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

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

Consumption of Prescription Opioids for Pain:
June 2, 2021
A Comparison of Opioid Use in the United
Johnathan H. Duff,
States and Other Countries
Coordinator
Analyst in Health Policy
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
Sara M. Tharakan
per capita opioid consumption. Most research suggests that high levels of prescription opioid
Analyst in Global Health
consumption in the United States have contributed to the current epidemic of opioid misuse and
and International
overdose deaths.
Development

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.
Carla Y. Davis-Castro
Research Librarian
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
Ada S. Cornell
addition, lawmakers in the United States could examine policies in peer countries for possible
Senior Research Librarian
approaches to curb excessive prescription opioid use.

Paul D. Romero
A review of the scientific literature through February 2020 on international opioid consumption
Research Assistant
and prescribing practices pointed to several possible underlying reasons explaining the difference

in opioid consumption per capita in the United States.

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.
Congressional Research Service

Consumption of Prescription Opioids for Pain

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.
Congressional Research Service

link to page 6 link to page 9 link to page 11 link to page 13 link to page 15 link to page 16 link to page 16 link to page 19 link to page 24 link to page 25 link to page 27 link to page 29 link to page 29 link to page 31 link to page 33 link to page 35 link to page 36 link to page 37 link to page 38 link to page 38 link to page 38 link to page 39 link to page 40 link to page 41 link to page 42 link to page 42 link to page 43 link to page 10 link to page 13 link to page 14 link to page 8 link to page 8 link to page 45 link to page 45 Consumption of Prescription Opioids for Pain

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 Mil igram 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

Congressional Research Service

link to page 45 link to page 47 link to page 48 Consumption of Prescription Opioids for Pain

Appendixes
Appendix A. International Opioid-Prescribing Regulations .................................................. 40
Appendix B. Methodology and Search Strategy ................................................................. 42

Contacts
Author Information ....................................................................................................... 43

Congressional Research Service

link to page 8 Consumption of Prescription Opioids for Pain

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 al other Organisation for Economic Co-
operation 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 economical y
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 mil igram
equivalents (MMEs) per dose—appears especial y high in the United States compared with other
countries. Although there is general y 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 al ows 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 high-

1 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 rep ort
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.
5 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.
6 Published MME conversion tables may vary, depending on the source.
Congressional Research Service
1

link to page 8 Consumption of Prescription Opioids for Pain

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 mil igram 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 medical y to treat pain.8 MMEs are an opioid’s
dosage equivalency to morphine, measured in mil igrams. 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
pil s, or potency of the medication, especial y since countries differ in average number of pil s 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 Pharm acol, 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 Pharm acol, vol. 67 (2011), pp.
847-854.
Congressional Research Service
2

Consumption of Prescription Opioids for Pain

management. Compared with most of its European counterparts, the U.S. medical system al ows
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 general y structured to monitor bad actors and general y 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
Equivalent
High Equivalency
(MME factor <1)
(MME factor =1)
(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 al ow 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 central y 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.
Congressional Research Service
3

Consumption of Prescription Opioids for Pain

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 specifical y, 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 international y and in the United States, along
with factors that may influence differences between the United States and other
economical y advantaged countries; and
 discusses issues related to this topic that may interest Congress.
Global Medical Opioid Use
Nearly al countries use opioids as medicines to manage or treat pain, typical y under the
supervision of a health care provider. In the United States, for instance, opioids are legal y
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 Problem atic Opioid Use in OECD Countries, OECD
Health Policy Studies, Paris, France, June 11, 2019, at https://www.oecd.org/health/addressing-problematic-opioid-use-
in-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.
Congressional Research Service
4

Consumption of Prescription Opioids for Pain

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 mil ion 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/.

16 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.
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 Problem atic Opioid Use,
2019.
18 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).
19 OECD, Addressing Problematic Opioid Use, 2019.
Congressional Research Service
5

link to page 10 Consumption of Prescription Opioids for Pain

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 il icit opioids, such as heroin21) has
increased in many economical y developed countries over the past 25 years.22 However, per
capita opioid consumption differs substantial y 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 global y, 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

20 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.
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: Estim ated World Requirem ents 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.
Congressional Research Service
6

link to page 13 Consumption of Prescription Opioids for Pain

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 higher-
potency 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
il ustrates 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.
31 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.
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: Estim ated
World Requirem ents 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 Problem atic 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.
Congressional Research Service
7

link to page 10
Consumption of Prescription Opioids for Pain

Figure 2. Oxycodone Consumption in G-7 Countries
Defined daily doses per 1 mil ion 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 overal 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 overal 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, 2011-
2019.
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.
Congressional Research Service
8

link to page 14 link to page 10 link to page 10
Consumption of Prescription Opioids for Pain

persons in 2012 to 51.4 prescriptions per 100 persons in 2018 (from 255 mil ion total opioid
prescriptions to 168 mil ion).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 mil igrams 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 mil igrams 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 global y, 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
overal consumption declined.45 CDC has noted that prescribing rates remain especial y 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 smal

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-
Congressional Research Service
9

Consumption of Prescription Opioids for Pain

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 chal enge. Economic, social, and health
care systems in G-7 and other economical y 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.
Congressional Research Service
10

Consumption of Prescription Opioids for Pain

Key Takeaways
Key findings from this section are as fol ows:

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 il ness, greater income inequality, or higher rates of other socio-economic stressors.

The United States uses opioids for pain management more frequently than other economical y 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
paral el 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 al pain management treatments are
reimbursed equal y.

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 Pharm acists Journal, vol. 149, no. 6, (November 2016), pp. 322 -
Congressional Research Service
11

link to page 14 Consumption of Prescription Opioids for Pain

prescribed more opioids than any other country in the world.55 Research shows that U.S.
providers general y 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 substantial y in the United States from the mid-
1990s 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
Pharm acother, 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,” Pharm acoepidemiol 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/
Congressional Research Service
12

Consumption of Prescription Opioids for Pain

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 partial y 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 fil 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
partial y 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.
62 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.
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 Managem ent, vol. 10, no. 6 (2014), pp. 383-393.
66 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.
67 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.
69 Keith Humphreys, Jonathan P. Caulkins, and Vanda Felbab-Brown, What the U.S. and Canada Can Learn From
Other Countries to Com bat 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-learn-
from-other-countries-to-combat -the-opioid-crisis/.
Congressional Research Service
13

Consumption of Prescription Opioids for Pain

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 typical y 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 Am ong 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 Am erica, 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?
Congressional Research Service
14

Consumption of Prescription Opioids for Pain

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 wel .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 il ness, 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,” Rheum atology, 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 Assessm ent and Managem ent Standards, Oakbrook T errance, IL, 2019, at
https://www.jointcommission.org/en/resources/patient -safety-topics/pain-management-standards-for-accredited-
organizations/.
81 See, for example, Richard Mularski, Foy White-Chu, Deborah Overbay, et al., “Measuring Pain as the 5th 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 Managem ent Nursing,
vol. 19, no. 2 (April 2018), pp. 125 -129.
82 Arnoud Arntz, Laura Dreessen, and Harald Merckelbach, “Attention, Not Anxiety, Influences Pain,” Behaviour
Research and Therapy, vol. 29, no. 1 (1991), pp. 41-50.
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.
Congressional Research Service
15

Consumption of Prescription Opioids for Pain

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, large-
scale 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 partial y explain higher opioid consumption in the United States.
The United States is a high-income nation overal , 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.
Congressional Research Service
16

Consumption of Prescription Opioids for Pain

has the highest level of income inequality.94 Some economics researchers have label ed 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 il ness rates do not differ substantial y 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 global y, European
countries tend to treat mental il ness 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/income-
inequality.htm.
95 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).
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
Am erican Board of Fam ily 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,
Congressional Research Service
17

Consumption of Prescription Opioids for Pain

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 general y 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 cultural y and social y.”108

