Japan (America) fact of the day

So consider the amount of standard daily doses of opioids consumed in Japan. And then double it. And then double it again. And then double it again. And then double it again. And then double it a fifth time. That would make Japan No. 2 in the world, behind the United States.

That is from German Lopez at Vox.


But the Japanese pharma industry is not the world leader that America's is.

Like Purdue Pharma - https://en.wikipedia.org/wiki/Purdue_Pharma

Though occasionally, it does seem as if the company could be a poster child for less pesky FDA regulation, so it can avoid problems like this - 'In May 2007 the company pleaded guilty to misleading the public about Oxycontin's risk of addiction and agreed to pay $600 million in one of the largest pharmaceutical settlements in U.S. history. Its president, top lawyer and former chief medical officer pleaded guilty as individuals to misbranding charges, a criminal violation and agreed to pay a total of $34.5 million in fines. Those executives are: Michael Friedman, the company’s president, who agreed to pay $19 million in fines; Howard R. Udell, its top lawyer, who agreed to pay $8 million; and Dr. Paul D. Goldenheim, its former medical director, who agreed to pay $7.5 million.

In addition three top executives were charged with a felony and sentenced to 400 hours of community service in drug treatment programs.'

The Vox article is quite poor at explaining American exceptionalism.

One can quibble about how good the entire 'How America became the world’s leading opioid prescriber' section was. Though if one is an American, it may be hard to understand that a 'pill mill' doctor is unlikely to exist in most other wealthy nation health care systems, or that doctors have an incentive to hand out pills to 'get patients out in a timely fashion to be able to bill insurers at the highest possible level.' And that doctors and patients are marketed to in the pursuit of profit also tends to be something not really normal in a system like Germany's. The Krankenkassen - call them health insurers - generally decide which medications are allowed and which aren't for treatment of insured patients.

American health care exceptionalism at this point has reached the point that Americans are unlikely to recognize just how different their system is, while non-Americans assume that the U.S. has a system that at least resembles what they grew up with, as both groups do not really share many points in common.

This provides a bit of insight, being written by an American doctor - 'We had to take a number to be registered, but waited less than 5 minutes. I gritted my teeth a bit in preparation for the we-are-not-from-the-UK conversation, but it wasn’t an issue at all. I offered my US insurance number for billing, but was told they didn’t need it. The clerk was, however, impressed with the fact that I flipped his eyelid and irrigated his eye before coming. “Well, you did all the right things,” and looking at his red and watering eye she smiled and said. “Looks like you are in the right place.”

Registration completed, we waited to be seen by the children’s part of the ER. A registrar (resident) did a quick triage within 5 minutes of our registering (also impressed with the eye irrigation) and then a nurse did his vitals and took a history. After that we waited less than 15 minutes for the registrar to do a formal assessment. He wanted ophthalmology to do the evaluation. I was a bit surprised the ER doc wouldn’t do it, but every facility is different and when they found out that Victor was born at 26 weeks and had retinopathy of prematurity they got a bit jumpy. Everyone does. I was ok with ophthalmology checking him out. What I have learned from years of medicine is don’t mess with the local order.

We were walked over to the urgent care clinic and were warned that the ophthalmology registrar was covering the whole hospital so it might be a while. This was our longest wait, about 20-30 minutes. She was very nice (also working on her PhD). Dr. Katie Williams (she gave me permission to use her name and her photo) diagnosed Victor with a corneal abrasion and easily snagged the offending speck of dirt wedged under his eyelid. Once removed Victor exclaimed, “It’s gone!,” and within a minute or two the redness cleared up. She put in antibiotic ointment and gave us a tube to use at home.

“So where do I pay?” I asked Dr. Williams.

The answer: you don’t. Perhaps they might bill us, she just wasn’t sure.

I was about as dumfounded at her answer as she was at my asking.

I protested that it wasn’t fair. We had used services and I was very prepared to pay. I also have insurance that covers emergencies when out of network, so I was pretty sure I would be reimbursed at least some of the visit. However, we were just sent away. They do have my address so it is possible I will get a bill in the mail.' https://drjengunter.wordpress.com/2014/08/12/an-american-doctor-experiences-an-nhs-emergency-room/

Great anecdote demonstrating why the NHS is unsustainable.

