Improving Kids’ Hand Hygiene Skills: A Global Campaign

Improving Kids’ Hand Hygiene Skills: A Global Campaign

Healthcare providers all over the globe are fighting the good fight, working to inculcate healthy hand hygiene habits among youngsters.

In Ottawa, Canada, schoolchildren aged 6 through 9 are following the World Health Organization’s (WHO) six-step hand-washing routine while singing kid-approved lyrics to the tune of “Frere Jacques”:

“Scrub your palms, between the fingers

Wash the back (one hand), wash the back (other hand)

Twirl the tips (one hand) around (other hand)

Scrub them upside down

Thumb attack (one thumb)! Thumb attack (other thumb)!”

To test the effectiveness of the didactic sing-and-wash routine, researchers applied fluorescent marks to the kids’ hands prior to hand-washing and checked for the reduction of the markings afterwards.

In southern India, researchers from the University of Glasgow in Scotland and Amrita Vishwa Vidyapeetham University have been conducting their own experiments in improving kids’ hand hygiene. At a government primary school in Kerala, 45 Indian students ages 5-10 were trained in hand-washing skills while guided by an anthropomorphic hand-shaped attendant named Pepe.

Mounted on a wall beside the school’s hand-washing stations, Pepe consists of a basic robotic arm assembly with a plastic hand and a videotronic “mouth” through which he “speaks” to students as they wash. As kids clean their hands, Pepe refers them to an illustrated poster depicting an eight-step hygienic hand-washing routine, and “follows” their progress with his moveable eyes. Pepe has taught students to wash their hands before meals and after using the toilet, and overall has improved their hand-washing skills by 40%, according to the researchers.

In addition to the marked improvement in the children’s hand hygiene habits, Pepe was a hit. Over 90% of the students said they would like to see Pepe again after their summer holiday, and “over seven in 10 of them thought Pepe was alive, largely due to its ability to talk.”

Other projects focus on the spreading of germs to emphasize the importance of proper hand hygiene. During a height-of-flu season lesson at Angie Grant Elementary in Benton, Arkansas, a school nurse, Ronda Wagner, collaborated with second-grade school teacher Anna Lawrence to depict the ease with which germs can be transferred. They coated a soft football with a special powder, which students then tossed among themselves in the room. Afterwards, viewing themselves under ultraviolet light, the kids could see that the powder had spread—not only to their hands—but also to their faces and arms.

The Centers for Disease Control (CDC) presents compelling reasons to encourage training in hand hygiene at an early age. According to the CDC, hand-washing education can:

  • Reduce the number of people who get sick with diarrhea by 23-40%
  • Reduce diarrheal illness in people with weakened immune systems by 58%
  • Reduce respiratory illnesses, like colds, in the general population by 16-21%
  • Reduce absenteeism due to gastrointestinal illness in schoolchildren by 29-57%

And if plain statistics on hand hygiene are too dry for youngsters with dirty hands, you can always refer them to the revolting findings of the (figuratively) viral “Bread” science project of behavioral Specialist Jaralee Annice Metcalf in Idaho.

Anti-Vax Groups Attack Pediatrician for Pro-Vaccine Post

Anti-Vax Groups Attack Pediatrician for Pro-Vaccine Post

“Dead Docs Don’t Lie”

When Nicole Baldwin, MD, made a playful TikTok touting the benefits of vaccination, she wasn’t expecting to fight an endless social media battle that destroyed her online ratings — and even led to a threat against her life.

In her TikTok, Baldwin, a pediatrician in suburban Cincinnati, listed a handful of diseases that vaccines prevent to the pop song “Cupid Shuffle,” ending on the note that vaccines don’t cause autism.

It wasn’t an instant hit when she posted it on Saturday, Jan. 11, but by Sunday it had 50,000 views so Baldwin decided to share it on Twitter.

“That’s when everything exploded,” she told MedPage Today.

Members of the “anti-vax” community discovered it and launched a “global, coordinated attack,” posting negative comments across Baldwin’s social media pages including her Facebook and Twitter.

They also went for the jugular: knowing that a physician’s online presence is critical, they barraged her online review sites, including Yelp and Google Reviews, with one-star reviews to sabotage her practice.

Some even called her practice, Northeast Cincinnati Pediatric Associates, and harassed the staff. One woman — whom Baldwin described as “very angry” — threatened to “come and shut down our practice,” prompting Baldwin to call the police.

But most intimidating was a post from an anti-vax Facebook group that said, “dead doctors don’t lie.”

