On average, clinicians in the United States prescribed higher doses of opioids than did doctors in Canada or Sweden.Credit: AP/Shutterstock

People who have low-risk surgery in Canada and the United States fill prescriptions for opioid painkillers at nearly seven times the rate seen in Sweden, according to recent research1. Studying these differences could help nations such as the United States to develop prescribing guidelines to counteract the surge in opioid use that is devastating some communities, say the study authors.

The findings, which are published on 4 September in JAMA Network Open, are the first to quantify the differences in opioid use for people who had similar types of surgery across countries.

There’s anecdotal evidence that clinicians tend to prescribe more opioids after surgery in some countries than in others, says Mark Neuman, an anaesthesiologist at the University of Pennsylvania in Philadelphia, who led the study. And over-prescription of opioids is associated with an increased risk of developing long-term dependence and addiction, he says.

To investigate further, Neuman and his team gathered prescription data from between 2013 and 2016 from Canada, the United States and Sweden. The countries all have similar levels of surgical care as well as detailed data on opioid prescriptions.

The team found that nearly 79% of people in Canada and about 76% of those in the United States who had one of 4 operations — and who filled their opioid prescriptions — did so within 7 days of leaving hospital, compared with 11% of people in Sweden (see ‘Painkiller prescriptions’). “That’s a striking difference,” says Gabriel Brat, a surgeon at Beth Israel Deaconess Medical Center in Boston, Massachusetts. The procedures were removals of the gallbladder, appendix, breast lumps or meniscus cartilage in the knee.

The study authors also found that people treated in the United States got prescriptions for higher doses of opioids than did those in Canada and Sweden — regardless of the type of surgery they had.

Neuman says that his team’s findings suggest that there are alternative approaches to pain management that don’t rely on opioids, and that looking at those approaches could inform new and existing prescription guidelines.

Brat agrees. “There’s a lot we can learn from other countries,” he says. Several health-worker associations and local governments in the US have started developing prescribing guidelines for clinicians to combat opioid over-prescription. One set of recommendations, developed by the city of Philadelphia, advises physicians to avoid prescribing opioid painkillers for low-risk procedures where possible.

It’s unclear why the prescription fulfilment rate is so much lower in Sweden than in the United States and Canada, or why US doctors prescribe higher doses of opioids than do those in Canada or Sweden. It might be because of differences in how clinicians approach pain, what patients expect in terms of pain control or societal factors such as drug marketing practices and regulations, says Neuman.

He cautions that the study didn’t measure pain levels in the people who filled prescriptions, so it's possible that individuals in Sweden were less satisfied with their pain control than were those in the United States and Canada. But that’s unlikely, Neuman says, because previous studies have found similar levels of satisfaction with pain care in all three countries.