After 33 years of universal health care, Australia spends less than half per capita on health care as the United States with better results. Australia's life expectancy is around the 4th highest in the world, while the United States is around 31st.

When someone insists that health care is the primary driver of life expectancy, in this country, it's best not to ask him what Waffle House his conception took place in,

How can you say it's "unsustainable" when they spend a small fraction of what we do?

The UK spends about 10%, a shade less than the OECD average of 11%. There's not a lot of variation: nearly everyone who counts is 11% +/- 2%. The US is a big outlier at 17%.

Generally, the expenditure range is so narrow that its crazy to argue that (disparate) health outputs are driven strongly by per-capita expenditures. Raising your expenditure from 10% to 11% is just not going to revolutionise outputs. The structure of the healthcare markets (or lack of them) explains far more of the variance.

The NHS is medium-cost inputs generating fair-to-poor outputs.

Great article. Demonstrates the NHS is completely unsustainable in the face of open borders. The estimates for "unpaid bills by foreigners" is merely Hundreds of Millions. With so many unreported incidents like this, I wouldn't be surprised if it is a ten times higher.

(No fault of this visitor, though, who made honest attempts to pay. But all the NHS staff involved deserve severe censure for their disgraceful waste of public money. There are clear rules for billing and they should apply them!)

For most first world countries we have bilateral and multilateral agreements giving access to the domestic health care system on the same basis as residents. The number of UK residents receiving healthcare abroad is roughly equal to the number of foreign residents receiving treatment here. As the costs are roughly equal it isn't really worth bothering to recover at times measures are taken to bring the books into balance, such as providing specialised treatment to residents of small .states which get a lot of tourists like Malta. The US is one of the few rich states not involved in one of these agreements.

Residents pay tax, while tourists are mostly from rich or middle income countries with cost sharing agreements, people in poor countries mostly can't afford tourism. Americans are supposed to pay, the NHS rarely bothers as it would require vastly more expensive admin which wouldn't really be worthwhile the costs of being able to do so would probably exceed the money recovered, so American tourists get to free load.

That is a sweet story. The last time I was in London, I walked through the University College Hospital instead of around it to get to my destination, because it was raining, and the whole place smelled like pee. It is supposed to be a good hospital and is part of one of the world's great universities, but it smelled like the worst nursing home in America.

That's what you get when you have government provided health care (not health *insurance*, health care). Whatever they feel like at the time. Sometimes good, sometimes horrible.

The main way American healthcare is different from other countries is that we don't ration care the way others do so it would be interesting to compare American opioid over-usage to usage of other healthcare. Do we also consume more non-opioid prescription drugs, heart surgeries, cancer treatments, etc.? Since our healthcare sector is bigger than other countries' --- American's spend more on healthcare than any other country, blah, blah, blah --- then I would guess the answer is yes.

By the way, ever notice that America's large healthcare GDP per capita is always stated as Americans *spend* more on healthcare rather than Americans produce more healthcare output? When it comes to government spending though --- even on Medicare and Medicaid healthcare spending ironically enough --- more spending is supposedly better: "The metric is money", at least according to Elizabeth Warren [http://reason.com/blog/2017/01/19/on-entitlements-elizabeth-warren-says-th].

I don't know what year their data are from but Canada has comparable and probably somewhat higher use of prescription opioids now.

The uncertainty comes from how you weight the different drugs for potency.

....precisely why should you and I worry about opioids in Canada, Japan, US or anywhere else ??

Possibility #1: Heavy use of opioid painkilers is the result of an aging population or changes in medical technology. Then we should expect to see it happening in other first-world countries with aging populations and good medical technology.

Possibility #2: Heavy use of opioid painkillers is the result of social, legal, or healthcare market features. In that case, we should expect to see it happening mainly in a small subset of countries (obviously including the US--the problem in the US is why we're looking).

This seems like evidence for possibility #2--probably this isn't just an inevitable consequence of an aging population and advancing medical technology.


