April 5, 2010


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ANNOUNCER: From the National Institutes of Health in Bethesda, Maryland, the Nation's medical research agency, this is Pinn Point on Women's Health with Dr. Vivian Pinn, Director of the Office of Research on Women's Health.
Now here's Dr. Pinn.

DR. PINN: Welcome to another episode of Pinn Point on Women's Health. Each month on this podcast, we take a look at some of the latest developments in the areas of women's health and the medical research that affects our lives. For our podcast today, I'm delighted that we will welcome Dr. Nora Volkow, who is Director of the National Institute on Drug Abuse, and she's going to discuss with us women and prescription drug abuse, but first, some hot flashes from the world of women's health research coming up in just 60 seconds when we continue with Pinn Point on Women's Health.

[Commercial break.]

DR. PINN: Welcome back to Pinn Point on Women's Health. As promised, I want to take a look at a few of the hot flashes in the news regarding women's health research.

First, there's been a recent Consensus Conference at the National Institutes of Health looking at vaginal delivery after cesarean section, and I am pleased to tell you that will be the topic of our next podcast. So join us for our next podcast, so that you can be updated on the results of this deliberation by the experts in the field.

Also, I want to make you aware of a new book, "Women in Science," that was prepared by the National Institutes of Health, the Office of Research on Women's Health, and our Institute liaisons, taking a look at a wide range of women who are scientists within the NIH community. These are doctoral-level women across the NIH who are in a variety of roles.

What makes this exciting, we think, is that this publication is not just a directory of women scientists at the NIH, but rather a snapshot in time of just a few of the highly accomplished women at the doctoral level at the NIH, and they discuss things that shape their careers, insight on how they manage their work-life balance, as well as their thoughts on mentoring or who mentored them and what was important for their career progression.

We think this book will serve as an inspiration to young women and men or maybe not such young women and men who are interested in careers in science and hope they will find inspiration from this publication. The last hot flash that I want to tell you about during this podcast are some new analyses from the Women's Health Initiative, which is a study of postmenopausal women led by the National Heart, Lung, and Blood Institute. These new analyses of data from that study again confirm that combination menopausal hormone therapy—that means taking combined estrogen and progestin in women who still have a uterus—continues to show that it does increase the risk of heart disease in healthy postmenopausal women.

This reconfirms the findings that were reported several years ago, now that there has been longer followup of the women who were in this study. The difference in the initial level of risk does not appear related to age, but is based on findings that increased risk of heart disease was similar between women in their fifties on combination hormone therapy and women in their sixties, and this study was published in the February 16th, 2010, Annals of Internal Medicine.

It has been made clearer than ever that women who are considering postmenopausal hormone therapy for menopausal symptoms should discuss their risk of heart disease and other risks such as breast cancer, stroke, and dangerous blood clots with their doctors before starting therapy.

Dr. Jacques Rossouw, who is Chief of the NHLBI's Women's Health Initiative Branch and a coauthor on the paper, added, "Although a number of recently menopausal women who would be expected to suffer a heart attack during the first years of combination hormone therapy is small, the risk is likely to be real. Our findings continue to support the Food and Drug Administration's recommendations that postmenopausal hormone therapy should not be used for the prevention of heart disease."

We'll have more updates in the next podcast, and coming up next, I'll visit with Dr. Nora Volkow for a discussion of women and prescription drug abuse. We'll be right back with more Pinn Point on Women's Health.

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DR. PINN: Welcome back to Pinn Point on Women's Health. Our guest today is Dr. Nora Volkow, who is the Director of the National Institute on Drug Abuse. Her work as a research psychiatrist and scientist has been instrumental in demonstrating that drug addiction is a disease of the human brain.

During her professional career, Dr. Volkow has been the recipient of multiple awards, including her selection for membership in the Institute of Medicine in the National Academy of Sciences and the International Prize from the French Institute of Health and Medical Research for her pioneering work in brain imaging and addiction science. She was also named one of Time magazine's Top 100 People Who Shape Our World and was included in Washingtonian magazine's 2009 list of the 100 Most Powerful Women. So it is wonderful to have her with us today to discuss with us women and prescription drug abuse. Welcome, Dr. Volkow. Thank you for joining us.

DR. VOLKOW: Thank you for having me here. Good morning -- or afternoon.

DR. PINN: Tell us what is the issue of women and prescription drug abuse. Is it really a problem?

DR. VOLKOW: The abuse of prescription medications is actually quite serious, and it affects both men and women. However, there are differences in the patterns of use between the women and men that are important to understand because it allows us, of course, to do interventions to prevent this abuse as well as to treat it when it has occurred.

