In the USA, pain is managed with pain relievers that include opioid analgesic drugs such as oxycodone, methadone, hydrocodone, and oxymorphone. With different types of opioid drugs available and frequently prescribed, these drugs have become increasingly prone to non-medical use. It is estimated that non-medical use of opioid drugs in the USA costs the health-care system US$72·5 billion each year. And in 2009, 500 000 emergency department visits in the USA were due to poisoning caused by painkillers.

A report released on Nov 1 by the US Centers for Disease Control and Prevention entitled Vital Signs: Overdoses of Prescription Opioid Pain Relievers - United - States, 1999 - 2008, provides comprehensive nationwide estimates for opioid drug sales, non-medical use of opioid pain relievers, and opioid drug death rates - all of which have increased substantially during the past decade. This picture suggests an epidemic of painkiller use in the USA. The number of deaths owing to painkiller overdose in the USA has quadrupled in the past decade (to 14 800 each year, or 40 daily), and is currently higher than the number of fatalities from illegal drugs such as cocaine and heroin combined, and in some states surpasses road accident fatalities. Likewise, the availability of opioid drugs in US pharmacies, hospitals, and doctors’ offices has quadrupled from 1999 to 2010 - an amount that is sufficient to medicate every American adult every 4 hours for a month. The report also mentions that 12 million Americans (one in 20) reported using opioid drugs for a non-medical purposes, mainly recreational, in the past year.

Although the report probably underestimates the true magnitude of painkiller misuse in the USA (stratification by intention of opioid use was not possible, death records often lack information about the type of drug used, and responders tend to under-report non-medical use of opioid drugs in surveys), it confirms risk groups for whom interventions should be tailored. Men, individuals aged 35 - 45 years, non-Hispanic whites and American Indians, and rural dwellers are more likely to die from a painkiller overdose. Poverty and unemployment have also now been linked to use of non-medical opioid drugs since US states with the largest poverty rates, and a high number of Medicaid users, were also those with the highest mortality rates from opioid drug overdose.

Although the problem of painkiller misuse and overdosing is preventable, its origin is complex. Painkillers are easily obtained in the USA from so-called pill mills - illegitimate pain clinics that provide opioid drugs without adequate evaluation or follow-up. Doctor shopping is another common practice by which opioid drug prescriptions are obtained by an individual from several different physicians. Chronic mild pain, such as back pain, headache, and arthritis, are most likely to be unnecessarily treated with opioid drugs by primary and family-care physicians, who also tend to overprescribe sedatives and muscle relaxants that have an additive effect with painkillers. Family medical cabinets provide easy access to opioid drugs - not only do 40% of drugs prescribed in the USA go unused, but seven out of ten medication misusers get their drugs from family or friends.

What are possible solutions to balance legitimate access to pain treatment with reduction of misuse of painkillers? There should be increased recognition that non-medical use of opioid drugs is frequently observed in illicit drug users, and that addiction is a multifaceted problem that is much more complex than easy access to a drug. Physicians must take responsibility to: first, screen patients, scrutinising medical and family history to look for past substance misuse problems; second, be properly trained in pain management, opioid pharmacology, and principles of misuse and addiction; and third, only prescribe painkillers as a last resort for management of chronic pain, and give shorter supplies for acute pain.

Patients must be educated in safe use, storage, and disposal of painkillers. Finally, local and federal government must take a lead with legislative measures that monitor prescription practices and prevent misuse and diversion of prescription of opioid drugs. 48 US states have already approved the prescription drug management programme which uses electronic databases to track all painkiller prescriptions within a state.

It is a paradox that opioid drugs are creating opposite public health problems in developed and developing countries - one caused by abundance and excess, and the other from lack of access for pain relief, which is a violation of a basic human right. This profound discrepancy must become a priority for policy makers and prescribers to properly balance opioid availability and misuse, and focus efforts on control of opioid demand rather than supply.

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The Lancet, Volume 378, Issue 9804, Page 1677, 12 November 2011
doi:10.1016/S0140-6736(11)61723-6