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The U.S. opioid crisis is currently the subject of two competing narratives. One holds that the nation is awash in opioids, causing epidemic levels of addiction and overdose. The other maintains that the pendulum has swung in the other direction to the point that patients in need are being denied pain relief en masse. But the latest opioid consumption data from the United Nations International Narcotics Control Board don’t line up perfectly with either claim.

Because prescription opioids are governed by international treaties, the United Nations has comprehensive data on how many “standard daily doses” each nation consumes. Unlike simple counts of opioid prescriptions, standard daily dose data takes account of the fact that prescriptions vary in the potency, amount, and dosage of opioids they contain. From 2015 to 2017, the UN calculated that the annual standard daily doses of prescription opioids was 40,240 per million Americans. This reflects a 20 percent drop from the 50,142 standard daily doses per million Americans during the 2012-2014 period.

Nevertheless, the U.S. still leads the world in per capita opioid prescriptions by a wide margin. For example, the U.S. consumes more than six times as many opioids per capita as France and Italy, despite all three nations having comparable levels of population pain.

The recent relative drop in U.S. opioid prescribing co-exists with a world-leading absolute rate because the prior run-up in prescribing was unprecedented in scope. Opioid prescribing almost quadrupled beginning in the 1990s, meaning it would take a 75 percent reduction to return to the U.S.’s original rate, which was similar to the average of other developed countries. In that sense, U.S. opioid prescribing is analogous to U.S. mass incarceration: It’s going down, but from a point so high that it’s absolute level still exceeds that of every other country.

Could the U.S. ever return to its prior, more careful, opioid prescribing rate? It’s unlikely, because once a patient is on a high dose of opioids—as millions of Americans now are—taking them off can harm them whether their initial prescription was warranted or not. Because some bells can’t be unrung, the safest place to reduce U.S. prescription opioid consumption is through curtailing the number of new opioid patients who do not really need opioids. U.S. dentists, for example, do not need to continue initiating prescribed opioids after dental procedures at 70 times the rate of English dentists. Nor should one in eight Americans seeking treatment for a sprained ankle continue being started on opioids. Epidemic modelling research suggests that a return to careful prescribing in such situations today will translate into reduced addiction, overdose, and deaths in the years to come.

Keith Humphreys

Keith Humphreys is the Esther Ting Memorial Professor at Stanford University. @KeithNHumphreys