Policy analysisPrescription opioid misuse in the United States and the United Kingdom: Cautionary lessons
Section snippets
Background
In the United States, opioid treatment of chronic pain is the focus of urgent attention due to increasing trends in misuse and non-fatal and fatal overdose among those to whom the opioids are prescribed as well as those who obtain them illicitly. Opioid overdose is now the second leading cause of accidental death in the United States after motor vehicle accidents (Centers For Disease Control and Prevention, 2010). These trends parallel an increase in opioid prescriptions (Hall et al., 2008).
Trends in opioid prescribing
Opioid prescribing for chronic non-cancer pain is increasing in the US and UK. This has occurred in spite of a paucity of evidence regarding the efficacy of opioid therapy for chronic non-cancer pain and a growing literature surrounding its harms (Kalso et al., 2007, Noble et al., 2010, Okie, 2010). Although the US currently consumes more opioids per capita than the UK, both countries have seen increases in opioid consumption over the last two decades (DCAMC, 2012). Notably, the per capita
Opioid misuse in the US and UK
Comparing opioid misuse requires a standard nomenclature. Since the nomenclature is not always consistent in the literature, for the purposes of this review, the term misuse will be used as a general term for behavioral problems – ranging from use other than as prescribed to addiction – that are associated with opioid use (Table 1).
According to national surveys, prescription opioid misuse is second only to cannabis in illicit drug use in the US with approximately 2% of the adult population
Lessons from drug poisoning data
Although the number of opioid prescriptions has increased in both the US and the UK, England and Wales have not seen a concurrent rise in opioid overdose (see Fig. 2). One important methodologic challenge, however, is that surveillance and classification of cause of death are not standardized within or between countries; thus, precise comparison of opioid overdose rates is impossible.
Several important trends have emerged in the analysis of overdose deaths in the US. First, misuse resulting from
Pharmaceutical industry and cultural influences in opioid misuse
Professional guidelines in the UK and US are largely in agreement in terms of recommendations for opioids for pain (Chou, 2009, The British Pain Society, 2010). However, the landscape of opioid treatment differs in these countries with approaches to health care delivery that are unique to their respective cultures and histories.
Pharmaceutical company marketing practices in the US have served to inflate the benefits and obscure the harms of opioids. Notably, Purdue Pharmaceuticals pleaded guilty
Forming opioid policies through regulation, surveillance, and education
Analogous to States, which have a degree of autonomy in public health governance in the US, the devolved administrations of the UK (Scotland, Wales, and North Ireland) differ in meaningful ways with respect to public health priorities, as well as structural aspects of healthcare delivery. Moreover, it is important to acknowledge regional variations in opioid use and opioid-related harms in the US and the UK. Nevertheless, in both the US and the UK there is consistency in their respective
Discussion
The comparison between the US and the UK in opioid consumption and overdose rates should serve as a call to action for UK physicians and policymakers. The trends in decreasing benzodiazepine prescriptions and limited use of methadone for the treatment of chronic pain in the UK as well as structural elements of the National Health Service (NHS) may serve to buffer opioid-related harms in the face of increasing prescriptions. In addition, the availability and price of heroin, as well as the ease
Authors contributions
DW performed the data analysis from national drug poisoning data from the United States and the United Kingdom as well as opioid consumption data compiled by the Drug Control and Access to Medicines Consortium (http://dcamconsortium.net/). DW wrote the first draft of the manuscript based on inter-continental discussions between the authors, and worked with CS, DF, and WB in revising it. All authors approved the final version of the manuscript.
Author information
CS, DF and WB are clinicians and researchers with extensive experience in the area of opioid prescribing. In addition, CS served as the UK Chair of the Consensus Group and Editor of the British Pain Society's and Medical Royal College's guidance entitled “Opioids for Persistent Pain: Good Practice”, and DF has served on the White House Office of National Drug Control Policy (ONDCP), Drug Control Research, Data, and Evaluation Advisory Committee, and the World Health Organization and United
Funding source
Funds from The Office of International Medical Student Education, Yale University School of Medicine, supported this study. Dr. Fiellin is supported by a grant from the National Institutes on Drug Abuse, DA020576-01. Dr. Becker is supported by a Veterans Health Administration Health Services Research & Development Career Development Award (08-276). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the institutions with which
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4th: Brigham and Women's Hospital, Department of Internal Medicine, Boston, MA, United States.