#1 Japan is very old.

#2 Bingo!

The first line of the article: "If you want a clear explanation of just how much of an outlier the US is..."

Actually, the 32x quote about Japan really tells us how much of an outlier *Japan* is: if its usage increased 32x, it would become No. 2 in the world. That doesn't say anything about the gap between No. 2 Canada and No. 1 US, or even the gap between No. 1 and Nos. 2-10, for example. No matter how many times I see it, I am still struck by how many people start with a conclusion, like "US has an opioid problem", and proceed to think that anything they observe, like Japan's low usage, must somehow support their conclusion.

the Toyotazation of medicine?

So, is this second opioid epidemic also responsibility of asians as the first one in 1890-1900?

yeah but what about Japanese suicide rates??????????????? (then no need for opioids)

but why single out Japan for the comparison? looking at the chart in the Vox article, the US consumes 2x-4x more opioids than most European countries. Which I guess is still concerning but doesn't sound as bad as consuming 32x more than Japan.

Japan has a lot of cultural resistance to narcotic medication as this article describes:


They only use medical morphine at about one sixth the rate as Australia, which is an absolute tragedy -- because of the unnecessary pain suffered by people and not because they buy their medical morphine from Australia.

I think the point is that Japan and the US are about equally successful at managing pain, despite the opioid disparity. The implication being that we could radically cut our opioid consumption with no ill effects.

Tell that to our heroin addicts!

How do we measure how successful they are at managing pain?

We punch them. If the don't yell or cry, their are managing their pain quite well.

I think the article just asserted it without providing evidence. It struck me as more of an extended "fact of the day" than a deep dive into the issue.

Because the author wants to associate the 32x figure with No. 2 so that an uncareful reader will get the misimpression that US usage is 32x larger than the next largest user.

Yeah, it seems like the real story here is why does Japan use so little opioids?

They sublimate their chronic pain into tentacle porn.

I was wondering along the same lines. What does japan use for pain medication?

Quesitoned answered, they suck it up. Oh, and they don't always tell you that you have cancer..


Opioids are relatively cheap (as compared to other pain medications), as are high fat content hamburgers and fries. The excessive use of opioids and the excessive consumption of high fat content food are related: the former provides cheap pain relief but with risk while the latter provides cheap hunger relief but with risk. Cheap, instant gratification with adverse consequences to come later. Does one blame the pharmaceutical industry and the fast food industry, or their customers? And while opioids and fast food are mostly marketed to the relatively poor, more expensive instant gratification is marketed to the relatively well off: spinal surgery for back pain even though the evidence is that such surgery more often makes the condition worse not better. It's the culture. Visit Walmart and observe the instant gratification, as customers purchase cheap goods that will soon find their way to the land fill.

Fatophobia is so 1990s.

+1 How about the entire bogus literature on "food deserts"? There's no fresh food in the ghetto, is it because discrimination? Or choices of ghettoians?

You know that in 2017 academia, not only is the former the only answer ever considered, it is enforced with charges of racism if you even consider the later.

Studies Question the Pairing of Food Deserts and Obesity http://www.nytimes.com/2012/04/18/health/research/pairing-of-food-deserts-and-obesity-challenged-in-studies.html

Ah, yes, "food deserts".

You know, in the 1950s and 1960s, the whole country was a "food desert"? Your choices on produce were seasonal, frozen, canned, or part of a tiny number of transportables (iceberg lettuce, for example). We ate somewhat more beef, too, but far, far less chicken. We, of course, had plenty of sugar-sweetened carbonated drinks, but only a handful of standard fruit juices. Candy bars were common and bigger, but granola bars were unknown. Potato chips lines the aisles.

And you know what? We had much lower obesity, and by modern standards zero childhood obesity. We called "Type 2" diabetes "adult-onset", because it didn't show up in kids.

Good points all. (I think we ate *less* food, because it was so much more expensive in real terms.)