“Shots Heard Round the World:” A Pro-Vax Sheriff in Town?

“Ultimately what the anti-vax community wants is to scare us into silence,” she told MedPage Today.

Baldwin first tried to stem the tide on her own by deleting comments and reporting abuses. Then she enlisted the help of a friend, and then her husband, until it became too much to manage — which was when she called in Shots Heard Round the World, a network of vaccination advocates who describe themselves as a “rapid-response digital cavalry.”

Founder Todd Wolynn, MD, a pediatrician in Pittsburgh, knows what it’s like to be on the receiving end of a global social media attack from anti-vaxxers. In 2017, his practice Kids Plus Pediatrics posted a video promoting HPV vaccination that triggered a massive blast from the anti-vaccine crowd.

Some 800 different accounts posted more than 10,000 negative anti-vax comments to the practice’s Facebook page, Wolynn said. Associates of Shots Heard who had infiltrated some of the anti-vax Facebook groups sent him screen shots of commenters who were celebrating their efforts of posting bad online reviews for the practice.

The 6-day onslaught against Kids Plus Pediatrics resulted in an academic publication that was widely picked up by the press, including the Los Angeles Times and the Washington Post.

Baldwin had learned about Shots Heard through a talk Wolynn gave in Ohio and had signed up to be part of that team. Little did she know she’d be the one needing the help.

“One doctor has no time to handle all of this,” Wolynn told MedPage Today. “We have a vetted rapid-response network that can come to your aid.”

He said anyone can send an email to the Shots Heard alert box, and once it’s vetted, the request for online help is distributed through an email blast to their network of vaccine advocates — other doctors, nurses, paramedics, parents, and others who promote vaccination science.

Baldwin said that since she allowed Shots Heard to take over her Facebook account, they’ve been posting positive comments and blocking commenters from her page; a total of 5,000 anti-vax accounts have been banned as of Monday night, she said.

“Docs Need to Know That There’s Help Out There”

Shots Heard is also helping to get the fake online reviews taken down, which is never easy, particularly with Google, Wolynn said. But ongoing media coverage likely pressed the tech giant into taking down the reviews, Baldwin said.

Yelp, which has a process for removing fake reviews, took most of them down and posted a box on the page noting that the practice has been in the news recently. Some fake reviews could still be seen on the page on Monday night.

“They’ve been amazing,” Baldwin said of Shots Heard. “Doctors need to know that there’s help out there if we’re attacked. We don’t need to give in to these bullies.”

While there’s been debate in the medical community over the utility of TikTok for sharing messages about medicine and health, Baldwin said she won’t be quitting anytime soon, and that it’s an effective way to reach the young people who are her patients.

That includes aspiring physicians, she said: “I’m getting messages from young people who say they want to go to medical school, asking about classes.” She adds, “It’s also showing that doctors are human and can have fun.”

by Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today

Originally published in MedPage Today

Well Women Visits at Any Age

Well Women Visits at Any Age

Well Women Visits at Any Age

Thinking creatively about access to women’s health care has always been part of the job for Tracie Kirkland, clinical assistant professor in the Department of Nursing at the USC Suzanne Dworak-Peck School of Social Work.

Kirkland, a former program coordinator for Johns Hopkins Pepsi Beverages Wellness Center in Mesquite, Texas set up a mobile breast screening unit at the Pepsi plant so women could take advantage of mammography screenings without having to take time off work.

“Seeking windows of opportunity to access health care may not always be in a traditional setting,” Kirkland said.

Accessing routine care may be harder for some women than others, depending on individual circumstances and institutional barriers. Scheduling and attending routine health care visits can help women care for all aspects of their physical and mental health as they age.

According to a 2018 survey by the Kaiser Family Foundation, almost half of millennials don’t have a primary care provider. Finding new ways to meet patients where they are is critical to maintaining women’s health, regardless of age.

“We plan for retirement, but how do we plan to take care of our bodies? Our health is our wealth,” Kirkland said.

What Keeps Women from Seeking Health Care?

Social determinants are environmental factors that affect how people work, live and age throughout the life span. These determinants can also be barriers to accessing care and keep women from finding a primary care provider.

Social determinants that affect women’s abilities to access health care:

Insurance coverage: Women without health care insurance will experience higher out-of-pocket payments to access and receive medical care. About 11 percent of women in the United States are uninsured, compared to 9 percent of all Americans.