DR. PINN: We hear a lot about prescription drug use in young teens. Is there a difference in patterns of prescription drug use or abuse by age in girls and women?

DR. VOLKOW: Yes, indeed, there is, and it's actually quite worrisome because overall, in general, men tend to take—males tend to take more drugs than females, except in the period of time between 12 and 17 years of age, and there, we see a higher rate of abuse of drugs, including psychotherapeutics, among girls than among boys.

The rate of use is actually significantly higher among adolescent girls 12 to 17 than males for all of the psychotherapeutics, and that includes the psychotherapeutics that are abused in general, but also by teenagers, pain medications that contain opiates, and these are drugs like Vicodin or OxyContin.

It does include stimulant medications, which are the medications used to treat ADHD, like amphetamines, Ritalin, and there again, adolescent girls have almost 60 to 70 percent higher rates of abuse of these substances than adolescent boys.

Then we have two other classes of medications that are described as sedatives and tranquilizers, and again adolescent girls tend to take more than boys, but that's just for 12 to 17. Then, as they grow into their twenties, boys start to have higher rates of abuse of these drugs.

DR. PINN: Well, I'm happy that you're here discussing this with us today because we don't hear as much in the media as we should hear about especially adolescent girls and their abuse of prescription drugs, and this is something that our listeners really need to know about and that I'm happy that you're focusing on.

I think you've really covered for us the differences in rates of abuse and dependence for adolescents and between boys and girls, and men and women, but could you just reconfirm that for our listeners, so they will be aware of where the differences are?

DR. VOLKOW: The differences in rates of abuse in the genders between 12 and 17 show higher rates of use of substances of abuse, including psychotherapeutics, among adolescent girls than among adolescent boys, but a particularly large difference favoring females unfortunately is stimulant medications. There, female adolescents tend to abuse them, misuse them much more than male adolescents.

DR. PINN: We're talking about prescription drugs. How do they get these drugs? What is the source?

DR. VOLKOW: Well, there are two surveys, one of them Monitoring the Future that targets adolescents from 12 to 18, and another one that targets individuals of all ages, starting from 12 upwards. Both of them are very consistent in showing that more than 50 percent of the cases get their psychotherapeutics from friends or relatives, who give them to them as a present. Then approximately, depending on the age, between 18 and 30 percent of them buy it from a friend or relative.

In adolescents, interestingly, approximately 30 percent they get from prescriptions that have been given to them by a physician, 30 percent, which is actually a very large number.

DR. PINN: What do we need to do in terms of educating physicians about prescribing these kind of medications and the potential for abuse of taking these medications?

DR. VOLKOW: Well, I think that physicians need to have a better understanding of under what conditions these psychotherapeutic medications may be necessary and under what conditions these same psychotherapeutic medications can be harmful.

We have seen a really dramatic—there's no other way that I can call it but dramatic—increase in the number of prescriptions for the main two types of psychotherapeutics abuse, which are pain medications and stimulants. Since 1992 to 2009, which is close to 20 years, there's been a ninefold—ninefold increase of the number of prescriptions for stimulant medications. They have gone from 4 million to 36 million. And for pain and analgesics, the numbers have grown fourfold. They have gone from 40 million to 180 million prescriptions in a given year. So what that means is that we are making these medications widely, widely available.

Yes, they have very beneficial effects when used properly, but, at the same time, it is also clear that we may be giving many more prescriptions than what are necessary or there is no evidence, of course, that we have such a high number of individuals that are requiring them for therapeutic purposes.

DR. PINN: That is really striking, the increase in the number of prescriptions that are being written and given, as you've just described, but why do women and girls take these prescriptions?

DR. VOLKOW: There are many reasons, and, actually, first of all, many adolescents, boys and girls, take them to get high. That's one of the reasons they use it.

But then it depends on the type of psychotherapeutic; for example, pain medications taken are also misused in order to actually overcome pain, even though it was not prescribed by a physician. Both adolescent girls and adolescent boys reported they will take it to treat their pain, and, similarly, you see that in other adults, that they had a prescription that was given to them, say, 6 months ago or 1 year ago by their dentist. Then they have pain, and they take it.

But they also take it, stimulant medications specifically—and this is particularly true for adolescents and 18- to 25-year-olds—in order to actually improve cognitive performance, to study for an exam, to prepare for something that requires a deadline of intense work. In the case of girls, another reason why they do take stimulants is in order to lose weight, and this is because stimulant medications are anorexigenic; that is, they take your hunger away.

DR. PINN: Do these prescription drugs really enhance performance?

