By Randy Scott
As in several other Latin American countries, you can buy opioids over the counter in drug stores in Cuenca. A 20-count box of two brands of synthetic opioids costs between $5 and $10, depending on the pharmacy where it’s purchased.
The pattern of opioids use varies widely around the world. In the United States, one daily dose of opioids was prescribed for one of every 18 people in 2019. In similarly wealthy Japan, one daily dose was prescribed for every 850 people over the same period. In Ecuador, the few opioids that require a physician’s prescription — such as oxycodone and vicodin — were ordered for only one in 1,000 patients.
As part of international drug-control conventions, countries report the use of narcotics — like opioids, cocaine, and cannabis — for legal medicinal and scientific use to the United Nations each year. Opioids include such drugs as morphine, oxycodone, tramadol and fentanyl. (Heroin is also an opioid, but is not reported on because it is not used legally.)
The UN’s 2019 report on narcotic use reveal that the U.S., currently facing a crisis of opioid overuse, is an extreme outlier. U.S. opioid use is the highest of any country in the world, and more than 50% higher than Germany, the second-ranked country of the twenty most populous countries.
Legal opioid use per capita in the U.S. is more than 2,000 times higher than in India.
In the U.S., far too many people are becoming addicted to drugs who would be better treated with other medicines or therapy. Jay Joshi, the former chairman of the National Pain Foundation, wrote in Quartz that ignorance among physicians and aggressive marketing by opioid manufacturers are the main reasons for overprescribing.
Yet in India and other poor countries, many people are not being prescribed opioids when strong pain relief is necessary, such the late stages of cancer. In many of these countries, there is still an unfortunate taboo around the use of these drugs.
Dig a little deeper into the data, and you find large variations in the types of opioids that are used in different countries. For example, of the five countries with the highest prescription rates, Germans are almost twice as likely to use fentanyl as the others, while hydrocodone is widely used in the U.S. but barely prescribed elsewhere.
This mostly comes down to regulations and cost. Due to its high addictiveness, hydrocodone is not available for medical use in most of the world (Vicodin is the drug’s most popular branded version). Hydrocodone was once a schedule III drug in the U.S., rather than the more restrictive schedule II, and people could get the a prescription refilled at the pharmacy without seeing a doctor, leading to it becoming highly popular. Fentanyl’s popularity in Germany is likely because it is cheap and can be easily administered via a patch.
Cuenca pharmacist Jorge Iglesias says the drug scheduling system, developed by the U.S. Drug Enforcement Administration, is often arbitrary. “As it applies to opioids, it has gone through many changes over the years and does not really protect the public,” he says. “Some types of opioids that are scheduled as safer can be just as dangerous as those on schedule II, depending on the situation and the dosage.”
He adds: “Today, the scheduling system is mostly an attempt to deal with the addiction epidemic in the U.S.”
Should the over-the-counter opioids available in Ecuador be sold only with a doctor’s prescription? No, says Iglesias, who went to pharmacy school at Florida A&M University in Tallahassee and worked in the U.S. for 15 years. “We don’t have the addiction problem here and have had very few confirmed cases of addiction or overdoses,” he says. “If used prudently, these drugs can have great short-term benefits and to put restrictions on their sale drives up the price and makes them less accessible for poorer patients. This is also the position of the United Nations World Health Organization.”
Iglesias says that Ecuador, Colombia and Peru — countries that allow over-the-counter sale of some opioids — are pressured by the U.S. government to make drugs like tramadol prescription only. “They’re afraid that these opioids could enter the U.S. on the black market but there is no indication that this is happening on a large scale. So far governments have resisted these efforts since there is no addicition problem down here and the drugs do, in fact, provide a medical benefit.”
Why is the addiction problem so much greater in the U.S. than in Ecuador and other countries? “That’s the big mystery,” says Iglesias. “The standard explanation — although you don’t hear it much in the U.S. — is that the emphasis on consumerism in the U.S. creates a culture of addiction. You add that to the fact that the middle class there is shrinking and that good jobs are disappearing and you have the recipe for addiction.”
Randy Scott is a retired pharmacist who moved to Cuenca in 2016.