boards, medical professional organizations, other health care regulatory boards, patient advocacy groups, pharmaceutical companies, state and federal regulatory agencies, and practicing physicians and other health care providers. The Model Guidelines have been endorsed by the American Academy of Pain Medicine, the Drug Enforcement Administration, the American Pain Society, and the National Association of State Controlled Substances Authorities. Many states have adopted pain policy using all or part of the Model Guidelines.(ref 1) Despite increasing concern in recent years regarding the abuse and diversion of controlled substances, pain policies have improved due to the efforts of medical, pharmacy, and nursing regulatory boards committed to improving the quality of and access to appropriate pain care.

    “Notwithstanding progress to date in establishing state pain policies recognizing the legitimate uses of opioid analgesics, there is a significant body of evidence suggesting that both acute and chronic pain continue to be undertreated. Many terminally ill patients unnecessarily experience moderate to severe pain in the last weeks of life (ref 2). The under treatment of pain is recognized as a serious public health problem that results in a decrease in patients’ functional status and quality of life and may be attributed to a myriad of social, economic, political, legal and educational factors, including inconsistencies and restrictions in state pain policies.(ref 3) Circumstances that contribute to the prevalence of undertreated pain include: (1) lack of knowledge of medical standards, current research, and clinical guidelines for appropriate pain treatment; (2) the perception that prescribing adequate amounts of controlled substances will result in unnecessary scrutiny by regulatory authorities; (3) misunderstanding of addiction and dependence; and (4) lack of understanding of regulatory policies and processes. Adding to this problem is the reality that the successful implementation of state medical board pain policy varies among jurisdictions.

    “In April 2003, the Federation membership called for an update to its Model Guidelines to assure currency and adequate attention to the undertreatment of pain. The goal of the revised model policy is to provide state medical boards with an updated template regarding the appropriate management of pain in compliance with applicable state and federal laws and regulations. The revised policy notes that the state medical board will consider inappropriate treatment, including the undertreatment of pain, a departure from an acceptable standard of practice. The title of the policy has been changed from Model Guidelines to Model Policy to better reflect the practical use of the document.

    “The Model Policy is designed to communicate certain messages to licensees: that the state medical board views pain management to be important and integral to the practice of medicine; that opioid analgesics may be necessary for the relief of pain; that the use of opioids for other than legitimate medical purposes poses a threat to the individual and society; that physicians have a responsibility to minimize the potential for the abuse and diversion of controlled substances; and that physicians will not be sanctioned solely for prescribing opioid analgesics for legitimate medical purposes. This policy is not meant to constrain or dictate medical decision-making.”

    This complete document can be found at http://www.fsmb.org/pdf/2004_grpol_Controlled_Substances.pdf.

    Many other links to address changes in US policy are available at our web site. It has never been the goal of PPSG to de-regulate opioid prescribing. Our goal is to ensure that access to opioids for those who have legitimate medical needs (which are not determined by PPSG or the FSMBs, as stated by that last sentence) is not impeded by policy or regulation.

    Pain and Policy Studies Group: http://www.painpolicy.wisc.edu

    Posted by Pain policy & palliative care | August 25, 2011, 8:41 AM

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