The ongoing Prospective Urban Rural Epidemiology (PURE) project has found both saturated and unsaturated fat intake linked to better heart health, that a high-carb diet is a better predictor of health risks than fat consumption, and that the health benefits of fruit, vegetables, and legumes like beans and chickpeas may plateau at three to four servings per day.

Maybe Americans shoulg organize a Bataam Death March. I am told it does wonders for one's mental health. If I were the American president, there would be no Japan whatsoever.

When I visited Japan 2 decades ago, Brazilian Japanese were the new underclass. They had reasoned that they needed more labor, due to the boom of the eighties and early nineties, and Brazilians with Japanese ancestry seemed like the least risky immigrants. But they were wrong. Thanks to the Brazilian culture, they did not have what was needed top succeed, and many of them went back to Brazil.

They always can import Muslims, it would work much better... It is sad to see that anti-Brazilian hatred and slanders are alive and well in the 21th Century. The truth is, as their economy engine broke down, the Japanese had a smaller demand for foreign workers. Also, the Japanese Fascist regime did not want immigrants to "succeed" any more than it wanted to free Asia in the 1940s. Maybe you should stop paying attention to the Fascist propaganda. Brazilians have been systematically discriminate against by the Japanese blackguards. You may measure a people's worth by how they treat their fellow men. In Brazil, even after they rebelled against us and tried to take over the country, the Japanese were well-treated.

Apparently, to be respected by Americans, a people must engage in the hideous killing of young Americans. Hence why the Japanese, the Chinese are praised and spoiled non-srop by the American corrupt intelligentsia, while Brazil, that has been a reliable partner and ally (for examplo, having fought in WWII and helped to defeat Dominican Republic's communist regime), is slandered and belittled. Maybe Mr. Kim Jong-un is right after all, and the only language Americans understand is force!!

How dare you! Brasil es the gratest country in the entire world. The Japanese should be so lucky that we allowed them to have a taste of our superior culture. Who's fault is it if the now enlightened Brasilian Japanese were unable to teach the ignorant native Japanese about the perfection of Brazilian culture.

@Thiago Ribeiro asked, "Who’s fault is it if the now enlightened Brasilian Japanese were unable to teach the ignorant native Japanese about the perfection of Brazilian culture"


Let's say you're a typical lefty reporter or blogger, and you want to advance the correct narrative on the opioid crisis.

Do you really want to discuss the economic devastation to the middle class over the last 8 years? The lack of opportunities, the underemployment, the outright joblessness, and the decay of so many cities, that fuel drug addiction?

Or would you rather blame doctors, thereby providing a convenient segue into why we need national single-decider health care?

Yeah, I thought so. Nice job staying in line, Ty.

Teuth is, Americans have chosen to pexchange their jobs and narional pride for a mess of pottage and cheap underwear.

Only transgendered plumbers qualify for a pexchange, and dammit that's a good thing.

Truth is, Americans have chosen to pexchange their jobs and narional pride for a mess of pottage and cheap underwear.

Poverty does not cause social problems (and the cream rises to the top) http://www.themoneyillusion.com/?p=32638

people in Japan are in much better health than in the US
obesity rates, life expectancy, the metrics are so different between both countries

Ten years ago, I had both knees replaced. I was on opioids for about two weeks between the surgeries and in-house rehab. I did not feel "high" or euphoric, just sleepy, and in less pain. On release, I asked what med to take besides the dope they prescribed. The nurse said "Extra-strength Tylenol is as strong a pain killer without the narcotics." That's what I used. I did not experience withdrawal symptoms.

Maybe the YUGE opioid usage is correlated with otherwise perpetually-outraged people that voted for Obama and Hillary; or with depression over eight years of Obama - fundamental transformation.

Let's be blunt: America, for the last decades, have hollowed itselt out for the sake of a quick buck. Choices have consequences.

Only one edit to your reply ". . . : America for the past, say, 50 decades, . . " In a former life, certain reviewers of formal reports would replace "last" with "past" or "recent" saying this is not the last analysis/audit our firm would perform.