“Japanese patients may be less likely to complain about pain because of strong cultural mores regarding self-
attention, 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 wil 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: Estim ated World Requirem ents 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 Yamakage, “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.
110 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.
111 Ibid.
Congressional Research Service
18

link to page 16 Consumption of Prescription Opioids for Pain

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 Guidelines,” 2017, National Academies of Sciences, Engineering,
and Medicine, The Role of Nonpharm acological 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 patients 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 long-
term 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).
116 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.
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
Congressional Research Service
19

link to page 29 Consumption of Prescription Opioids for Pain

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 partial y 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 pal iative 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 al owed 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. 187-
191.
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;
Congressional Research Service
20

Consumption of Prescription Opioids for Pain

providers.127 In the European Union, direct-to-provider marketing is discouraged, with
enforcement of national and international policies delegated to professional groups and self-
regulatory bodies.128 The European Union bans direct-to-consumer marketing explicitly,129 while
the United States al ows 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 Am erica: 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 Fram ework for Governing
Medicinal Products for Hum an 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 Adm inistrative Action in Me m ber States concerning the
Pursuit of Television Broadcasting Activities, https://op.europa.eu/en/publication-detail/-/publication/63084a3f-be4a-
4415-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 Action 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 Am erica: 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 Epidem ic,
Exposing the Financial Ties between Opioid Manufacturers and Third -Party Advocacy Groups: Minority Staff Report,
2018.
133 Andrew Joseph, “‘A Blizzard of Prescriptions’: Documents Reveal New Details about Purdue’s Marketing of
OxyContin,” STAT News, January 15, 2019.
134 Dasgupta et al., “Opioid Crisis: No Easy Fix,” 2018, and Fischer et al., “Non -medical Use of Prescription Opioids,”
2013.
Congressional Research Service
21

link to page 26 link to page 25 Consumption of Prescription Opioids for Pain

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 mil ion to 14 third-party advocacy organizations between 2012 and 2017, and al ocated $1.6 mil ion
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 States
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 painkil ers 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, potential y 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

135 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 Epidem ic, Exposing the Financial Ties between Opioid Manufacturers and Third -Party
Advocacy Groups: Minority Staff Report, 2018.
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. Prescr ibing 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 Epidem iology, November 3, 2015, and B.M. Kuehn, “ Major disparities in opioid prescribing among states:
some states crack down on excess prescribing,” Journal of the Am erican 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,
Congressional Research Service
22

Consumption of Prescription Opioids for Pain

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 (especial y 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 Overal , U.S. opioid use patterns through

2011, at https://apps.who.int/iris/handle/10665/44519; INCB, Narcotic Drugs: Estim ated World Requirem ents 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 Con trolled Medicines, Geneva, Switzerland, 2011, at
https://apps.who.int/iris/handle/10665/44519; INCB, Narcotic Drugs: Estim ated World Requirem ents 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
Congressional Research Service
23

Consumption of Prescription Opioids for Pain

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 paral el constraints on services or costs, an FFS model (and other profit-
driven 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 bil 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 resource-
intensive 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 Em ergency 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
Am erican 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 Paym ent
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 Managem ent, 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).
Congressional Research Service
24

link to page 45 Consumption of Prescription Opioids for Pain

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 wil 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 Managem ent/Opioid Safety Initiative, available at htt ps://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 Am erican Board of Fam ily 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
Congressional Research Service
25

Consumption of Prescription Opioids for Pain

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, especial y 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 al .169

Abuse and Mental Health Services Administration, Office of the Surgeon General, U.S. Department of Health and
Human Services, Facing Addiction in Am erica: 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
Paym ent: Effects on the Behaviour of Prim ary 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
Problem atic 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 Treatment for Chronic Pain: A
System atic Review, Comparative Effectiveness Review Number 209, Rockville, MD, June 2018.
167 Michael Schatman and Lynn Webster, “T he Health Insurance Industry: Perpetuation the Opioid Crisis through
Policies of Cost -Containment and Profitability,” Journal of Pain Research, vol. 8 (March 18, 2015), pp. 153 -158, and
Stoicea et al., “Current Perspectives on the Opioid Crisis in the US Healthcare System,” 2019.
168 James Heyward, Christopher Jones, and Wilson Compton, “Coverage of Nonpharmacologic T reatments for Low
Back Pain Among US Public and Private Insurers,” JAMA Network Open, vol. 1, no. 6 (October 5, 2018).
169 Ibid. One commentary on pain treatment in the United States proposed that the displacement of nonpharmacological
Congressional Research Service
26

Consumption of Prescription Opioids for Pain

Some experts have suggested that the limited insurance coverage of alternative pain treatments—
primarily for “cost-containment and profitability” reasons—has contributed to overuse of opioids
for chronic pain management.170 The disproportionate coverage for some treatments, such as
opioids, but not others, such as acupuncture, may have a trickledown effect on chronic pain
management.171 The absence of financial incentives to treat pain in a comprehensive manner may
in turn produce a health care system with fewer providers learning about and using these
therapies effectively.172
Recent changes in health care coverage suggest that more insurers—both public and private—
may be limiting payments based on the dosage in opioid prescriptions.173 In addition, more
insurers may be moving to offer comprehensive pain treatments. For example, the Centers for
Medicare & Medicaid Services announced in 2019 that Medicare would cover some (but not al )
possible nonopioid interventions as part of a comprehensive pain treatment regimen.174
Other characteristics of health care systems, such as provider and patient knowledge of insurance
coverage, may affect opioid use. Insurance coverage may not be obvious to providers
coordinating care, and the system may be chal enging for patients to navigate.175 If coverage of
opioid medications is common and wel -known, providers may default to pharmacological
treatment over nonpharmaceutical interventions.
Medication costs may also play a role. One study examining opioid purchases and expenditures
across Europe found that the same drug costs different amounts in different countries.176 The
researchers noted that costs to purchasers—such as hospitals and patients—differed between
countries, and that pricing may factor into differential opioid use.177 The reasons behind different
costs for identical opioid medications are complex and beyond the scope of this report. What is
notable is that the costs of opioids differ across countries, and it is possible that these disparities
affect use.

treatments in favor of greater opioid use was not coincidental, noting that “ as insurers limited coverage of behavioral
pain therapy, biopharmaceutical manufacturers sensed an opportunity. Pharmaceutical innovation propagated extended-
release formulations, transdermal patches, nasal sprays, and oral dissolving strips. Medical device manufacturers drove
a proliferation of novel pain modulating implants.”
170 See, for example, Michael Schatman, “T he Role of the Health Insurance Industry in Perpetuating Suboptimal Pain
Management,” Pain Medicine, vol. 12 (2011), pp. 415-426.
171 T he lack of coverage for nondrug and nonmedical treatments may contribute to a dearth of providers who are
knowledgeable and willing to provide these services for people with chronic pain, particularly in the rural United States
(including in some areas disproportionately affected by the opioid crisis). See Gross et al., “T he Strengt hs and
Weaknesses of Current US Policy to Address Pain,” 2019, and Schatman, “Role of Health Insurance Industry,” 2011.
172 Gross et al., “T he Strengths and Weaknesses of Current US Policy to Address Pain,” 2019.
173 Stephen Bernard, Paul Chelminski, and T imothy Ives, “Management of Pain in the United States—A Brief History
and Implications for the Opioid Epidemic,” Health Services Insights, vol. 11 (2018), pp. 1-6, and Dora H. Lin,
Christopher M. Jones, Wilson M. Compton, et al., “Prescription Drug Coverage for T reatment of Low Back Pain
Among US Medicaid, Medicare Advantage, and Commercial Insurers,” JAMA Network Open, vol. 1, no. 2 (2018).
174 Centers for Medicare and Medicaid Services, Medicare Coverable Services for Integrative and Non-
pharm acological Chronic Pain Management, MLN Matters Number: SE19008, August 19, 2019. For more
information on Medicare and Medicaid, see CRS Report R40425, Medicare Prim er, and CRS Report R43357,
Medicaid: An Overview.
175 Gross et al., “T he Strengths and Weaknesses of Current US Policy to Address Pain,” 2019.
176 Franco De Conno, Carla Ripamonti, and Cinzia Brunelli, “Opioid Purchases and Expenditures in Nine Western
European Countries: ‘Are We Killing Off Morphine?’” Palliative Medicine, vol. 19 (2005), pp. 179-184.
177 De Conno et al., “Opioid Purchases and Expenditures in Nine Western European Countries,” 2005, p. 184.
Congressional Research Service
27

