With 300 million prescriptions written in 2015, the U.S. population outpaces all other nations in opioid prescription use.44 In fact, the average morphine milligram equivalent (MME) dosage dispensed per capita in the United States was 599.3 in 2016 and 358 MME per capita in Australia.45 In the U.S., this is enough to give every adult a bottle of pills and have some leftover!44 Americans are prescribed six times more opioids per capita than citizens in France, despite nationalized medicine in France allowing for easier access to healthcare and more healthcare visits per capita.44 This disparity is particularly well-delineated for hydrocodone, a drug that Americans consume over 99% of the world supply (Figure 2).44 This disparity persists despite the fact that Americans are not older than other populations; the U.S. ranks 42nd in proportion of the population over the age of 65.46
Several explanations for these differences in prescribing patterns may be at play. Pain perception and the attitudes of healthcare providers towards pain varies widely between cultures. Americans are more likely than their European or Asian counterparts to view pain as a malady rather than a natural consequence of aging or injury.47-50 Regulatory controls and healthcare provider oversight also differs greatly between countries. In the U.S. much of the regulation is performed at the state rather than the Federal level, which may afford more variation and less tight control.51,52 The United States and New Zealand are also the only countries that allow prescription drugs to be advertised on television, which may create a consumer-driven approach to prescribing patterns with patients requesting and, in many cases, receiving drugs that they have seen in advertisements.53 While opioid prescription advertisements are generally not seen on television, the 2016 Super Bowl featured an ad for a drug designed to combat opioid-induced constipation, which drew ire from Physicians for Responsible Opioid Prescribing and the White House.54 Finally, differences in how healthcare is delivered and reimbursed lead to differences in how patients are treated when they present with pain, a multifactorial symptom which can relieve many underlying ailments. The average primary care physician or healthcare provider in the U.S. spends around 15 minutes with each patient and covers an average of six topics in that time frame.55,56 This may not be enough time to fully assess a patients’ condition and may contribute to a less holistic approach to pain control.
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