Training to help healthcare providers properly prescribe painkillers

BALINTFY: Welcome to episode 179 of the new NIH Research Radio. The new NIH Research Radio is your source for weekly news and information about the ongoing medical research at the National Institutes of Health – NIH...Turning Discovery Into Health®. I'm your host Joe Balintfy, and coming up in this episode our news summary at the end of the program includes items on:

• Phase 1 trial results on a single-dose vaccine for dengue,
• A clinical trial beginning for treatment of a rare, fatal neurological disorder, and
• A study showing H1N1 flu shots are safe for pregnant women.

But first, our feature interview on prescription painkillers.

Training to help healthcare providers properly prescribe painkillers

BALINTFY: The Centers for Disease Control and Prevention (CDC) classifies prescription drug abuse as an epidemic: there are roughly 100 people dying each day from drug overdoses, driven primarily by prescription drugs. The number of prescriptions filled for opioid pain relievers has increased dramatically in recent years. From 1997 to 2007, the use of prescription opioids in the U.S. has increased from 74 to 369 milligrams per person; that’s an increase of 402 percent. In 2000, retail pharmacies dispensed 174 million prescriptions for opioids; by 2009, 257 million prescriptions were dispensed; that’s an increase of 48 percent.  Further, opiate overdoses, once almost always due to heroin use, are now increasingly due to abuse of prescription painkillers.

Yet opioid-based prescription painkillers do have an important role in helping manage pain. I’m here with Dr. Nora Volkow, the director of the NIH’s National Institute on Drug Abuse to discuss a new training opportunity for doctors, as well as information for patients and the public about the risks and benefits of prescription painkillers, including talking about those risks and benefits. First Dr. Volkow, why is it important for doctors to talk with their patients about prescription painkiller use?

VOLKOW: It’s very important because many patients don’t have a good understanding about what are potential, adverse or beneficial effects of opioids and as a result of that to start with some patients may upfront reject the use of an opioid mediation that would be very helpful to them. At the same time, there are other individuals that don’t realize that when they are not used properly, opioid medications can result in addiction and if taken at quantities outside those recommended, it actually can lead to overdoses. So it’s extraordinary important for a physician to be able to educate a patient that they are thinking to give opioid medications about what the medications can do and what to expect from them and how to take them is extraordinary important.

BALINTFY: Basically to understand the risks and benefits associated with opioid medications.

VOLKOW: Correct and also to make it very clear how to take the medications, when to take them, how not to combine them with other medications, which is also one of the problems that at least it’s particularly among elderly people they have other diseases. So they may be prescribed many medications and it is important that they recognize and in some instances some of these medications may when combined have untoward effects. So physicians need to be trained also themselves on what is it that they need to ask and know about the patients they are going to be prescribing these very powerful pain medications.

BALINTFY: Do doctors feel perhaps uncomfortable talking to their patients about use of prescription painkillers, and if so, why?

VOLKOW: Well I think that doctors particularly feel uncomfortable asking about their patients as it relates to abuse of substances and that includes alcohol. Actually, many of them are intimidated to ask the questions do you drink, do you drink more than is necessary, have you ever been addicted to drugs and that actually includes tobacco. They feel less uncomfortable asking about tobacco but they do feel uncomfortable asking about illicit substances because they are stigmatized and yet it is very important for a doctor that’s going to be prescribing opioids to ask these questions because opioid medications have the potential to produce addiction in individuals that are vulnerable. What one of the pieces of information that you have regarding vulnerability for addiction is have you had that problem before, is there a history of addiction in your family. So if the doctor does not ask the question, he may be prescribing an opioid to someone with a high addiction vulnerability and not realize that.

BALINTFY: How then can a doctor learn to ask, is there training on this?

VOLKOW: Well unfortunately, there is very little in medical schools that they learn about actually just even how to screen and treat pain properly. But there is even less education as it relates of how do you screen and even interview an individual regarding their substance abuse history. Also there is very little education with respect to once you’ve prescribed these opioid medications, how do you really probe and question the patient to try to get information that would alert you that the patient may be using the medications inappropriately or that they may be transitioning into addictive behaviors and you have to ask.

BALINTFY: So now the Office of National Drug Control Policy (ONDCP) and your National Institute on Drug Abuse (NIDA) have launched a new online learning tool, which includes videos. How can these help Dr. Volkow?

VOLKOW: Well these are videos that portray two cases of individuals who are suffering from pain for which the physician has prescribed an opioid medication. They follow them through the treatment procedures and as time progresses, you can start to see the different trajectories of both of these patients. It shows how by inquiring in a nonjudgmental way the physician actually can elicit the information that can help the patient protect them against the transition into more serious addictive behaviors. Also, in other instances how they can understand that the patient indeed is taking the medication as prescribed, there’s no problem with it and when it will be time to terminate the use of the opioid medications.

BALINTFY: These videos, along with the new online training materials also provide an opportunity for healthcare professionals to earn continuing medical education, or CME credits. Where can they find this training tool?

VOLKOW: They are on MedScape and if they enter through MedScape they can get CME credits. They also can get a link through our website at NIDA but they won’t get CME credits if they look at them through our website.

BALINTFY: Do you know how many people have taken them so far?