DR. VOLKOW: It depends on the context and the conditions. Definitively, they do improve performance when they are prescribed for the treatment of individuals that suffer from attention deficit/hyperactivity disorder because they are able to improve the attention, the attention capacity of these individuals. In individuals who don't have ADHD, however, stimulant medications may improve performance, for example, if you are extremely tired or if you are sleep-deprived.

They may improve performance also on tasks that are very repetitive and boring because they actually may make the task more interesting, enabling you to pay more attention, to be driven by it.

However, not even under these conditions, not all of the cognitive operations are improved by stimulants, and, in fact, some of them may deteriorate. For example, stimulants may make you be very persevering, which is very good if you are doing a repetitive task, but may not be desirable if the cognitive task requires that you have the flexibility to shift the mode at which you are processing information and to shift the patterns that you are going to be using in order to resolve a problem. That may deteriorate with the use of stimulant medications.

It is also evident that not all people, actually not all individuals, respond in the same way to stimulants. Some may actually improve, but some may overall deteriorate with a stimulant medication. So it is not a universal panacea that you take a stimulant and that it will allow you to study better, even if you are sleep deprived. It may help you for certain tasks, and in some individuals, it may actually deteriorate your performance.

DR. PINN: Hearing about the striking number of prescription drugs that are being taken, what are some of the risks of abusing these drugs?

DR. VOLKOW: Well, again, it depends on the class of medications. Overall, regardless of whether it's a tranquilizer or a sedative or a stimulant or an analgesic, these drugs can produce addiction. If you look at the surveys, it is estimated between 10 and 15 percent of individuals that have reported misuse of these psychotherapeutics in the past year have a diagnosis of dependence or abuse. So addiction is real. These drugs can make medications, when used inappropriately, can produce addiction.

Apart from that, there are other side effects. Opiate medications can produce overdoses, and this is very serious because, in fact, it has been reported that over the past 10 years, there has been more than a doubling of the fatalities from overdoses, and this is believed to reflect the increase in the number of prescriptions of opiate analgesics. So opiate analgesics, like any opiate, can produce overdose.

Stimulants, when abused at high concentrations, can produce psychosis and can also in individuals that are vulnerable induce seizures or they can also produce cardiac arrhythmias.

DR. PINN: You are internationally recognized for your work on drug addiction as a disease of the human brain. Could you just say a little bit about what your research has been in this area and why we call it a "disease of the human brain"?

DR. VOLKOW: Well, for many years now, I've been studying the effects that drugs have on the human brain to try to understand how those changes in biochemistry and function can actually help us understand the dramatic deterioration of the behavior of people that become addicted to drugs. So, through these imaging studies that are predominantly based on positron emission tomography and more recently on using MRI with various techniques, we have been able to identify that repeated use of drugs affects how the brain works, disrupting many, many functional circuits that include the reward, which is the ability to feel pleasure, the learning and memory circuit, which basically leads to conditioned responses. These are almost reflex responses that are generated when you get exposed to the drug or to drug cues that elicit the intense desire to take the drug.

We have also shown significant disruption of frontal areas of the brain that are involved with executive control and that enables you to make decisions, to judge, to control your desires and your emotions.

So there is actually a quite complex pattern of disruptions that have emerged from these studies, knowledge that has come from these studies that give us a perspective of drug addiction as a disease that has disrupted multiple circuits that ultimately lead to the compulsive intake of drugs, and that becomes very, very difficult to inhibit, even though it's at the expense of pretty catastrophic consequences for the individual.

DR. PINN: Very exciting work you're doing, helping us understand drug addiction.

Now, we've been talking about abuse of prescription drugs. Do individuals who abuse prescription drugs tend to also abuse illicit drugs?

DR. VOLKOW: Yes, indeed. In surveys, just again averaging estimates, individuals that have misused psychotherapeutics are at least twofold higher prevalence rates of the misuse of illicit substances. So, yes, they are more, a little bit more than double the likelihood of using other illicit substances.

DR. PINN: What kind of treatments do we have for girls and women or even boys and men who abuse prescription drugs? If we have listeners who are hearing this who fear that there's someone in their families who may be abusing prescription drugs, what would you advise them? What kind of advice and what kind of treatment might they seek?

DR. VOLKOW: Well, first of all, I would advise them to take it very seriously. Whether the individual is already addicted or is just consuming large quantities of these psychotherapeutic drugs, this has to be taken very seriously. One, because of the adverse medical consequences, and second, because of the risk of addiction, which I mentioned before is estimated to be 10 to 15 percent.

Currently, what type of treatment will again depend very much on the type of psychotherapeutic. Fortunately for opiate analgesics, we have medications that can be actually, that look quite promising. We're currently at NIDA funding a trial, conducting a trial to investigate the use of buprenorphine in the treatment of opiate, addiction to opiate analgesics, and the results appear to be quite promising. So that should be considered if someone is addicted to opiate analgesics and the utilization of buprenorphine as a means to help them overcome the problem of addiction.

