April 22, 2011
NIH Podcast Episode #0132
Balintfy: Welcome to episode 132 of NIH Research Radio with news about the ongoing medical research at the National Institutes of Health – the nation's medical research agency. I'm your host Joe Balintfy. Coming up in this episode, we have a double-feature about common pain drugs being abused…
“The fact that these are so commonly available is what concerns us.”
Plus news on how stroke patients can get back on their feet, a report on prevention efforts in California, and a new possible risk factor for heart disease. But first, this news update. Here’s Craig Fritz.
Fritz: For the first time in nearly 3 decades, the clinical diagnostic criteria for Alzheimer’s disease have been revised. The National Institute on Aging and the Alzheimer's Association Diagnostic Guidelines for Alzheimer’s Disease outline some new approaches for clinicians and provides scientists with more advanced guidelines for moving forward with research. They mark a major change in how experts think about and study Alzheimer’s disease. The original criteria were the first to address the disease and described only later stages, when symptoms of dementia are already evident. The updated guidelines cover the full spectrum of the disease as it gradually changes over many years. The guidelines now address the use of imaging technologies and biomarkers in blood and spinal fluid that may help determine whether changes in the brain and those in body fluids are due to Alzheimer’s disease. Scientist note that Alzheimer’s research has greatly evolved over the past quarter of a century. Bringing the diagnostic guidelines up to speed with those advances is both a necessary and rewarding effort that will benefit patients and accelerate the pace of research.
The National Institute on Aging is launching a study and thousands of Medicare beneficiaries will receive an invitation in May to take part in research looking at the impact of age-related changes on functional ability. The National Health and Aging Trends Study will be seeking about 9,000 people aged 65 and older to participate in this long-term study. Scientists will examine how the daily lives of older adults change as they age. This research will help them understand the social and economic consequences of late-life disability for individuals, families, and society. Study participants will be interviewed once in person in 2011 for the initial sample and then once a year. Researchers will also conduct short tests of function and physical performance. They ask that anyone that receives an invitation to take part and contribute to this important research.
For this NIH news update – I’m Craig Fritz
Balintfy: News updates are compiled from information at www.nih.gov/news. Coming up, stroke news, prevention efforts and heart disease risk. But part one of our painkiller prescription story is next.
(BREAK FOR PUBLIC SERVICE ANNOUNCEMENT)
Analysis of opioid prescription practices finds areas of concern
Balintfy: A recent analysis of national prescribing patterns shows approximately 56 percent of painkiller prescriptions were given to patients who had filled another prescription for pain from the same or different providers within the past month.
Weiss: Most of these are short term prescriptions; they're for two to three weeks.
Balintfy: Dr. Susan Weiss is the Acting Director of the Office of Science Policy and Communications at the National Institute on Drug Abuse.
Weiss: The question really is why is there so much prescribing, and why is there so much prescribing within a short period of time?
Balintfy: The prescription data analyzed is from a privately owned national-level prescription and patient tracking service. The sample included 79.5 million prescriptions dispensed in the United States during 2009; that represents almost 40 percent of all the opioid prescriptions filled nationwide. Dr. Weiss adds that the prescriptions could all be perfectly legitimate.
Weiss: We can’t tell that from this database. But it certainly raised questions for us and in particular it made us think that physicians should be asking their patients, "Do you already have a prescription that's sitting at home that you haven't finished using?" Before giving them another prescription for it.
Balintfy: Most of the prescriptions were for hydrocodone- and oxycodone-containing products, like Vicodin and Oxycontin. While these medications are crucial for pain management, their wide availability may also result in leftover pills in family medicine cabinets, increasing opportunities for abuse, as well as a host of serious medical consequences, including addiction. Dr. Weiss says the fact that these medications are so commonly available is cause for concern.
Weiss: It may be that most of these are being used for very legitimate reasons and I don't want to underemphasize the importance of these medications for treating pain appropriately, both acute pain and chronic pain. However, we do think that their availability has gone up tremendously and we're seeing some of the consequences of that.
Balintfy: From 1991 to 2009, prescriptions for opioid analgesics increased almost threefold, to over 200 million. According to the Drug Abuse Warning Network system, which collects reports from hospital emergency departments across the nation, the non-medical use of prescription opioids doubled between 2005 and 2009. For more information on the recent analysis of opioid prescription practices, visit www.nida.nih.gov.