VOLKOW: Yeah, it’s actually very impressive because we have had 20,000 individuals that have taken the course. So it was very surprising to see these very high numbers, which of course in my brain what it tells you is the tremendous need that there is for educational material as it relates to how to prescribe and monitor individuals that are being giving opioid medications for their management of pain.

BALINTFY: This wouldn’t just be for doctors taking the online course for credit? Why?

VOLKOW: Because in many instances, the first interview is made by nurses so it’s not always physicians that are following up carefully the transition of patients. I mean they may be seeing them at periodic times and in other instances it is the nurse that actually follows them through. It’s also important even for a pharmacist or a dentist who also prescribe these opioid medications to be aware how to ask a question regarding prior substance abuse without feeling intimidated. So by looking how others do it, it’s actually one of the best ways of learning, observing how other do things in a way that does not intimidate the patient but it’s effective in generating the information that you need.

BALINTFY: The National Institute on Drug Abuse is one of the 27 institutes and centers here at NIH. In what other ways does NIDA specifically reach healthcare providers?

VOLKOW: Well we have large initiative in terms of how can we make health providers much more aware of the importance of substance use disorders in their patients. So one of them is to educate the healthcare providers about the relevance of substance use in terms of the outcomes for a wide variety of medical diseases including fatal overdoses from the use of medications that they may be giving them to treat the disorder with drugs of abuse. So they need to ask the question.

So we’ve been generating what we call the Centers of Excellence and the Centers of Excellence are grants that we gave to academic centers in order for them to develop curriculum that can be used to teach about substance use disorders in medical schools. That way physicians will be better prepared to screen their patients for substance use disorders and also to know how to intervene if in fact their patients may be taking drugs or starting to abuse them or addicted. So that’s one of the ones.

We’ve also generated material that would make it easier for physicians to screen for their patients. One of the products is called NIDA med and there are several products within the NIDA med that allows a physician to be able to screen patients and to follow them through. Actually, we’ve made that material available in mobiles, in tablets so that a physician can use it while they are actually interviewing their patients.

BALINTFY: Dr. Volkow, before we wrap up, is there something that you want to emphasize in this discussion about prescription painkillers?

VOLKOW: Yeah, I think that one of the aspects and challenges in the management of chronic pain is the difficulty that doctors have to make with respect to the need of initiating an opioid medication and the potential negative effects that these medications have. These answers will come on a personalized basis because each patient is different but it does highlight the responsibility that both the physician and the patient have to maintain a dialogue that will allow them to be able to optimize the beneficial effects of these really remarkable medications when used as needed but also minimize the risk associated with their improper utilization.

BALINTFY: Dr. Nora Volkow, director of the NIH’s National Institute on Drug Abuse. Thank you very much.

VOLKOW: You are very welcome.

BALINTFY: For more information on prescription painkillers, including those training opportunities for healthcare providers, visit www.drugabuse.gov. And in just a minute, news headlines on results from a dengue vaccine trial, a clinical trial for treatment of a rare disease, and results on a flu vaccine study in pregnant women. That’s next on NIH Research Radio.

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News Summary

BALINTFY: Now for some recent news headlines from NIH, here’s Craig Fritz.

FRITZ: An experimental dengue vaccine developed by scientists at NIH has been found to be safe and to stimulate a strong immune response in most recipients. Dengue fever, prevalent in many tropical and subtropical regions of the world, is caused by any of four related viruses that are transmitted to humans by a type of mosquito. The World Health Organization estimates that every year, 50 million to 100 million cases of dengue occur worldwide, resulting in 500,000 hospitalizations of patients with severe disease, many of them in children.

A clinical trial has begun to evaluate a drug as a possible treatment for a rare and fatal neurological disorder called Niemann-Pick disease type C1, or NPC. The clinical trial will be conducted at the NIH Clinical Center. No therapies approved by the FDA are available to treat NPC. The disease is characterized by the inability of cells to metabolize and dispose of cholesterol and lipids. It causes excessive amounts of cholesterol to accumulate within the liver, spleen and brain. NPC leads to progressive impairment of motor and intellectual function in early childhood. In childhood onset cases, life expectancy does not normally exceed a patient’s teenage years.

Scientists at the NIH and Norwegian Institute of Public Health have shown that pregnant women who received a vaccine against the 2009 H1N1 influenza virus showed no increased risk of pregnancy loss, while pregnant women who experienced influenza during pregnancy had an increased risk of miscarriages and still births. The study suggests that influenza infection may increase the risk of fetal loss. The research was conducted following the H1N1 influenza pandemic that took place between spring 2009 and fall 2010. Norwegian public health officials had urged pregnant women to be vaccinated. However, media reports of pregnancy losses after flu shots caused some expectant mothers to forgo vaccination.

For this NIH news update, I’m Craig Fritz.

BALINTFY: You can get more information on these news items at www.nih.gov/news.

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BALINTFY: And that’s it for this episode of the new NIH Research Radio. Please join us again next Friday, February first when our next edition will be available. Coming up in that episode…

Women should recognize that heart disease is the number one killer for women and, you know, that heart disease is treatable, preventable, is something that we really want people to understand and take action.

BALINTFY: In the meantime if you have any questions or comments about this program, or have a story suggestion for a future episode, please let me know. Send an email to NIHRadio@mail.nih.gov. Also, please consider following NIH Radio via Twitter @NIHRadio, or on Facebook. Until next week, I'm your host, Joe Balintfy. Thanks for listening.

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