Consumption of Prescription Opioids for Pain

Government Regulations
National policies likely influence prescribing practices for opioids, particularly in Europe, where
many governments have instituted national-level regulations on opioid prescribing. Many
European regulations are more stringent than those in the United States; possibly because many
European countries have public health care systems that, general y speaking, can be regulated
more uniformly.178 European governments use a variety of regulatory restrictions, including179
 the requirement for permission to prescribe or receive opioids;
 limitations on the amount to be prescribed;
 restrictions regarding dispensing privileges;180
 national formularies to regulate which opioids can be prescribed under what
conditions;181
 requirements for a permit or license to prescribe; and
 restrictions regarding the authorization to prescribe, administrative provisions,
and requirements for the storage of controlled medicines or prescription forms.182
Dispensing rules include
 stipulations for the pharmacies authorized to dispense,
 limitations on the dispensing of controlled medicines, and
 administrative requirements, storage requirements, and delivery restrictions.183
For example, several countries restrict opioid prescriptions to less than three weeks’ supply.
Germany and other countries specify dose limits and require that opioids be prescribed in
duplicate or triplicate using special forms (see the text box below).184
Global health experts have noted that several European countries introduced stricter control
measures in response to the increase in deaths due to oxycodone overdose reported in North
America.185 Recent observations indicate that, in some countries, regulations on opioid
prescribing may becoming more permissive.186

178 Christopher Adolph, Scott L. Greer, and Elize Massard da Fonseca, “Allocation of Authority in European Health
Policy,” Social Science & Medicine, vol. 75, no. 9 (2012), pp. 1595-1603; and U.S. Congress, Office of T echnology
Assessment, Medicare’s Prospective Paym ent System , 1985.
179 Van Amsterdam et al., “T he Misuse of Prescription Opioids,” 2015.
180 Marjolein Vranken, John Lisman, and Aukje Mantel-T eeuwisse, “Barriers to Access to Opioid Medicines: Results
of a Review of National Legislation and Regulations of 11 Central and Eastern European Countries,” The Lancet
Oncology, vol. 17, no. 1 (2016), pp. e13-e22.
181 Aiden Meyer, Cheryl LeClair, and James McDonald, “Opioid Prescribing in Western Europe and the United States,”
Rhode Island Journal of Medicine, March 2020.
182 Vranken et al., “Barriers to Access to Opioid Medicines,” 2016.
183 Ibid.
184 N.I. Cherny, J. Baselga, F. de Conno, et al., “Formulary Availability and Regulatory Barriers to Accessibility of
Opioids for Cancer Pain in Europe: A Report from the ESMO/EAPC Opioid Policy Initiative,” Annals of Oncology,
vol. 21 (2010), pp. 615-626.
185 Bosetti et al., “T rends in the Consumption of Opioids,” 2019.
186 Humphreys et al., “What the US and Canada Can Learn,” 2020.
Congressional Research Service
28

link to page 45 Consumption of Prescription Opioids for Pain

Opioid-Prescribing Regulations in Germany
Germany has the largest population and the largest economy in the EU, and it has the second-highest opioid
consumption rate in the world.187 Opioid prescription in Germany is strictly regulated by the Narcotic Drugs
Prescription Ordinance (Betäubungsmittel-Verschreibungsverordnung, BtMVV) and by the German Narcotic
Drugs Act (Betäubungsmittelgesetz, BtMG), which entered into force in 1992.188 The BtMVV established detailed
prescription guidelines, which, among other things, regulate

the maximum quantities of opioids that can be prescribed within a certain timeframe, and

the maximum amount of different opioids prescribed during one visit to a health care provider/prescriber.
In Germany, every opioid dispensed requires a prescription by a physician. Under the BtMG, al opioids classified
as “strong” and “intermediate”—except Tramadol and Codeine, which are classified as “weak” opioids and do not
need a special prescription—require a specific narcotic prescription known as a “BtM” prescription.
The majority of opioid prescription regimens in Germany are based on the WHO guidelines for cancer pain
treatments published in 1986 (and updated in 2019) and fol ow the WHO’s pain treatment ladder.189 These
guidelines also apply to acute pain conditions. In 2008, a separate guideline for long-term treatment of chronic
noncancer pain (CNCP) was published. The guideline established rules for long-term use of opioids (four weeks or
longer) and treatment methodology.190 Some observers have noted that having multiple guidelines governing
opioid prescribing practices in different health care settings may have myriad unintentional outcomes, such as
increasing opioid prescription rates and sowing confusion among providers.191 Though German guidelines do not
recommend opioids as the first-line treatment for CNCP, since the early 2000s Germany has seen an increase in
the prevalence of “strong” opioid prescriptions.192 Although prescription opioid use in Germany has increased
significantly since 2000, the prescription opioid overdose death rate has not increased at a comparable rate.193 In
comparison, in the United States, adverse events such as opioid overdose deaths paral eled increased prescription
opioid use from 1996 to 2010.
Table A-1 identifies several common legal or regulatory provisions regarding opioid distribution
and prescribing practices in G-7 and other economical y advanced countries.
Public policies governing opioid use in the United States differ from most European countries in
a number of ways. At the federal level, the United States does not impose limits on the daily dose
of opioids a person can receive, place caps on long-term use, or restrict who can receive opioids,
among other regulations commonly seen abroad. Federal programs such as the FDA’s Risk
Evaluation and Mitigation Strategies (REMS)194 institute risk-mitigation procedures to promote
the safe use of medications, although questions remain about the effectiveness of these policies.195

187 Bastian Rosner, Jessica Neicun, Justin Yang, et al., “Opioid Prescription Patterns in Germany and the Global Opioid
Epidemic: Systematic Review of Available Evidence,” Plos One, August 28, 2019; and International Narcotics Control
Board, Narcotic Drugs: Estim ated World Requirem ents 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.
188 Ibid.
189 World Health Organization, WHO Guidelines for the Pharmacological and Radiotherapeutic Management of
Cancer Pain in Adults and Adolescents, January 2019.
190 Rosner et al., “Opioid Prescription Patterns in Germany,” 2019.
191 Ibid.
192 I. Schubert, P. Ihle, and R. Sabatowski, “Increase in Opiate Prescription in Germany between 2000 and 2010,”
Dtsch Arztebl International, vol. 110, no. 4 (2013), pp. 45-51. A. Werber, U. Marschall, H. L’hoest, et al., “ Opioid
T herapy in the T reatment Of Chronic Pain Conditions in Ger many,” Pain Physician, vol. 18, no. 3 (May-June 2015).
193 European Monitoring Centre for Drugs and Drug Addiction, Germany, Country Drug Report, 2019.
194 For more information on REMS, see CRS Report R44810, FDA Risk Evaluation and Mitigation Strategies (REMS):
Description and Effect on Generic Drug Developm ent.
195 Suzanne Murrin, FDA’s Risk Evaluation and Mitigation Strategies: Uncertain Effectiveness in Addressing the
Opioid Crisis, U.S. Department of Healt h and Human Services Office of Inspector General, OEI -01-17-00510,
Washington, DC, September 2020; and James Heyward, Lily Olsen, Joshua Sharfstein, et al., “Evaluation of the
Congressional Research Service
29

Consumption of Prescription Opioids for Pain

Although other restrictions, such as medication storage and frequency of patient visits to receive
prescriptions are imposed on the national level,196 most prescribing practices are regulated at the
state level. At the national level, the U.S. system governing opioid prescriptions appears to al ow
for more provider autonomy than in many European countries. Several states have instituted
opioid-prescribing regulations similar to those in Western Europe, though there is substantial
variation between states. This decentralized system may create oversight chal enges, making it
more difficult to consistently monitor safe prescribing, enforce laws, and identify bad actors.197
Prescription Drug Monitoring
The ability of national governments and other oversight or regulatory bodies to monitor the use of
controlled substances used in medicine—such as opioids—may affect national consumption rates.
Prescription drug-monitoring programs consist of electronic databases that track prescriptions for
controlled medicines such as opioids.198 PDMPs are designed to provide health authorities with
timely information about prescribing patterns and patient behaviors. Evaluations suggest that such
programs have a positive impact in controlling problematic drug use by influencing both health
care and law enforcement systems.199 Recent studies in the United States have shown that
prescription opioid misuse increased more slowly in states with PDMPs than in states without
them,200 and that states with more robust PDMPs have fewer prescription opioid overdose
deaths.201
Most economical y advanced countries use PDMPs to monitor opioid prescribing, but to varying
degrees.202 Compared with PDMPs in the United States and Canada, most European countries use
PDMPs to assert more control over prescribing practices. The North American PDMPs appear
primarily designed to detect individual instances of inappropriate prescribing rather than to
promote safe and effective prescribing practices.203 In addition, the United States lacks a
systematic post-dispensing control mechanism. Although the Drug Enforcement Administration