Large NIH-funded rehabilitation study looks at getting stroke patients back on their feet
Balintfy: We’ll have more from Dr. Weiss later in the program. Now, new research has compared physical therapy options for stroke survivors. Britt Ehrhardt reports that stroke patients in a recent study not only improved their ability to walk but have shown that they can continue to improve up to one year after stroke, offering new hope to patients and their families.
Ehrhardt: More than four million stroke survivors experience difficulty walking. New research tests physical therapy options for these stroke survivors, with encouraging results.
Koroshetz: Many stroke patients will benefit from more intensive therapy than they are probably receiving.
Ehrhardt: Dr. Walter Koroshetz is Deputy Director of NIH's National Institute of Neurological Disorders and Stroke. He says standard and more intense types of physical therapy have been tested in the study.
Koroshetz: Both of the intense physical therapy programs performed better than the standard-of-care program.
Ehrhardt: Dr. Koroshetz explains that the largest stroke rehabilitation study ever conducted in the United States compared three types of physical therapy.
Koroshetz: One is called standard-of-care, which is the outpatient physical therapy sessions that are generally prescribed to patients after stroke. The second was an intensive, treadmill-based locomotor therapy…
Ehrhardt: Locomotor therapy employs a harness that partially supports body weight, suspending a patient over a treadmill. This high-tech therapy is increasingly popular.
Koroshetz: And the third one is a strength and balance exercise therapy that’s done by a physical therapist, but it's done in the patient's home. So those were the three that were looked at: two intensive and one standard.
Ehrhardt: Dr. Koroshetz says that the intense at-home sessions and the treadmill training program were equally effective forms of physical therapy.
Koroshetz: Both of the intensive therapies performed equally well.
Ehrhardt: At the end of one year, 52 percent of all the study participants had made significant improvements in their ability to walk. Dr. Koroshetz adds that the study gives new reason for hope.
Koroshetz: There is a general notion that the recovery after stroke tends to plateau out somewhere between three and six months.
Ehrhardt: But the study shows that patients can continue to improve six months to a year after stroke, despite the conventional wisdom that improvement stops at three to six months.
Koroshetz: The institution of intensive therapy at the six month time period actually caused a great deal of benefit in the patients. They benefitted from the intensive therapy even six months after the stroke, which I think is a surprise to many people.
Ehrhardt: Dr. Koroshetz says that rigorously comparing available physical therapy treatments is essential to determine which is best. He adds that NIH-funded studies of stroke are ongoing.
Koroshetz: We’re always looking for more clever ways in which we can aid the brain in its recovery process.
Ehrhardt: For more information on stroke, neurological disorders, and this study, visit www.ninds.nih.gov. This is Britt Ehrhardt at the National Institutes of Health, Bethesda, Maryland.
California Right Care Initiative: Community Wide Efforts to Prevent Heart Attacks and Strokes
Balintfy: The California Right Care Initiative, funded in part by an NIH grant, is a project designed to help improve the quality of California’s health care maintenance organizations. The Initiative has identified two areas of concern: hospital acquired infections and cardiovascular risk factors. Cherry Graziosi has the details.
Graziosi: Improving the quality of America’s managed health care organizations one state at a time, beginning with California where the performance rates for many standard chronic care quality measures, such as high blood pressure and high cholesterol rank substantially below those of other states. Dr. Robert Kaplan, Director of the National Institutes of Health’s Office of Behavioral and Social Sciences Research has spoken extensively on this subject.
Kaplan: California Right Care Initiative is a program in California to try and improve the quality of care in California managed care organizations. In particular we hope that we can save a significant number of lives by getting people to adhere to the best evidence-based approaches to the prevention of cardiovascular disease and stroke.
Graziosi: The plan, funded in part by NIH, focuses on two areas, hospital acquired infections and the prevention of cardiovascular disease, where Dr. Kaplan says patients have fallen through the cracks because of the extra steps they have to go through to get care.
Kaplan: Cardiovascular disease in particular, we have a lot of epidemiologic evidence suggesting that people who have identified risk factors can benefit if they get those risk factors modified.
Graziosi: Dr. Kaplan says one way of modifying risk factors and reaching patients who are at risk for cardiovascular disease is by redesigning the standard physician practice – and that is by bringing in new technology to reach these patients.
Kaplan: The really good systems – the ones that seem to be doing the best job are ones that are using electronic medical records to identify the people who have these problems and they are much more proactive in getting people in to be evaluated.