Income: Women and girls in families with low income may be unable to afford copays or other fees required to see a provider. In 2017, 11 percent of women lived below the federal poverty line, compared to 8 percent of men.

Geography: People living in areas far from health providers may find it difficult to travel several hours for an appointment. In a 2017 report on social determinants, researchers found that geography contributed to differences in mortality and morbidity related to smoking, obesity, air pollution and several chronic illnesses.

Family obligations: Women who are parents of young children or caregivers for other family members may have to arrange for child care or other forms of assistance in order to make time for health visits. Data from a 2018 caregiving report from Pew Research Center indicates that women spend more time providing child care than men.

Work obligations: Taking leave from work can be a challenge for women who don’t have paid time off. The 2018 Current Population Survey from the Department of Labor shows that 57 percent of women and 71 percent of mothers are in the labor force.

Transportation: In rural communities, women without a car or public transit options may be unable to access a provider. In urban areas, residents might not find care within walking distance or be able to afford costly public transit fares.

Education: An individual’s education can affect their language proficiency, as well as their ability to understand complex medical information. Low educational attainment has been linked to higher rates of morbidity for cardiovascular disease and cervical cancer.

Health literacy: The ability to access, understand and apply health information to daily life can be a challenge for women who may be vulnerable to false information and advertising or may have limited experience with a health care provider. Only 12 percent of American adults have a proficient health literacy.

Where to Find Women’s Health Care Resources

Even after women attend a health care appointment, social determinants can keep them from being able to understand and apply health information to their lifestyles. That includes knowing how to reach a provider for a follow-up conversation or how to fill a prescription at the nearest pharmacy. Providers like nurse practitioners can make use of one-on-one time to guide patients through next steps and counsel them on how to make appointments for other visits or needs.

“Know where to seek out services that may be free of charge, like the public health department or Planned Parenthood, where you can utilize a sliding scale in order to receive services,” Kirkland said. Sliding scale services use a variable cost to determine a fee based on how much the patient can afford to pay.

Providers can also look for innovative ways to reach patients for follow-ups or spread awareness about health information.

“We need to really be savvy in the way that we’re utilizing social media to disseminate information versus our traditional face-to-face visits,” Kirkland said.

Social media can help providers reach captive audiences by promoting health information during specific health awareness months. Patients can also use social media to find locations in their community to access health care and information:

  • Places of employment
  • Sorority organizations
  • Places of worship
  • Faith-based employers
  • Local and state departments of health
  • Local school district
  • Publicly funded clinics
  • Mobile units
  • Planned Parenthood and women’s health clinics

When using any of these venues to access care, it’s important that patients find a way to follow up with a provider or keep in contact.

“Once we create a connection through rapport, we generally are able to keep bringing [patients] back on a regular basis,” Kirkland said. “Depending on what we find in the clinical examination.”

Recommended Health Screenings for Well-Woman Visits

Even when feeling healthy, women have a lot to gain from routine checkups, including screenings for future medical changes, family planning, vaccinations and healthy lifestyle maintenance.

“Do you wait until your car breaks down to have it serviced, or do you maintain it by changing your oil and your tires?” Kirkland said. “Do you wait until your body breaks down, or do you maintain it?”

A well-woman exam is an annual appointment for women throughout the life span. As women age, their health needs evolve, so the visit may include different types of exams or interviews between a patient and provider.

Similar to an annual physical for children, a well-woman visit includes assessments of physical and mental health but also includes conversations about reproductive and sexual health.

An initial visit, often done when women are seeing their provider for a physical for the first time, may just be a one-on-one to discuss what would actually take place in a well-woman visit, Kirkland explained.

Depending on age and health needs, a well-woman exam can look different for each patient.

What to Expect at a Well-Woman Visit

Teens (Ages 13-18)

  • Blood pressure
  • Heart rate
  • Height
  • Weight
  • Hepatitis B
  • Tetanus, diphtheria and pertussis (Tdap)
  • Human papillomavirus (HPV)
  • Influenza (annually)
  • Chickenpox
  • Meningococcal (A, B, C, W, Y)
  • Physical
  • Vision
  • Hearing
  • Sexually transmitted infections (STIs)
  • Drug and alcohol consumption
  • Vaping and tobacco use
  • Driving and seatbelt safety
  • Menstrual cycle
  • Gender identity
  • Sexual identity and activity
  • Mental health
  • Body image
  • Exercise and nutrition
  • International travel
  • Blood pressure
  • Cholesterol
  • Heart rate
  • Height
  • Weight
  • HPV
  • Influenza
  • Tetanus
  • Cervical cancer
  • Pelvic exam
  • Pap smear
  • STIs
  • Breast exam/mammogram
  • Vision
  • Pre-diabetes
  • Family planning and contraception
  • Pre- and post-natal care
  • Drug and alcohol consumption
  • Vaping and tobacco use
  • Menstrual cycle
  • Gender identity
  • Sexual identity and activity
  • Mental health
  • Body image
  • Exercise and nutrition
  • International travel
  • Blood pressure
  • Cholesterol
  • Heart rate
  • Weight
  • Influenza
  • Tetanus
  • Cervical cancer
  • Pelvic exam
  • Pap smear
  • Breast exam/mammogram
  • Vision
  • Hearing
  • Diabetes
  • Colorectal cancer