Extended-Release/Long-Acting Opioid Prescribing Risk Evaluation and Mitigation Strategies by the US Food and
Drug Administration,” JAMA Internal Medicine, December 30, 2019, pp. E1-E9.
196 See, for example, T itle II of P.L.91-513, T he Controlled Substances Act, as amended; 21 C.F.R. §1301.71 et seq.;
and 21 U.S.C. §823.
197 Sara Imhof and Brian Kaskie, “How Can We Make the Pain Go Away? Public Policies to Manage Pain at the End
of Life,” The Gerontologist, vol. 48, no. 4 (2008), pp. 423-431.
198 OECD, Addressing Problematic Opioid Use, 2019.
199 U.S. Government Accountability Office, State Monitoring Programs Provide Useful Tool to Prevent Diversion,
GAO-02-634, May 2002, at https://www.gao.gov/new.items/d02634.pdf. One review noted that PDMPs effectively
reduced “doctor shopping” strategies, curbed prescription misuse, and improved physicians’ prescribing practices. See
Julie Worley, “Prescription Drug Monitoring Programs, a Response to Doctor Shopping: Purpose, Effe ctiveness, and
Directions for Future Research,” Issues in Mental Health Nursing, vol. 33, no. 5 (2012), pp. 319-328.
200 See, for example, Liza Reifler, Danna Droz, and J. Elise Bailey, “Do Prescription Monitoring Programs Improve
State T rends in Opioid Abuse/Misuse?” Pain Medicine, vol. 13, no. 3 (March 2012), pp. 434 -442.
201 Bryce Pardo, “Do More Robust Prescription Drug Monitoring Programs Reduce Prescription Opioid Overdose?”
Addiction, vol. 112, no. 10 (October 2017), pp. 1773 -1783.
202 Australia and the Netherlands appear to have robust national systems, for instance, while France’s program is
limited in its ability to identify and monitor national trends over time. See OECD, Addressing Problem atic Opioid Use,
2019, and Chenaf et al., “Prescription Opioid Analgesic Use in France,” 2019.
203 Ibid., and Cherny et al., “Formulary Availability and Regulatory Barriers,” 2010.
Congressional Research Service
30

Consumption of Prescription Opioids for Pain

(DEA) oversees one-day prescription drug take-back events biannual y (with the first occurring in
2010), no coordinated system exists to manage prescription opioid supply after dispensing.204
The absence of a mandated centralized PDMP may contribute to higher rates of opioid use in the
United States. Although states are not required to operate PDMPs, al 50 states, the District of
Columbia, and two territories (Guam and Puerto Rico) have operational PDMPs.205 How PDMPs
are organized and operated varies among states, which can slow interoperability and
coordination.206 The decentralized nature of PDMPs in the United States may explain some of the
differences in opioid consumption compared with European countries that have uniform national
programs designed to promote, or ensure, safe prescribing practices.
Cultural Factors207
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. A full exploration of al of the cultural factors that may explain differences in
opioid consumption is beyond the scope of this report. Instead, this section identifies certain
cultural factors commonly highlighted in existing research that may affect opioid consumption
rates.208
Social, cultural, and educational factors “influence il ness behaviour in a number of ways
including defining what is regarded as ‘normal’ and ‘abnormal,’ determining the cause of il ness,
influencing the decision-making control in healthcare settings and impacting on health-seeking
behaviour.”209
Research indicates that culture likely influences
 communication about pain between patients and physicians;210

204 Okie, “A Flood of Opioids,” 2010. Section 3032(a) of the SUPPORT Act (P.L. 115-271) allows the HHS Secretary
to require, as part of a REMS for a drug that has a serious risk of abuse or overdose, that the drug be dispensed with a
safe disposal packaging or safe disposal system. T his provision did not require such packaging or disposal system,
however, and it is unclear whether the provision has had any effect on drug disposal practices.
205 T he state of Missouri does not have a state-wide system. It is operated on the county level, with some counties
opting to collaborate with one another.
206 Each state determines which agency houses the PDMP; which controlled substances must be reported; which types
of dispensers (e.g., pharmacies) are required to submit data; how often data are collected; who may access informa tion
in the PDMP database (e.g., prescribers, dispensers, or law enforcement); the circumstances under which the
information may (or must) be accessed; and what enforcement mechanisms are in place for noncompliance. For more
information on prescription drug-monitoring programs in the United States, see CRS Report R42593, Prescription
Drug Monitoring Program s, by Lisa N. Sacco, Johnathan H. Duff, and Amanda K. Sarata. See also, Office of National
Drug Control Policy, Prescription Drug Monitoring Program s, Fact Sheet, Washington, DC, April 2011, at
https://www.ncjrs.gov/pdffiles1/ondcp/pdmp.pdf; and Dianne Goede and Scott Joy, “ It Is Past T ime for A National
Prescription Drug Monitoring Program,” SGIM Forum , vol. 41, no. 7 (July 2018). T here may be benefits to having
different state PDMPs; however, evaluating the benefits and drawbacks is beyond the scope of this report. What is
notable is that the partitioned structure of the PDMP system in the United States may explain some differences in
opioid consumption compared with other countries.
207 For the purposes of this report, “culture” refers to the customary beliefs and social norms of a particular racial,
religious, or social group, and the set of shared attitudes, values, and practices that characterizes a group of people.
208 Bosetti et al., “T rends in the Consumption of Opioids,” 2019.
209 Sue Peacock and Shilpa Patel, “Cultural Influences on Pain,” British Journal of Pain, vol. 1, no. 2 (2008).
210 For example, one study of pain in minority populations found that if clinicians and patients were of different ethnic
backgrounds, the patient s were less likely to be fully honest about the intensity of their physical pain . Shaurab Sharma,
J. Abbott, and Mark Jensen, “Why clinicians should consider the role of culture in chronic pain,” Brazilian Journal of
Congressional Research Service
31

Consumption of Prescription Opioids for Pain

 beliefs about the cause of physical pain, and a focus on physical pain as opposed
to psychological distress caused by the pain;211
 expectations and acceptance of pain (e.g., as a normal part of life or as a medical
problem that needs clinical intervention);
 displays of emotion or verbal expression in response to pain or injury;212 and
 pain intensity and tolerance.
Other research demonstrates that established attitudes and beliefs about pain are important
predictors in identifying who is likely to develop long-term and disabling pain.213 For example,
some researchers note that Americans believe pain can be controlled, and thus they may have
lower pain tolerance and more permissive attitudes toward pain treatment and human intervention
in the treatment of pain, compared with some of their European counterparts.214
Further research highlights the way national laws and regulations may influence cultural beliefs
about pain and an individual’s expectations of pain management. For example, U.S. health care
providers can be held personal y liable for pain control; patients can sue a practitioner if they
perceive pain control to be inadequate.215 One study found that as medical care has increasingly
been viewed as a consumer good (including, in this case, advertisements that contain subjective
information about pain relief), more individuals believe there should be a quick solution to pain—
ideas that may have permeated American culture.216
Issues for Congress
Congress has demonstrated continued interest in addressing the opioid epidemic in the United
States. The 114th and 115th Congresses enacted several laws addressing opioid use, such as the
Comprehensive Addiction and Recovery Act of 2016 (CARA, P.L. 114-198), the 21st Century
Cures Act (P.L. 114-255), and the Substance Use-Disorder Prevention that Promotes Opioid
Recovery and Treatment for Patients and Communities Act (SUPPORT Act, P.L. 115-271). These
laws included provisions specifical y designed to address widespread overprescribing and abuse
of opioids in the United States.217 Future efforts by Congress could continue to address the United
States’ comparatively high use of prescription opioids through oversight, hearings, or legislation
on this topic. As described below, Congress could consider several options when addressing
opioid consumption in the United States.

