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.
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