  • Drug and alcohol consumption
  • Vaping and tobacco use
  • Menstrual cycle
  • Gender identity
  • Sexual identity and activity
  • Mental health
  • Body image
  • Exercise and nutrition
  • Dietary supplement intake
  • Cardiovascular health
  • International travel
  • Hearing/vision loss
  • Family relationships
  • Occupational hazards
  • Blood pressure
  • Cholesterol
  • Heart rate
  • Weight
  • Influenza
  • Tetanus
  • Measles, mumps, rubella
  • Varicella
  • Zoster (shingles)
  • HPV
  • Hepatitis (A and B)
  • Meningococcal (A, B, C, W, Y)
  • Pneumococcal (conjugate and polysaccharide)
  • Cervical cancer
  • STIs
  • Diabetes
  • Osteoporosis
  • Lung cancer
  • Breast exam/mammogram
  • Colorectal cancer
  • Vision
  • Drug and alcohol consumption
  • Vaping and tobacco use
  • Menstruation/menopause
  • Mental health
  • Body image
  • Exercise and nutrition
  • Dietary supplement intake
  • Cardiovascular health
  • International travel
  • Hearing/vision loss
  • Family relationships
  • Stroke Prevention
  • Sun exposure
  • Incontinence

When Should Women Seek Reproductive and Sexual Health Care?

Women don’t have to be planning a family to need reproductive health screenings and care. They should start seeking care at the age of menarche — which is when they begin having menstrual cycles — or when they start having sexual partners. “It depends individually on their desire to be intimate, and where they are in terms of maturation,” Kirkland said.

Reproductive and sexual health care are not synonymous. People of any age, gender or sexual identity can engage in sexual activity without a desire to reproduce. Birth control pills may be used for a variety of reasons unrelated to family planning. Therefore, it’s important for patients and providers to candidly discuss sexual health and reproductive plans.

Reproductive and Sexual Health Screenings:

STI and HIV testing: This screening can be a physical exam or a consultation from a provider to discuss sexual activity and test for sexually transmitted infections. The best time to get tested is before being active with a new sexual partner, and it can be done as often as a patient desires.

Breast exam: This is a physical exam that is done routinely on patients even if they have no other signs of developing breast cancer. Any abnormalities can be further tested with a mammogram, which is an X-ray screening for tumors that can’t be felt with a breast exam.

Pelvic exam: This is a physical examination of reproductive organs and is used to screen for ovarian cancer or other abnormalities that can develop as women age. The provider will inform the patient if they need to return for additional testing.

Menstrual health: A provider will ask about the regularity of a patient’s menstrual cycle, contraceptive use and any abnormalities with pain, bleeding or mood.

Pap smear: This is a physical exam during which a provider collects cells from the cervix to test for cervical cancer. This exam can also help find cells caused by HPV and is recommended every few years for women between the ages of 21 and 65.

Literacy about sexual health can be pivotal to women’s ability to control and plan for their future. Being able to afford contraception is one thing, but maintaining a treatment plan can be an issue — particularly when there is a lack of understanding about different types of contraception, their efficacy and how to use them. The more that providers can empower patients about seeking and understanding health information, the more meaningfully women can be engaged in their decision-making and health care.

Additional Resources for Women’s Health Care




Legal Disclaimer: Please note that this article is for informational purposes only. Individuals should consult their health care professionals before following any of the information provided.


Posted courtesy of [email protected], the online FNP program from the University of Southern California

What Women Need to Know About Strokes and Heart Attacks

What Women Need to Know About Strokes and Heart Attacks

When it comes to serious health conditions like heart attack and stroke, women are more likely to be misdiagnosed and receive delayed care.