Physical Therapy, vol. 22, no. 5 (Sept.-Oct. 2018).
211 Hauser et al., “T he Opioid Epidemic and Long-T erm Opioid T herapy,” 2016.
212 Ibid.
213 See, for example, Van Hecke, “Chronic Pain Epidemiology and Its Clinical Relevance,” 2013.
214 Ibid., and R. Zaslansky, W. Meissner, and C.R. Chapman, “Pain After Orthopaedic Surgery: Differences In Patient
Reported Outcomes In T he United States Versus Internationally,” British Journal of Anaesthesiology, vol. 120, no. 4
(February 2, 2018). Prodita Sabarini, “ How Different Cultures Experience and T alk About Pain,” The Conversation,
2015.
215 Van Amsterdam et al., “T he Misuse of Prescription Opioids,” 2015.
216 Ibid.
217 For more information on the SUPPORT Act, see CRS Report R45405, The SUPPORT for Patients and
Com m unities Act (P.L. 115-271): Food and Drug Adm inistration and Controlled Substance Provisions.
Congressional Research Service
32

Consumption of Prescription Opioids for Pain

Policy Options for Congress
Congress may have a number of options in seeking to reduce the overutilization of opioids for
pain. Although regulating the practice of medicine is mostly left up to the states, Congress has
several policy levers at its disposal to influence opioid-prescribing practices. The federal
government is involved in multiple aspects of regulating the use of scheduled drugs in medicine,
for example, such as establishing annual quotas for production,218 specifying storage and
dispensing rules,219 requiring certain training for health care providers,220 and regulating federal
health care programs such as Medicare and Medicaid. The federal government—often through the
annual appropriations process—provides substantial funding to states specifical y for opioid-
related activities. Congress has sometimes linked states’ receipt of discretionary funding with
their employment of certain policies or practices aimed at reducing prescription opioid use.
Congress could consider using mandatory or discretionary funding for innovative activities
designed to promote best clinical practices. For example, research has shown that default settings
in electronic medical record systems can influence lower opioid utilization for pain without
compromising the quality of pain care.221 Sometimes referred to as “nudges” in the scientific
literature, these default settings could promote alignment with clinical guidelines without any
additional burdens to health care providers or additional costs to the system.222
Reducing Opioid Consumption
Congress could also consider other policy or program strategies to reduce consumption of
opioids. For example, lawmakers in the United States could look to policies in peer countries for
possible approaches to curb excessive prescription opioid use. Congress could consider broadly
applying some strategies from the Veterans Health Administration’s Opioid Safety Initiative,223
which, according to the VA, reduced prescription opioid use in patients within the VA health care
system by 64%.224 Possible strategies for reducing prescription opioid use are discussed further
below.
Prescription Drug-Monitoring Programs and Electronic Medical Records
Congress funds state prescription drug-monitoring programs (PDMPs) through initiatives such as
the Harold Rogers grant program.225 Although the current authorizing statute outlines best
practices for PDMPs, states must meet few requirements—none of which mandate state PDMPs
to interact with other electronic medical record (EMR) systems. Congress could use the PDMP

218 21 U.S.C. §826.
219 21 U.S.C. §826 and 21 C.F.R. §1301.71 et seq.
220 See, for example, 21 U.S.C. §823.
221 Alexander Chiu, Raymond Jean, Jessica Hoag, et al., “Association of Lowering Default Pill Counts in Electronic
Medical Record Systems With Postoperative Opioid Prescribing,” JAMA Surgery, vol. 153, no. 11 (July 18, 2018).
222 Mitesh Patel, Kevin Volpp, David Asch, et al., “Nudge Units to Improve the Delivery of Health Care,” New
England Journal of Medicine, vol. 378, no. 3 (January 18, 2018).
223 U.S. Department of Veterans Affairs, VHA Pain Management/Opioid Safety Initiative (OSI), https://www.va.gov/
PAINMANAGEMENT /Opioid_Safety_Initiative_OSI.asp.
224 U.S. Department of Veterans Affairs, Office of Public and Intergovernmental Affairs, “VA Reduces Prescription
Opioid Use by 64% during the Past Eight Years,” press release, July 30, 2020, https://www.va.gov/opa/pressrel/
pressrelease.cfm?id=5492#:~.
225 42 U.S.C. 280g-3.
Congressional Research Service
33

Consumption of Prescription Opioids for Pain

grant program to encourage states to integrate their PDMPs with EMRs , for example. Congress
could also revise the grant stipulations for PDMPs to encourage, or require, use of PDMPs in
promoting best clinical practices, rather than primarily for diversion enforcement. In its toolkit
outlining state strategies to improve PDMPs, the National Governors Association recommended
integrating PDMPs with EMRs, using PDMPs to support clinical decision-making, and providing
PDMP data access to health care institution leadership to facilitate oversight and best practices.226
Integrating PDMPs with EMRs may be chal enging and burdensome. EMRs have substantial
financial costs and are often not interoperable across systems, among other possible drawbacks.227
Further federal regulation on EMRs could actual y restrict operability and curb innovation,
having a counterproductive effect on opioid-related clinical practices.
As mentioned above, opioid-prescribing rates are not equal y distributed across geographic areas
in the United States. A relatively smal percentage of health care providers are responsible for a
disproportionate amount of opioid prescriptions.228 Congress could encourage the use of PDMPs
to target regions or providers for education campaigns, training programs, or other PDMP-related
interventions shown to curb excessive opioid use.229
Setting Annual Quotas for Controlled Substances
The Controlled Substances Act (CSA) includes a production quota system that requires the DEA
to establish the total amount of each basic class of Schedule I and II controlled substances and
listed chemicals230 that may be manufactured in a given calendar year “to provide for the
estimated medical, scientific, research, and industrial needs of the United States for lawful export
requirements, and for the establishment and maintenance of reserve stocks.”231 Many prescription
opioids are Schedule II controlled substances under the CSA.232 The DEA establishes aggregate
production quotas (APQs) and then assigns individual production quotas to manufacturers that

226 National Governors Association, State Strategies to Improve the Use of Prescription Drug Monitoring Programs to
Address Opioid and other Substance Use Disorders, Washington, DC, July 2020, https://www.nga.org/wp-content/
uploads/2020/07/NGA_PDMP_T oolkit -July-2020.pdf.
227 For more detailed information on health information technology and EMRs, see, for example, Comm ittee on Patient
Safety and Health Information T echnology, Institute of Medicine, Health IT and Patient Safety: Building Safer System s
for Better Care, Washington, DC, November 10, 2011, https://www.ncbi.nlm.nih.gov/books/NBK189661/.
228 Guy et al., Vital Signs: Changes in Opioid Prescribing in the United States: 2006 -2015, 2017; and Zhu et al.,
“Initial Opioid Prescriptions among U.S. Commercially Insured Patients,” 2019.
229 Centers for Disease Control and Prevention, CDC/Opioid Information/State Information/State Successes, 2019,
https://www.cdc.gov/drugoverdose/policy/successes.html.
230 T hese listed chemicals are ephedrine, pseudoephedrine, and phenylprop anolamine, which are ingredients commonly
found in over-the-counter cold medicines that may be used in the production of methamphetamine and amphetamine.
See Drug Enforcement Administration, CMEA (Com bat Metham phetamine Epidemic Act) Questions & Answers,
https://www.deadiversion.usdoj.gov/meth/q_a_cmea.htm.
231 21 U.S.C. §826(a).
232 For more information on the CSA, see CRS Report R45948, The Controlled Substances Act (CSA): A Legal
Overview for the 117th Congress.
Congressional Research Service
34

