Why opioids are such an American problem

When it comes to taking opioids, the United States has the dubious honour of leading the world.

For every one million Americans, almost 50,000 doses of opioids are taken every day. That's four times the rate in the UK.

There are often good reasons for taking opioids. Cancer patients use them for pain relief, as do patients recovering from surgery (codeine and morphine are opioids, for example).

But take too many and you have a problem. And America certainly has a problem.
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In two years, the town of Kermit in West Virginia received almost nine million opioid pills, according to a congressional committee.

Just 400 people live in Kermit.

Nationally, opioids killed more than 33,000 people in 2015, according to the Centers for Disease Control and Prevention.

That figure includes deaths from heroin, an illegal opioid. But almost half involved a prescription opioid - that is, a painkiller available from a pharmacy with a note from a doctor.

So why does America - more than any country in the world - have an opioid problem?

There is more than one cause. But these are some of the most important.
American doctors prescribe - a lot

Unlike most European countries, the US does not have universal healthcare paid for by taxes.

Instead, Americans must get their own insurance - usually via an employer or the government.

"Most insurance, especially for poor people, won't pay for anything but a pill," says Professor Judith Feinberg from the West Virginia University School of Medicine.

"Say you have a patient that's 45 years old. They have lower back pain, you examine them, they have a muscle spasm.

"Really the best thing is physical therapy, but no one will pay for that. So doctors get very ready to pull out the prescription pad.

"Even if the insurance covers physical therapy, you probably need prior authorisation (from the insurer) - which is a lot of time and paperwork."

The CDC says opioid prescriptions have fallen by 18% from their peak in 2010. But the total is still three times higher than in 1999.
'I saw this drug on TV'

The US and New Zealand are the only countries that allow prescription drugs to be advertised on television.

According to the research firm Kantar, spending on advertising by pharmaceutical companies in the US reached $6.4 billion in 2016 - a rise of 64% since 2012.

None of the 10 most-advertised brands in 2016 was an opioid. But mass-marketing of drugs has an effect, says Professor Feinberg.

"As a clinician, people will come and say 'I saw this on TV - can you give me this drug'.

"Sometimes they were so confused, they were already on the drug - they were using the brand name, where I used the generic name."

In 2015, the American Medical Association called for a ban on adverts for prescription drugs. It didn't happen.

Three months later, the extent of America's opioid culture was seen at half-time of the Superbowl - the country's most expensive advertising slot.

A 60-second ad was devoted to opioid-induced constipation. The advert - paid for by AstraZeneca - advised sufferers to visit their doctor and "ask about prescription treatment options".

President Obama's chief of staff was not impressed.