When Andrea thought she was having a heart attack and called 911, the emergency medical technicians told the 35-year-old Nashville, Tennessean that she was likely just experiencing a bout of anxiety.

“They made me walk outside, down my driveway to the ambulance. They never turned on the sirens or lights and stopped at every light on the way to the hospital,” she told Today. 

But Andrea was not having an anxiety attack. As it transpired, she had experienced a major cardiac event as a result of a spontaneous coronary artery dissection, an uncommon condition that can affect otherwise healthy individuals.

“The delay in my care caused me to have severe heart damage and heart failure that I am still living with” she said.

While Andrea’s condition is rare, her experience with emergency care is not.

How Are Symptoms of Heart Attack and Stroke Different for Women?

Myocardial infarction, more commonly known as a heart attack, occurs when the flow of oxygen-rich blood to the heart becomes blocked.

A heart attack can be caused by:

  • The full or partial blockage of an artery as a result of plaque buildup.
  • A coronary spasm, in which a coronary artery tightens and cuts off blood flow.

When people think of what a heart attack looks like, they might picture a man grabbing his chest and describing severe pain that extends to his arm. While chest pain is the most notable symptom of a heart attack, many people— especially women—experience less common symptoms. This can lead to misdiagnosis and delayed treatment among female patients.

According to a study from the American Heart Association, almost 62% of women who have a heart attack experience more than three non–chest pain symptoms, compared to 54.8% of men.

The perception of which symptoms necessitate emergency care can lead women to delay seeking treatment, which affects their chances of surviving and making a full recovery.

“If you have nausea and vomiting and back pain or epigastric pain … the first thing that comes to you is not, ‘I’m having a heart attack,’” said Melissa Frisvold, PhD, CNM, APRN, faculty at the Georgetown University School of Nursing & Health Studies.

Symptoms of Heart Attack in Women

Heart Attack warning signs in women
Less commonly known symptoms of heart attack that are more likely to be present in women than men include stomach pain, shortness of breath, chest palpitations, nausea, and dizziness.

Strokes in Women

For women, perceptions of symptoms can also affect treatment of another life-threatening condition — stroke.

Sometimes referred to as a “brain attack,” a stroke occurs when a clot blocks the blood supply to the brain or when a blood vessel in the brain bursts.

The three main types of stroke include:

  • Ischemic stroke — occurs when blood flow through the artery that supplies oxygen-rich blood to the brain becomes blocked.
  • Hemorrhagic stroke — caused by a leak or rupture in an artery in the brain.
  • Transient ischemic attack — also referred to as a “mini-stroke,” blood flow to the brain is blocked for a short time and is a warning for future stroke.

In a 2014 study, researchers found that women experiencing a stroke were at greater risk than men for misdiagnosis in the emergency room. They attributed this disparity to a greater frequency of non-classic stroke presentations, including headache and dizziness.

In addition to having misinformation about symptoms of heart attack and stroke, Frisvold said women may also put more focus on other health risks that they perceive to be bigger threats.

According to the Centers for Disease Control and Prevention’s (CDC) report on the leading causes of death in 2017 (PDF, 2.4 MB), women were most likely to die as a result of heart disease, followed by cancer. Stroke was the fourth-leading cause of death in women.

“Women worry about breast cancer or cervical cancer,” she said. “But heart disease is the leading cause of death in women, not breast cancer or cervical cancer.”

Symptoms of Stroke in Women

Stroke symptoms in women
Less commonly known symptoms of stroke that are more likely to be present in women than men include loss of consciousness, general weakness, difficulty breathing, disorientation, sudden behavioral change, hallucination, nausea or vomiting, seizures, and hiccups.

How Does Gender Affect Health Care?

The misdiagnosis of heart attack and stroke in women is part of the larger issue of gender bias in health care. This stems in part from how clinical research has been performed in the past, which informs how care is provided to patients today.

In a research study on sex bias in clinical studies from the Allen Institute for Artificial Intelligence, researchers examined medical research from 1993 to 2018 and found that women were underrepresented subjects in the research of several health conditions, including cardiovascular health.

“Women worry about breast cancer or cervical cancer, but heart disease is the leading cause of death in women.”

— Melissa Frisvold, PhD, CNM, APRN

Another study on clinical trials for stroke treatment indicated that women were underrepresented in such trials, leading to suboptimal conclusions for women in outcomes and stroke care delivery.

Implicit Bias Affects Treatment

The exclusion of marginalized groups, including women and people of color, may lead to a misunderstanding of the many ways a health condition can present itself and how it should be treated. “Medical bias,” a term for that disparity, refers to cases in which an individual may receive different care from a provider who is unknowingly acting on partial judgement.

