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Americans and Canadians are about seven times more likely than Swedes to prescribe opioid pain pills in the week following the operation, according to a new study among the first to quantify international differences.
More than 75% of patients in the United States and Canada have prescribed opioids following one of four common surgeries, compared to 11% of Swedes, researchers said Wednesday at the JAMA Network Open. Americans also received the highest doses of opioids.
Does this mean that Americans and Canadians have less tolerance for pain or is something else going on?
"There are a lot of difficult people in many places," said Dr. Mark Neuman, an anesthetist in medicine at the Perelman School of Medicine at the University of Pennsylvania and co-author of the study.
He drew attention to a host of other potential factors, ranging from cultural differences to variations in marketing, regulatory and prescribing practices.
"It's possible that Americans perceive opioids as a relief from pain in a radically different way than other places," he said.
The study involved approximately 129,000 US patients with employment-based insurance, 84,600 in the province of Ontario, and 9,800 in Sweden. The United States and Canada were chosen because they have the highest per capita opioid consumption in the world. Sweden was chosen as a European counterpoint because researchers could obtain detailed information on prescriptions in databases.
The authors examined four types of surgeries: minimally invasive procedures to remove the gallbladder or appendix, and arthroscopic surgery to repair a knee meniscus tear and breast tumor. The 223,834 surgeries took place between January 2013 and March 2016, a period of growing concern about opioid dependence in the United States, but before more recent guidelines suggest that it be necessary to reduce the number of pills as a result of many common surgical procedures.
"For the same surgery, the same tissue trauma, we have seven times more people in the US who are opioid," Neuman said.
On average, US patients have prescribed about 33 tablets, each equivalent to 5 milligrams of oxycodone, he said, although the type of medication varies. Swedes who completed their prescriptions received an average of 26 tablets, compared to 22 for Canadians.
Canadians and Swedes were also significantly more likely to take codeine or tramadol, pain relievers that work differently in the body and are considered lower opioid types. Americans were much more likely to receive hydrocodone or oxycodone, some of which were heavily marketed to doctors. (States and cities are currently suing the manufacturers, claiming that they misstated the drug risks and did not properly monitor suspicious sales, contributing to the opioid crisis.)
The study authors noted that during the research period, low-dose codeine was available over-the-counter in Canada. Tramadol is still not classified as a controlled substance in this country, although it has been a controlled substance in Sweden since 2007 and in the United States since 2014.
"Although prescribers may consider these so-called weak opioids as safer alternatives, the data suggests that both codeine and tramadol have the potential for both life-threatening abuse and adverse effects." ", says the study.
The researchers noted some limitations of their report. On the one hand, they could not know how many prescribed pills had been taken by the patients. Nor could they tell how many patients had not performed the prescriptions they had been given. They also lacked data on how patients felt their pain was controlled after their surgeries.
"It is possible that in Sweden, the pain treatment of all patients is lower than that of the United States, although this is unlikely," said Neuman. He added that other studies have shown that patients who are operated on in the United States often do not take all the medications they have been prescribed.
In some cases, patients who are prescribed fewer pills after surgery do not report greater dissatisfaction. Researchers in Michigan, for example, recently reported that after dozens of hospitals had adopted new prescribing guidelines recommending fewer pills, patients were not reporting increased pain.
University medical centers and experts have recently published guidelines calling for fewer pills after many procedures. They began to worry that patients with acute pain – the type who follows surgical procedures, for example – receive far too many pills.
Studies have shown that the use of opioids after surgery may result in long-term dependence in a limited but significant number of patients, but that unused pills may also pose a hazard. These tablets can end up in the street or fall into the hands of family members.
Dr. Chad Brummett, a pain researcher working on the Michigan guidelines, said he believed that the prescribing of quantities in the United States and Canada had probably declined in recent years, as because of increased attention to the risk of addiction.
He warned, however, that the amounts were probably too high in both countries and that the new study illustrated the great disparity between North America and at least one European country.
"We know that marketing in the United States has affected the prescription in all areas, including surgery," Brummett said. "This study and others show that [surgeons] in the United States and Canada can significantly reduce prescribing standards without harming patient care. "
Appleby writes for Kaiser Health News, a non-profit news service covering health issues. It is an independent editorial program of the Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
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