Otherwise, we don't have any specific medications for other types of addictions, whether it is stimulants or sedative hypnotics and tranquilizers. There are several evidence-based behavioral interventions that include motivation intervention strategies, incentive intervention strategies, group therapy intervention strategies that have been shown to be effective.

It is also evident from what we have learned about the treatment of drug addiction that each should use a chronic model of disease; that is to say, that treatment should be continued. And there is evidence that treatments actually that are less than three months are actually not useful at all. Ideally, again, how long someone needs to be in treatment will vary, but the best results are obtained when individuals maintain some level of therapeutic care that extends over several years.

DR. PINN: I have asked you a number of questions, but I haven't given you a chance to kind of summarize, so let me ask you. Are there some major points that we haven't addressed that you'd like to make about women and prescription drug abuse?

DR. VOLKOW: Yes, I would. One of them pertains to the reason why we've seen an increase in the use of psychotherapeutics, the misuse of psychotherapeutics, and that is actually true for men and women, for younger and older individuals, which is that the belief, the misguided belief that abuse of psychotherapeutics is less dangerous than that of illicit substances because they are prescribed by physicians, and that is basically a fallacy. When you take psychotherapeutics outside the surveillance of a physician, these drugs, these medications can be as dangerous as illicit substances. So this is one of the messages that should be clear, clean and clear and simple. Psychotherapeutics, when used outside the surveillance of physicians, can actually have very adverse consequences that include drug addiction.

The other issue is, at the same time, the message that I do want to send is that different from illicit substances where you cannot come out with any argument why you need them, psychotherapeutic medications can be very beneficial when used properly, and certainly, opiate analgesics can be life-saving to those individuals that suffer from severe pain, so again the importance of educating both the public as well as the health care system about how these drugs work and under what conditions their use is beneficial and under what conditions their use can lead to adverse medical consequences.

DR. PINN: As a concluding statement, could you just give our audience your view on how they might approach taking prescription drugs, especially if they have chronic illness, chronic pain, and how best to balance the need to take them if they need them and if they are prescribed, while at the same time not becoming addicted?

DR. VOLKOW: One of the aspects that is important is, of course—and I am going to reiterate—these medications should only be taken under close surveillance by a physician. The patient should be evaluated actually, and again the patient should express whether in the past they had had a history of addiction to drugs because, if they do, that means they are at greater risk of becoming addicted, even if the pain medications may be prescribed for pain by a physician.

Family history of addictive disorders—and that can include nicotine. Nicotine is an addiction, tobacco, cigarette smoking, or alcohol, any of that information is of use in order to be aware that that individual may be at higher risk. It does not negate the fact that they still can be prescribed, but it does highlight that their surveillance will have to be monitored more carefully. So anyone who is considering taking a pain medication should actually discuss with their physicians their past history of substance use, abuse, and as well as that of their family.

DR. PINN: Thank you so much, Dr. Volkow, for a very informative discussion about women and prescription drug abuse, and I hope our listeners have really gotten the message that you have put across so wonderfully during this discussion. So thank you for being with us, and we hope you will join us again in the future.

DR. VOLKOW: Thanks very much.

DR. PINN: Coming up next, a few final thoughts for this month when Pinn Point on Women's Health continues.

[Commercial break.]

DR. PINN: And now a few final thoughts for this podcast. You have just heard a discussion with Dr. Nora Volkow, who is Director of the National Institute on Drug Abuse here at the National Institutes of Health, where she has discussed women and prescription drug abuse. She has given us some wonderful information, not wonderful in itself in that she has pointed out the increase in the number of prescriptions that are being written and the increase in the numbers of girls and women and others who are abusing these prescription drugs.

She has alerted us to how we as individuals need to pay attention to our own addictive histories and our family's, how physicians need to be more careful in giving these prescriptions, and taking a history of those they prescribe them for and monitoring their patients who are taking these medications And for all of us, if we take these medications, to be aware that some of them can be addictive, and if they are, their real risk to our health and our future. Thanks for joining us for this episode of Pinn Point on Women's Health. In just a moment, the announcer will tell you where to send your comments and your suggestions for future episodes.

I am Dr. Vivian Pinn, Director of the Office of Research on Women's Health here at the National Institutes of Health in Bethesda, Maryland. Thank you for joining us.

Pinn Point on Women's Health comes from the Office of Research on Women's Health and is a production of the NIH Radio News Service, News Media Branch, Office of Communications and Public Liaison in the Office of the Director at the National Institutes of Health, an agency of the U.S. Department of Health and Human Services.