Consumption of Prescription Opioids for Pain

prevent the APQ from being exceeded.233 Registrants234 may not manufacture a Schedule I or II
controlled substance that is (1) not expressly authorized by their registration and by the individual
quota assigned to them by the DEA, or (2) in excess of that quota.235
For any year in which the approved APQ for a covered controlled substance is higher than in the
previous year, the Attorney General, in consultation with the HHS Secretary, includes in the final
order an explanation of why the public health benefits of increasing the quota clearly outweigh
the consequences of having an increased volume of the covered controlled substance available for
sale, and potential diversion, in the United States.
In trying to control the opioid supply and reduce opioid abuse, Congress has imposed tighter
oversight of opioid production and distribution, including through oversight of annual APQs for
opioids quotas. For example, Section 3282 of the SUPPORT Act strengthened considerations for
DEA’s opioid quotas.236 Congress may consider further amending the quota process to control the
nation’s opioid supply. For instance, Congress could amend data considerations for the DEA in its
annual APQ determinations. In the annual APQ notices, the DEA has stated that it has difficulty
relying on overdose death data provided by CDC because the data do not distinguish between, for
instance, licit fentanyl and il icit fentanyl.237 Congress could diversify the quota process and
involve other federal agencies, such as the FDA, in the decisionmaking process. The DEA has
often stated that the quota decision is a careful balance between providing an adequate supply to
those who need such substances for medical care and limiting the supply to prevent diversion to
unlawful users.
Prescription Drug-Marketing Practices
Congress could look to peer countries for examples of national policies that appear to reduce
opioid prescribing. The United States, for example, is the only country in the world besides New
Zealand that al ows direct-to-consumer marketing for prescription drugs, including opioids.238

233 Statement for the record of Joseph T . Rannazzisi, Deputy Assistant Administrator, Office of Diversion Control,
Drug Enforcement Administration, before the U.S. Congress, United States Senate Caucus on International Narcotics
Control, Im proving Management of the Controlled Substances Quota Process, 114th Cong. 1st sess., May 5, 2015; and
21 U.S.C. §826(b). By regulation, the DEA Administrator must consider specific factors in making APQ
determinations. See 21 C.F.R. §§1303.11(b)(1)-(5). In establishing quotas for fentanyl, oxycodone, hydrocodone,
oxymorphone, or hydromorphone, the Attorney General estimates the amount of diversion that occurs in the United
States. In estimating such diversion, the Attorney General must consider, in consultation with the HHS Secretary,
information they determine to be reliable on rates of overdose deaths and abuse and overall public health impact related
to the substance, along with whatever other sources of information the Attorney General determines reliable. After
estimating the amount of diversion, the Attorney General makes appropriate reductions from the quota that would have
otherwise been established had such diversion not been considered.
234 Under the CSA, every person who manufactures, distributes, or dispenses any controlled substance, or who proposes
to engage in any of those activities, must register with DEA, unless an exemption applies. See 21 U.S.C. §822 and 21
C.F.R. Part 1301.
235 21 U.S.C. §§842(b). T he CSA allows registrants to apply for an increase in individual manufacturing quota if it is
necessary “to meet … estimated disposal, inventory, and other requirements during the remainder of that year.” See 21
U.S.C. §826(b) and (e).
236 21 U.S.C. §826.
237 See Drug Enforcement Administration, “Proposed Aggregate Production Quotas for Schedule I and II Controlled
Substances and Assessment of Annual Needs for the List I Chemicals Ephedrine, Pseudoephedrine, and
Phenylpropanolamine for 2021,” 85 Federal Register 54407-54414, September 1, 2020; and Drug Enforcement
Administration, “Proposed Aggregate Production Quotas for Schedule I and II Controlled Substances and Assessment
of Annual Needs for the List I Chemicals Ephedrine, Pseudoephedrin e, and Phenylpropanolamine for 2020,” 84
Federal Register 48170-48177, September 12, 2019.
238 For more information, see Lisa Schwartz and Steven Woloshin, “Medical Marketing in the United States, 1997 -
Congressional Research Service
35

Consumption of Prescription Opioids for Pain

The pharmaceutical industry in the United States spends over $20 bil ion annual y on marketing
to health care professionals.239 These expenditures are general y tax deductible as business
expenses.240 Many other countries either prohibit direct-to-provider marketing or place limitations
on such practices. As examples, Congress might consider
 imposing a moratorium on advertising of certain prescriptions drugs;
 expanding FDA’s authority to review advertisements for drugs with high risk of
abuse;
 eliminating tax deductions for the costs of advertising of certain prescription
drugs;241 or
 limiting certain types of marketing practices, such as gifts to providers.242
Reducing direct-to-provider marketing could have drawbacks, such as practitioners being less
informed about available medications or the proper use of certain formulations. In addition, a
complete ban on direct-to-consumer (or health care provider) advertising may raise First
Amendment issues.243
Clinical Best Practices
National-level policies do not need to be purely restrictive to effectively reduce unnecessary
opioid prescribing. Several other countries—such as Japan—operate national provider training
curriculums or stewardship programs designed to help practitioners learn and employ best clinical
practices. In the United States, such programs are primarily instituted by states, if at al . FDA’s
opioids REMS requires pharmaceutical companies that market opioids to make training available
to prescribers. Prescribers are encouraged to participate in training, but they are not required to do
so as a condition of prescribing.244 Congress could consider instituting national training programs
similar to those of other countries, or international training and mentorship exchange programs,
such as international twinning programs, where U.S. providers and public health professionals
shadow counterparts in other countries to learn certain best practices.245

2016,” JAMA, vol. 321, no. 1 (2019), pp. 80-96.
239 Lisa M. Schwartz and Steven Woloshin, “Medical Marketing in the United States, 1997 -2016,” JAMA, vol. 321, no.
1 (January 2019).
240 Richard Frank, Keith Humphreys, and Harold Pollack, “Policy Responses to the Addiction Crisis,” Journal of
Health Politics, Policy, and Law, vol. 8970796 (January 22, 2021). See §162 and Rev. Rul. 92 -80, 1992-2 C.B. 57,
September 11, 1992, and 26 U.S.C. §162.
241 For more information on this issue, see CRS Report R40590, Direct-to-Consumer Advertising of Prescription
Drugs.
242 Matthew D. Eisenberg, Elizabeth M. Stone, Harlan Pittell, et al., “The Impact of Academic Medical Center Policies
Restricting Direct -T o-Physican Marketing on Opioid Prescribing,” Health Affairs, vol. 39, no. 6 (June 2020).
243 CRS Report R40590, Direct-to-Consumer Advertising of Prescription Drugs.
244 For a list of FDA REMS opioid-related continuing education resources, see https://search.opioidanalgesicrems.com/
RPC-RMS-PROD/Guest/GuestPageExternal.aspx. For more information on REMS, see CRS Report R44810, FDA
Risk Evaluation and Mitigation Strategies (REMS): Description and Effect on Generic Drug Developm ent .
245 See, for example, European Commission, Twinning, European Neighbourhood Policy and Enlargement
Negotiations, August 10, 2020, https://ec.europa.eu/neighbourhood-enlargement/tenders/twinning_en; and Centers for
Disease Control and Prevention, Clinical Mentors Make a Real Difference in Training New Frontline Health Workers
in South Africa, Global Health Stories, February 16, 2017, https://www.cdc.gov/globalhealth/stories/clinical-mentors-
health-workers-in-south-africa.htm.
Congressional Research Service
36

Consumption of Prescription Opioids for Pain

National consumer education campaigns warning of the dangers of opioid use are another way to
reduce inappropriate demand for these drugs. The federal government could encourage providers
to discuss the risks of opioid use by reimbursing these conversations through Medicare—an
activity currently not reimbursed, nor required. Recently, Medicare began reimbursing providers
for similar nonclinical activities (such as conversations surrounding advanced care planning).246
In a recent survey of 1,000 Americans, most respondents were unable to correctly identify opioid
medications.247 Of respondents prescribed opioids, less than a quarter of them stored them in a
locked cabinet as recommended. Medicare rules—or other policies related to health insurance
coverage and payment—could promote strategies to reduce opioid use and promote best
practices, such as conversations about risks or alternative treatments for pain.
Prescribing Rules
Special prescription forms—required in some states domestical y—are common international y
and have been shown to reduce opioid prescribing.248 Other countries have instituted national-
level restrictions on the duration, number of pil s, or dose in a single prescription. This practice
has been adopted by about half of U.S. states to reduce excessive opioid pil s in circulation and to
align clinical best practices with law.249 Congress may consider federal-level legislation
restricting the duration, number of pil s, or dose in a single prescription. Considerable federal
requirements would deviate from convention; the practice of medicine is mostly regulated at the
state level. Additional regulations could add burdens to practitioners and affect pain care.
Congress could consider removing certain high-potency opioids from the market, though doing so
could have negative consequences for some pain patients.
Access to Other Pain Treatments
Reducing opioid use may involve a chal enging balance: providing pain relief while limiting
adverse consequences of excessive opioid use. Restricting access to opioids—or otherwise
reducing their use—could have consequences for pain patients. Without comparable and effective
pain treatments to replace opioids, some pain patients may experience increased pain if opioids
are restricted. Reducing opioid use does not necessarily translate to poor pain treatment, however.