Graziosi: Dr. Kaplan stresses that not all of California’s managed health care programs are failing; in fact, he points to the Sharp Rees-Stealy Medical Group in San Diego as a practice where technology has proven to be very successful in reaching patients and changing physician performance.
Kaplan: They use information systems to identify people- they provide a rewards system to physicians that provide the right feedback and they have a whole series of behavioral things that they do to make their practices more efficient.
Graziosi: To hear more about Dr. Kaplan speak on this project, visit the website videocast.nih.gov. I’m Cherry Graziosi, the National Institutes of Health, Bethesda, MD.
NIH-funded study finds new possible risk factor of heart disease
Balintfy: Turbulence on an airplane means a bumpy flight. But what about heart rate turbulence? Wally Akinso reports.
Akinso: Abnormal heart rate turbulence is associated with an increased risk of heart disease in otherwise low-risk older individuals.
Boineau: Heart rate turbulence is a measurement that is done with a Holter monitor and it measures the body's response to an abnormal beat called the premature ventricular contraction.
Akinso: Dr. Robin Boineau is a Medical Officer at the National Heart, Lung, and Blood Institute. She says the Cardiovascular Health Study analyzed data collected from nearly 1,300 participants.
Boineau: Cardiovascular Health Study is the study of people age 65 or older that are in four U.S. communities. And data was collected on them over a period of time, and it’s a Holter monitor data collected where people had to wear a device with electrodes that were on their chest. The information was collected over a 24 hour period and then that information was compared to how people did down the road.
Akinso: According to the study, heart turbulence was an even stronger heart disease risk factor than elevated levels of C-reactive protein. C-reactive protein is a potential heart disease biomarker that has emerged in recent years. Dr. Boineau explains the link between having an abnormal heart rate turbulence response and heart disease risk.
Boineau: If you didn’t have a sign that your heart rate turbulence was abnormal you were less likely to have a cardiovascular mortality event in the near future. If you had evidence of abnormal heart rate turbulence you were more likely to have an event; cardiovascular event in the near future.
Akinso: Dr. Boineau says the study shows a great potential value for heart rate turbulence in diagnostic settings.
Boineau: If we can replicate this in other studies, we maybe able to have a new biomarker with a non evasive test, that we can do a Holter monitor on you and see if you are at increase risk for cardiovascular event therefore get you managed and treated for risk factors that are likely to contribute to a cardiovascular event.
Akinso: Risk factors for a cardiovascular event, such as a heart attack, are high blood pressure, high lipid levels, diabetes and obesity. For more information on this study, visit www.nhlbi.nih.gov. This is Wally Akinso at the National Institutes of Health, Bethesda, Maryland.
Balintfy: Coming up, part two on prescription painkillers – who should be concerned. That’s next on NIH Research Radio.
(BREAK FOR PUBLIC SERVICE ANNOUNCEMENT)
Analysis of opioid prescription practices finds areas of concern – Part 2
Balintfy: Earlier in the program, we heard from Dr. Susan Weiss at the National Institute on Drug Abuse. She covered the basics on how analysis of national prescribing patterns shows that more than half of patients who received an opioid prescription in 2009 had filled another opioid prescription within the previous 30 days. Now we’re talking more with Dr. Weiss about that. Can you explain why opioids are prescribed – what are they supposed to be used for?
Dr. Weiss: Opioids are used -- they are used to treat pain, and they can be incredibly useful and in fact life-saving medications, so we do need to keep that balance in mind when we're looking -- we’re looking -- because I work for the National Institute on Drug Abuse, our focus is on abuse and the consequences, but these medications are also extremely helpful, which makes it very important to get a balance of appropriate prescribing for people who really need them, versus having widespread availability so that someone who doesn't need them can just pick them up out of a medicine cabinet somewhere and take them, or bring them to a party and throw them in with a bunch of other pills and take them.
Balintfy: What has research been showing about opioid abuse?
Dr. Weiss: We have been seeing, for the last number of years, that there is a lot of abuse of opioid prescriptions, and the consequences associated with its abuse have really been increasing tremendously. So we've seen unintentional poisonings going up from something like 3,000 to 12,000 between 1997 and 2007; and this has now become the second-leading cause of unintentional death in the United States, behind motor-vehicle crashes. We've also seen increases in treatment admissions. And when we look in our national surveys and we ask where people are getting these medications that they are abusing, they're using non-medically, they almost always say that it's from friends or relatives, and occasionally from the prescriptions that they have prescribed themselves. And also the number of opioid prescriptions that have been given over the last number of years, which has increased massively from something like 75 million in 1991 to over 200 million in 2010.