Anyhow, it's always someone else's fault. [sigh]

Webster has the good sense to back my choice of words: 3 a: "next before the present: most recent last week his last book was a failure" Evidently the many meanings the word "last" has may be off-putting for some people (reviewers of formal reports among them), but much less off-putting than the meanings of the word "late". Churchill was surprised when Chaplin called him the late Prime Minister because he was not aware he had died. Chaplin replied that "former Prime Minister" sounded strange. Unfortunately, business are enemies of the language. In Brazil, they have done too much to destroy the language of Camões, Pessoa, Machado, Barreto e Prophet Bandarra, which poet Bilac called the "last flower from Latium". https://en.m.wikipedia.org/wiki/Latium

Dick, when prescribed in reasonable amounts, opiates tend to cancel out pain rather than result in pleasurable feelings. This "cancelling out" means it is possible for them to be taken for a prolonged time by people who are in pain without addiction developing. Addiction tends to result when their use is not decreased as a person recovers from a health problem and pain subsides.

This was fairly well documented well before the Obama or Clinton administrations.

Fortunately, in my country we have a system in place to avoid addiction to opiate painkillers where irregular health care operators, often called Pigdog and Spider, pay high prices for any opiate medicines people recovering from health problems may have, discouraging overuse.

@Crikey I hope you enjoyed the Purdue Pharma Kool-Aid

Purdue middlemen? Please, I'm shilling for the source. Medical opium isn't grown in Thailand, you know.

The proportions run the other way if you look at seaweed consumption.

I guess that sentence is illustrative of a philosophy major's writing style for communication of mathematical or statistical data. It's really quite shitty.

The cause of the opiod crisis can be explained with one word: Obamacare's Medicaid expansion to single males without children.

Everything else is at best a tertiary cause.

Only a government program can cause this much societal destruction and yet be largely unmentioned as a cause.


That's more than one word.

Bullshit! Your timing is off, for one thing. http://www.tennessean.com/story/news/2017/04/08/timeline-how-opioids-crisis-began-took-hold-tennessee/98866140/

As is your scope: I've got good private insurance, and for any minor mishap, things that need maybe a little ibuprofen, they automatically prescribe a bottle pf opioids.

Only a small fraction of those addicted to opioids started with taking drugs that were actually prescribed to the individual. This is an illegal drugs problem, not a prescription problem.

Spotted Toad has made the best argument for linking the ACA to the opiod crisis, but even he acknowledges it merely contributed to something that was a large & growing crisis already.

+1 but I would not say cause, I would say a significant contributor to.

What MD's are most likely to take Medicaid? Right the unethical.

According to the chart presented in the article, it looks like Japan is more the outlier than the US is. I have a problem with public health concerns affecting my medical treatment... i.e. if the most effective treatment for my condition is opioids then I should be able to easily get them, regardless of the public health ramifications - my doctor should only be considering my personal well being when determining a treatment. If there are public health externalities then they should be reflected in the cost of treatment, not in availability.

'then I should be able to easily get them'

The DEA might just disagree with that - 'A DEA number (DEA Registration Number) is an identifier assigned to a health care provider (such as a physician, optometrist, pharmacist, dentist, or veterinarian) by the United States Drug Enforcement Administration allowing them to write prescriptions for controlled substances.' https://en.wikipedia.org/wiki/DEA_number

It is not just the FDA that is involved in how physicians can prescribe medications, after all.

Highest Overdose & Drug Related Death Rates In The World

Looks like the USA is number 3 in drug deaths. Legalization might actually help, but USAers just seem wild, could also be that we are having an epidemic and we will fall once it runs its course. Convince your family and friends to not use.

Why would legalization help?

There would be more incentive for drug companies to work on creating opioids and delivery mechanisms that have less danger of OD. More predictable dosage. More use of pure heroin and less fentanyl.

Regulation and health: The case of mandatory prescriptions and an extension

"Pharmaceutical Freedom" Jessica Flanigan

Well, I guess it depends on your definition of "success" here. I don't think the main problem is overdose which is still a small percentage compared to overall addicts... the main problem is the large population of addicts who are unable to have a normal life and end up creating a huge financial/emotional drain for themselves and the people around them. I don't see how legalization helps any of that (it might make it worse...)

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