246 U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services, “Medicare Program;
Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016; Proposed
Rule,” 80 Federal Register 41773, July 15, 2015; and Centers for Medicare & Medicaid Services , Advance Care
Planning, Medicare Learning Network (MLN) Fact Sheet, August 2019, pp. 1 -6, https://www.cms.gov/outreach-and-
education/medicare-learning-network-mln/mlnproducts/downloads/advancecareplanning.pdf.
247 DrFirst, DrFirst Survey: Americans Think They Know Whether or Not They Are Prescribed an Opioid, But They're
Wrong, Press Release, Rockville, MD, August 20, 2020, https://drfirst.com/press-releases/drfirst-survey-americans-
prescribed-opioids/.
248 See, for instance, Leonard Paulozzi and Daniel Stier, “Prescription Drug Laws, Drug Overdoses, and Drug Sales in
New York and Pennsylvania,” Journal of Public Health Policy, vol. 31 (2010), pp. 422-432; and Linda Wastila and
Christine Bishop, “T he Influence of Multiple Copy Prescription Programs on Analgesic Utilization,” Journal of
Pharm aceutical Care in Pain & Sym ptom , February 17, 2010, pp. 3-19.
249 Corey Davis, Amy Judd Lieberman, Hector Hernandez-Delgado, et al., “Laws Limiting the Prescribing or
Dispensing of Opioids for Acute Pain in the United States: A National Systematic Legal Review,” Drug and Alcohol
Dependence, vol. 194 (2018), pp. 166-172. States that have imposed restrictions on the duration, number of pills, or
dose in a single prescription include Alaska, Connecticut, Delaware, Hawaii, Illinois, Indiana, Kentucky, Louisiana,
Massachusetts, Maine, Minnesota, Missouri, North Carolina, New Hampshire, New Jersey, Nevada, New York, Ohio,
Pennsylvania, Rhode Island, South Carolina, T ennessee, Utah, Virginia, and Vermont. T he specific restrictions vary by
state.
Congressional Research Service
37

Consumption of Prescription Opioids for Pain

Although some patients may benefit from an opioid medication regimen for chronic noncancer
pain, many may not need to initiate opioids if they use other treatments first.
Congress may seek to ensure that as opioids are reduced, access to other treatments are increased,
so that nonopioid replacement therapies prevent a gap in pain treatment. For example, to facilitate
access to nonaddictive pain products, the SUPPORT Act directed FDA to hold at least one public
meeting with stakeholders and subsequently issue at least one guidance document addressing the
chal enges of developing nonaddictive medical products for the treatment of pain or addiction.250
In response to this directive, FDA convened both an advisory committee meeting and a public
meeting and issued draft guidance.251 Congress may consider creating new incentives aimed at
encouraging the development and use of new nonopioid or nonaddictive therapies.252 In addition,
Members of Congress could consider tasking the U.S. Preventive Services Task Force with
evaluating the efficacy of nonopioid pain treatments for potential reimbursement by the Centers
for Medicare & Medicaid Services, for example. Of note, comprehensive, multidisciplinary pain
management would likely result in increased financial costs for treatment.
Comorbid Opioid Use and Mental Health Issues
Congress could seek to address the apparent underlying factors related to high opioid use, such as
undertreated mental health disorders. Pain and subsequent opioid use are correlated with mental
health conditions such as depression and anxiety.253 Moreover, comorbid and untreated mental
health disorders are associated with substance use disorders, such as opioid use disorder.254 The
mental health treatment system in the United States is largely segregated from mainstream
medicine.255 Yet, many individuals presenting to medical providers may be experiencing
underlying mental health conditions causing or exacerbating their physical pain.256 Integrating
mental health care into mainstream medical care could be one approach to using multimodal
approaches to improving pain care and reducing opioid use. Screening for these mental health
issues, and subsequently treating them, could reduce the demand for opioids.257 Integrating

250 Section 3001 of P.L. 115-271.
251 FDA, “ Statement on agency’s first year accomplishments implementing SUPPORT Act authorities to address the
opioids crisis,” October 24, 2019, https://www.fda.gov/news-events/press-announcements/statement-agencys-first-
year-accomplishments-implementing-support-act-authorities-address-opioids.
252 T he National Institutes of Health (NIH) operates the Helping to End Addiction Long-term (HEAL) Initiative, which
includes supporting research on, among other things, the management and treatment of pain without the use of opioids.
For more information, see https://heal.nih.gov/.
253 See, for example, Anke Hinrichs-Rocker, Kerstin Schulz, Imke Jarvinen, et al., “Psychosocial Predictors and
Correlates for Chronic Post -Surgical Pain (CPSP)—A Systematic Review,” European Journal of Pain, vol. 13, no. 7
(August 2009), pp. 719-730; and Danielle Reddi and Natasha Curran, “ Chronic Pain After Surgery: Pathophysiology,
Risk Factors, and Prevention,” Postgraduate Medical Journal, vol. 90, no. 1062 (2014).
254 See, for example, Lynn Webster, “Risk Factors for Opioid-Use Disorder and Overdose,” Anesth Analg., vol. 125,
no. 5 (2017), pp. 1741-1748.
255 T homas W. Croghan and Jonathan D. Brown, Integrating Mental Health Treatment Into the Patient Centered
Medical Hom e, U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, AHRQ
Publication No. 10-0084-EF, Rockville, MD, June 2010, https://pcmh.ahrq.gov/page/integrating-mental-health-
treatment-patient-centered-medical-home.
256 Natalie Sachs-Ericsson, Kiara Cromer, Annya Hernandez, et al., “A Review of Childhood Abuse, Health, and Pain -
Related Problems: T he Role of Psychiatric Disorders and Current Life Stress,” Journal of Trauma & Dissociation, vol.
10, no. 2 (2009).
257 Few prospective longitudinal studies examining the relationship between mental health interventions and subsequent
opioid use exist; however, some studies suggest adequate mental health treatment could potentially reduce future opioid
use. See, for example, Mark Sullivan, Mark Edlund, Lily Zhang, et al., “ Association Between Mental Health Disorders,
Congressional Research Service
38

Consumption of Prescription Opioids for Pain

mental health care would likely involve initial financial costs, and the effectiveness of integrated
care for chronic pain awaits further research. Congress may consider funding research examining
comorbid pain and mental health conditions that might provide insights into effective approaches
to care.