So because of the fact that there seems to be -- people are abusing medicines that they're finding fairly readily available, we were interested in looking at prescribing practices.
Balintfy: What did you see by analyzing prescribing practices?
Dr. Weiss: We think that, you know, we recognize that physicians are prescribing these things legitimately for problems associated with pain, but we also have found out from this analysis that dentists are the top prescribers to kids between the ages of 10 and 19. It's probably mostly for third molar extractions. The question really is, do they need to be prescribing them? Do they need to give them as many pills as they're giving them, or can they consider doing other types of analgesics, such as non-steroidal anti-inflammatory drugs? They are certainly practicing what they think is appropriate pain management, but maybe they're not well enough trained on the fact that adolescence is a time of vulnerability for abuse and addiction to drugs, and that exposing kids to these drugs, or giving them enough so that there could even be leftover drugs, which they may then try and use at another time when it's not appropriate, is really potentially a problem.
Balintfy: Dr. Weiss, does the analysis show there are other audiences who should hear about these survey results?
Dr. Weiss: So we have an audience of parents, which we think are really important to reach because we think that parents are, you know, they don't necessarily realize that when you give your kid one of your opioid medications that you got for back pain because your daughter is having premenstrual syndrome, that that could be her first experience with an opioid, and she might really like it. And we know that youth are the most vulnerable to starting to become addicted to medication -- to drugs in general.
So we think that parents are either inadvertently, or with the best interests in mind of their kid, somehow exposing them to these drugs in ways that they really wouldn't want to. One reason we think that this is such a problem is that people don't think of these as harmful drugs. They don't realize that an opioid medication works in the brain the same way that heroin works in the brain. Now there's obviously differences there, because when you take heroin, it gets into the brain very quickly, and that's part of what makes it so addictive. But nevertheless, when you're taking an opioid, you're still acting in some of the same parts of the brain that any other illicit opioid or street drug is doing.
So people aren't thinking about these drugs as being in any way similar to street drugs. They're not thinking about them as being dangerous because they're prescribed by physicians. But physicians are prescribing them to treat a particular problem, they're prescribing them -- or they should be prescribing them -- based on what they know about the patient's history, as well as what other medications they're taking, their age, their weight, all of these things are factors that a physician will take into account when prescribing a drug. And when somebody is just using another person's drug, they are at risk for adverse effects, including becoming addicted to these drugs.
So one of our key targets is parents, we think that these -- or grandparents, or anyone who's leaving unused medications in an unlocked cabinet where it's available for anybody to use.
Balintfy: So it’s not just the prescriber or the person getting the prescription?
Dr. Weiss: Right, so when we look at the surveys, the surveys ask -- we have -- NIDA has a “Monitoring the Future” survey which is conducted annually among eighth, tenth, and twelfth graders. And we've been asking about, actually two of the most widely prescribed opioids, Vicodin and Oxycontin, since 2002. And we found that among high school seniors, nearly one in 10 have been using Vicodin, not for medical purposes. And by that, we mean that they're either using it for the feeling that it gives them or to -- it's basically something that is not prescribed for them for pain, and so they are taking it because it makes them feel better, or they're using it to get high.
Also what we know from the national surveys is that the main abusers of these drugs are between the ages of 18 and 25, so that really is a group that also needs to be targeted. Those between 18 and 25, they are vulnerable to abusing a number of different drugs and to becoming addicted. And another issue that's a big concern with these medications if they're abused is that they're often combined with alcohol, with other drugs, which could really amplify the adverse effects of them.
Balintfy: Thank you Dr. Susan Weiss. Again for more information on the recent analysis of opioid prescription practices, visit www.nida.nih.gov. And that’s it for this episode of NIH Research Radio. Please join us again on Friday, May 6th when our next edition will be available. We’ll have a report on the use of complimentary and alternative medicine:
“Like the rest of Americans, people 50 and over are using complimentary and alternative medicine.”
But are they talking with their regular doctors? That’s next time. Until then, if you have any questions or comments about this program, or have story suggestions of your own for a future episode, please let me know. Best to reach me by email—my address is firstname.lastname@example.org. I'm your host, Joe Balintfy. Thanks for listening.
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