Joseph Tu, MD, Medical Director, Cedars-Sinai Medical Group Pain Management, Beverly Hills California
The opioid epidemic has recently gained the spotlight in the realm of political and healthcare policies. Its infamy lies in the fact this epidemic is costing the United States, as a nation both economically and in lives lost. The societal and economic burden of chronic pain has been well documented, affecting more than 100 million Americans and with total direct and indirect costs ranging from $560 billion up to $635 billion per year.1 To put this into perspective in terms of the landscape of chronic conditions, chronic pain affects more Americans than diabetes (29 million), coronary heart disease, including strokes (18.7 million), and cancer (14.5 million) combined.2,3,4 In addition to economic costs, opioids are the most common prescription drug implicated in overdose deaths, involved in up to 75 percent of overdoses, and estimated to be responsible for at least 17,000 deaths annually.5 What is astounding is that, in 2014, more than 240 million prescriptions were written for prescription opioids, which is more than enough to give every American adult their own bottle of pills.6 An estimated 1 out of 5 patients with non-cancer pain or pain-related diagnoses are prescribed opioids in office-based settings.7 From 2007 – 2012, the rate of opioid prescribing has steadily increased among specialists more likely to manage acute and chronic pain. Prescribing rates are highest among pain medicine (49%), surgery (37%), and physical medicine/rehabilitation (36%). However, primary care providers account for about half of opioid pain relievers dispensed.7 The statistics could go on for paragraphs; however, the purpose of this paper is not to reiterate what has been well documented and well recognized as an epidemic in the U.S. but to compare our opioid situation with other countries, in particular Taiwan, where I was born and where some of my family and friends still reside and see if there are any differences.
I had the fortunate opportunity to participate in an exchange program with the Division of Pain Medicine, a part of the Department of Anesthesia at the National Taiwan University Medical Center (NTUMC) in Taipei, Taiwan. National Taiwan University is one of the most prestigious universities in Taiwan, and their Medical Center is the most well respected and serves as the leader and the standard of medical care in the country. Part of my exchange experience is to rotate through various clinics, and I was introduced to Dr. Chih-Peng Lin, the Division Chief of Pain Medicine at NTUMC. Dr. Lin manages patients with cancer and/or non-cancer pain with both interventional techniques and medications. I began to notice a major difference in how his patients were being managed compared to pain practices in the United States, particularly in the realm of opioids. It is astounding how small the proportion of his patients are on opioid medications, and when they are, the doses were much lower than what we typically see in the United States. Dr. Lin was kind enough to answer some questions on the topic of opioid prescribing in Taiwan during my time at NTUMC.
"We have seen an increased number of patients visiting emergency rooms and urgent cares seeking pain control or, worse yet, going to ‘alternative sources’ to obtain their opioids"
Taiwan has a nationalized healthcare system; hence they can monitor all prescriptions, including opioids. In Taiwan, like the U.S., opioids are categorized as controlled substances with similar regulations and restrictions, with some minor differences in the categorization. For example, morphine is listed as a Schedule I controlled substance along with heroin and opium in Taiwan.8 Medications like methadone, oxycodone, amphetamines are schedule II.8In the U.S., morphine is a schedule II medication along with their opioid medications. These medicines are highly regulated in Taiwan, and prescribers of scheduled medications will need to go through arduous registration and certification processes, and their prescribing habits are closely monitored through a national database. In addition to the government, these medicines are also monitored by drug manufacturers, and importation and distribution of these medications are reported to governing agencies. Under these nationally mandated statutes, Taiwan keeps an accurate account of the number of patients who were prescribed and dispensed of these opioids and what their diagnoses were.
Taiwan’s population is around 23,160,000 (according to the 2011-2012 census), and around 500,000 patients have a diagnosis of cancer. Around 25percent or 125,000 patients were prescribed opioid medication9. In contrast, for patients with a chronic pain diagnosis but without a cancer diagnosis, only 644 people are on Schedule I or II medications9. The difference in the ratio of cancer vs non-cancer patients who were prescribed opioids between Taiwan and the United States is staggering. Consider there are over 100 million Americans with chronic pain diagnosis and only 14.5 million with a cancer diagnosis, however, there were over 240 million opioid prescriptions prescribed, as noted previously. The great majority of opioids are prescribed to patients without a current active cancer diagnosis. The astonishing difference in opioid prescribing patterns between the U.S. and Taiwan ‘may be’ a major reason why the opioid epidemic is an isolated United States problem, not seen in Asian or European countries as this discrepancy is not only observed when compared to Taiwan but also when looking at opioid prescription data amongst other countries in Asia and Europe.
There are numerous theories why the discrepancy is observed in the U.S., ranging from social, political, to economical reasons to a combination of all three. Recently, the media has publicized the role of pharmaceutical companies on the epidemic, and it has given the public a common enemy to blame… Regardless, this resulted in numerous governmental changes that affect millions of patients that are on chronic opioid medication to manage their chronic pain. Furthermore, these new regulations on the manufacturers, distributors, and prescribers of opioid medications often leave these patients unable to get their chronic opioid medications that they have been using for years to manage their pain and maintain their function. Frequently, patients will experience either abrupt discontinuation or a sudden drastic decrease of their opioids due to the lack of practitioners’ willingness to continue to manage these medications, due to the increased regulations and borderline harassment for prescribing opioids from insurance companies and pharmacies that are incentivized by the governing bodies. Concomitantly, manufacturers and pharmacies are unable to dispense these medications due to heavy regulations resulting in a limited supply of these medications. We have seen an increased number of patients visiting emergency rooms and urgent cares seeking pain control or, worse yet, going to ‘alternative sources’ to obtain their opioids. This puts them at increased risk for adverse events or even death as patients obtain opioid medications from various sources just to maintain their function.
It is important to have regulations on opioids to prevent further propagation of our epidemic, however, there must also be more incentives from regulatory agencies and insurance companies for programs and prescribers to not just discontinue these medications, but to help find alternatives or wean down these medications for their patients. For instance, if a pain management provider or program can register to be an opioid weaning or risk reduction program, they may bypass the labor-intensive process and financially penalizing regulations of dealing with multiple government agencies, insurance companies, and dispensing pharmacies to manage these patients and help decrease their opioid dependency and lower their risks. This would motivate prescribers of chronic opioids to ‘help’ their patients to wean down or get off opioids instead of abandoning their patients…
Things are often easier said than done, however, if we truly would want a population less dependent on opioids and try to find a true solution out of the opioid epidemic in this country, stricter regulation on the prescribing and dispensing of these medications are only part of the solution. It is important that governing agencies, insurance companies, manufacturers, and dispensing pharmacies all make an attempt to work with the prescribers and, more importantly, the patients to ensure that we change the trajectory of this country’s overprescribing of opioids without sacrificing the patient’s function and inadvertently elevate their risk of adverse events and death due to the stringent regulations. Sobriety often takes a community; going forward, I hope for a less adversarial relationship and more of a united effort to help this patient population through this epidemic.