Problem Drug Use, and Regular Prescription Opioid Use,” Arch Internal Medicine, vol. 166, no. 19 (2006), pp. 2087-
2093.
Congressional Research Service
39

link to page 46 link to page 46 link to page 46 link to page 46 link to page 46 link to page 46 link to page 46 link to page 46 link to page 46 link to page 46 link to page 46 link to page 46 link to page 46 link to page 46 Consumption of Prescription Opioids for Pain

Appendix A. International
Opioid-Prescribing Regulations
Table A-1. Common National Regulatory Systems for Medical Opioid Use in
OECD Countries
Regulation
Description
National clinical practice guidelines
Recommendations for the appropriate use of prescription opioids in the treatment
of pain. Guidelines may be issued by governmental bodies, professional
organizations, or other stakeholders. For example, most guidelines agree on several
opioid risk-mitigation strategies, including upper dosing thresholds, cautions with
certain medications, attention to drug-drug and drug-disease interactions, use of
risk assessment tools, treatment agreements, and urine drug testing.a
National provider training and
Didactic programs that include specific evidence-based guidelines combined with
stewardship programs
educational initiatives and direct training curriculums and activities for prescribing
health care professionals. Outreach campaigns promote judicious use of opioids and
access to trainings and resources.b
Special permit/license required for
National laws limit the competence to prescribe control ed medicines to certain
prescribing
specified medical specialists; designated institutions and/or providers are al owed to
prescribe control ed medicines if a special permit or license is obtained.c
Special prescription forms
Special forms or multiple copies are required and/or other administrative
required/prescribing in multiple
requirements for health care professionals prescribing opioids.d
copies required
Limited prescription validity
Prescriptions for some control ed medicines expires within a certain time after
issuance.d
Amount of control ed medicine to be Restrictions on the duration, number of pil s, or total MMEs in a single
prescribed is limited
prescription.d
Daily dosage is limited
Limits on the maximum daily dosage for an opioid prescription.d
National prescription drug
National electronic databases that track prescriptions for control ed medicines,
monitoring program
such as opioids.a
National prescription drug adverse-
National electronic databases that track adverse events for medical products and
events tracking system
control ed medicines, such as opioids.b
Disciplinary action for
Deliberate or unintended violation of administrative requirements and regulations
overprescribers
may result in sanctions for health care providers.e
Marketing restrictions
Limits on al owable marketing practices for the pharmaceutical industry, including
constraints or prohibitions on direct-to-consumer or direct-to-provider activities.f
Consumer warning systems
Labels on medications contain warnings regarding possible adverse outcomes
associated with use.g
Consumer education campaigns
Messaging campaigns that seek to inform the public about the possible dangers
associated with opioid use and misuse.h
Postdispensing control mechanisms
Widespread and systematic mechanisms to safely col ect or dispose of excess
medications.i
Source: CRS analysis. See table notes below for selected citations.
Notes: Table format and information based on those provided in Marjolein Vranken, John Lisman, and Aukje
Mantel-Teeuwisse, “Barriers to Access to Opioid Medicines: Results of a Review of National Legislation and
Regulations of 11 Central and Eastern European Countries,” The Lancet Oncology, vol. 17, no. 1 (2016), pp. e13-
e22, and OECD, Addressing Problematic Opioid Use in OECD Countries, OECD Health Policy Studies, Paris, France,
Congressional Research Service
40

Consumption of Prescription Opioids for Pain

June 11, 2019, at https://www.oecd.org/health/addressing-problematic-opioid-use-in-oecd-countries-a18286f0-
en.htm.
a. 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-use-in-oecd-countries-a18286f0-
en.htm.
b. See, for instance, 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. Bul ., vol. 42, no. 5 (2019), pp. 801-809.
c. See, for instance, Bastian Rosner, Jessica Neicun, Justin Yang, et al., “Opioid Prescription Patterns in
Germany and the Global Opioid Epidemic: Systematic Review of Available Evidence,” Plos One, August 28,
2019.
d. For examples, see Marjolein Vranken, John Lisman, and Aukje Mantel-Teeuwisse, “Barriers to Access to
Opioid Medicines: Results of a Review of National Legislation and Regulations of 11 Central and Eastern
European Countries,” The Lancet Oncology, vol. 17, no. 1 (2016), pp. e13-e22.
e. For examples, see Winfried Hauser, Stephan Schug, and Andrea Furlan, “The Opioid Epidemic and National
Guidelines for Opioid Therapy for Chronic Noncancer Pain: A Perspective from Different Continents,” Pain
Around the World, vol. 2, no. e599 (2017).
f.
European Medicines Agency, The European Regulatory System for Medicines: A Consistent Approach to Medicine
Regulations across the European Union, EMA/71625/2016, 2016; Gerard Arnoldus Kalkman, Cornelis Kramers,
Robert von Dongen, et al., “Trends in the Use and Misuse of Opioids in the Netherlands: A Retrospective,
Multi-source Database Study,” Lancet Public Health, vol. 4 (2019), pp. e498-505; and Health Canada,
“Minister of Health Ginette Petitpas Taylor Announces Intent to Severely Restrict Marketing of Opioids,”
press release, June 19, 2018, at https://www.canada.ca/en/health-canada/news/2018/06/minister-of-health-
ginette-petitpas-taylor-announces-intent-to-severely-restrict-marketing-of-opioids.html.
g. See, for instance, Health Canada, New Regulations to Provide Better Information for Patients on the Safe Use of
Opioid Medications, May 2, 2018, at https://www.canada.ca/en/health-canada/news/2018/05/new-regulations-
to-provide-better-information-for-patients-on-the-safe-use-of-opioid-medications.html.
h. See, for instance, The Royal Col ege of Anaesthetists, “Opioids Aware, A Resources for Patients and
Healthcare Professionals to Support Prescribing of Opioid Medicines for Pain,” London, England, 2018, at
https://fpm.ac.uk/opioids-aware.
i.
For more information, and examples, see National Academies of Sciences, Engineering, and Medicine, Pain
Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid
Use, Washington, DC, 2018.

Congressional Research Service
41

Consumption of Prescription Opioids for Pain

Appendix B. Methodology and Search Strategy
To gather relevant articles and information for this report, CRS research librarians conducted
literature searches in February 2020. One search was for literature on pain management practices
in the United States and comparisons with other countries within PubMed, the National Library
of Medicine’s online database of biomedical literature. The other search was for global and
international (non-U.S.) comparisons of pain management practices within The Lancet Global
Health, a peer-reviewed medical journal focusing on global health issues. Terms used in both
searches included geographic terms (i.e., United States, America, Europe, international, global,
country names) in combination with the following clinical words and their variants, listed
alphabetical y:
 Chronic pain
 Complementary
 Integrative
 Nonaddictive
 Noncancer pain
 Noninvasive
 Nonnarcotic
 Nonpharmacologic
 Opioid/Nonopioid
 Pain
 Pain Management
 Pal iative
 Prescribe
 Prescription
 Surgical/nonsurgical
 Treatment/intervention/therapy
This search initial y identified 108 scientific articles and government reports. CRS reviewed this
literature to identify information that offered insight into differences in opioid consumption
global y. References, additional citations, and primary sources from the initial articles were
reviewed when appropriate—including several published throughout 2020. In total, over 200
journal articles, white papers, and government, agency, or scientific reports were reviewed. The
information collected from these sources was then organized into themes surrounding possible
explanations for international differences.258 CRS identified 10 themes based on analysis of the
literature. Each theme represents a possible reason the United States consumes more opioids than
other countries.

258 Identification and classification of themes followed principles of content analysis; however, no formal coding
occurred. For more on content analysis, see Robert Philip Weber, Basic Content Analysis (Newbury Park, CA: Sage
Publications, 1990).
Congressional Research Service
42

Consumption of Prescription Opioids for Pain

Author Information

Johnathan H. Duff, Coordinator
Ada S. Cornell
Analyst in Health Policy
Senior Research Librarian

Sara M. Tharakan
Paul D. Romero
Analyst in Global Health and International
Research Assistant
Development

Carla Y. Davis-Castro

Research Librarian

Acknowledgments
Lisa Sacco, CRS Analyst in Illicit Drugs and Crime Policy, contributed to this report.

Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan
shared staff to congressional committees and Members of Congress. It operates solely at the behest of and
under the direction of Congress. Information in a CRS Report should n ot be relied upon for purposes other
than public understanding of information that has been provided by CRS to Members of Congress in
connection with CRS’s institutional role. CRS Reports, as a work of the United States Government, are not
subject to copyright protection in the United States. Any CRS Report may be reproduced and distributed in
its entirety without permission from CRS. However, as a CRS Report may include copyrighted images or
material from a third party, you may need to obtain the permission of the copyright holder if you wish to
copy or otherwise use copyrighted material.

Congressional Research Service
R46805 · VERSION 1 · NEW
43