The consequences of implicit bias in health care can be seen in how women receive treatment in comparison to men in life-threatening situations.

For example, a study from the American Stroke Association found that in cases of ischemic stroke, men were more likely than women to receive ultrafast Alteplase administration, a clot-busting drug that helps restore blood flow to the brain.

Additionally, in the aforementioned study from the American Heart Association, 53% of young women (aged 18 to 55) said their health care provider did not think their initial symptoms were heart-related, compared to only 37% of young men who said their provider got it right. These researchers also discovered a pattern in female patients who said they hesitated to seek help because they feared being labeled a hypochondriac.

Because of women’s experiences with the health care system, these biases may affect how women view their own health.

How to Advocate for Women’s Health

Women, their family members and friends, and even bystanders can take steps to help improve care for heart attack and stroke. From advocating for oneself in the emergency room to taking action when someone is in distress, the following resources are a starting point for women’s health advocacy.

How to Communicate With Your Clinician

Women sometimes express that they do not feel heard by their provider when sharing health concerns. Frisvold provided these tips for self-advocacy:


Another person can provide support, ask additional questions, and help navigate the treatment process.


If an individual believes he or she may be having a heart attack or stroke, being prepared to specifically communicate all concerns to the clinician can help.


Engaging in dialogue allows for an individual to push back in a way that is specific and may help a provider check his or her bias.


“When you talk to somebody who had a heart attack, they [often] say, ‘I just knew something wasn’t right, but I just kept trying to downplay it.’ You’re better off going to the emergency room and finding out it was nothing than to err the other way,” Frisvold said.

How Bystanders Can Take Action in Health Emergencies

When another person appears to be experiencing a heart attack or stroke, there are steps you can take to help improve the chances of a positive health outcome:


“Time is of the essence,” Frisvold said. “Those early moments are critical. Take steps early in the process to improve the health outcome of the person experiencing a heart attack or stroke.”


If a stroke is suspected and the person is conscious, the bystander should ask what symptoms the individual is experiencing so the information can be shared with emergency responders if the situation worsens and requires an advocate.


A 2019 study showed that women were less likely to receive CPR from a bystander than men. This step is critical in cases where an individual goes into cardiac arrest while waiting for emergency response. If the bystander has no CPR training, a 911 dispatcher can provide guidance in performing chest compressions.

Resources for Further Reading

Citation for this content: [email protected], the online MSN program from the School of Nursing & Health Studies

The Problem of Pain: Prescribing Opioids to Addicted Populations

The Problem of Pain: Prescribing Opioids to Addicted Populations

Between 2006 and 2012, more than 32 million prescription pain pills circulated through Berkshire County, Massachusetts, a rural area of about 130,000 people.

Patients recovering from opioid addiction are seen at the local emergency department every day, according to Martha Roberts, a critical care Nurse Practitioner (NP) and Georgetown University School of Nursing & Health Studies alumna. Roberts works in Berkshire’s emergency department, which sees 50,000 patients per year — more than a third of the county’s population.

“It’s challenging,” she said. “It’s also an opportunity to help those patients in a way that may improve their outcomes.”

Patients in addiction recovery aren’t exempt from the need for pain relief in the case of acute injuries, surgical operations, or chronic pain. Providers like Roberts are tasked with finding and offering alternatives to opioids.

How can clinicians balance the weight of ethical responsibility with a patient’s need for immediate relief?

Opioid Dependence and Addiction in the United States

About 21% to 29% of individuals who are prescribed opioids misuse them, and 8% to 12% of them develop an addiction, according to the National Institutes of Health. Though only a small percentage of patients are likely to develop an addiction, there is still a chance of dependence, which is characterized by a physical reliance on the medication that, if unaddressed, can lead to addiction.

Even if the patient is not demonstrating symptoms of addiction, providers look for specific signs of dependence, according to Dr. Jill Ogg-Gress, assistant Family Nurse Practitioner (FNP) program director at Georgetown University.

“Opiate medications have side effects of dependence,” said Ogg-Gress, who works as a board-certified emergency NP in several Iowa and Nebraska emergency rooms. “If a provider recognizes that a patient is experiencing dependence, or if a patient demonstrates behaviors of dependence, it should be recommended to the patient they should talk to their primary care provider or the prescriber of the opioids.”

Signs of opioid dependence
  • Taking painkillers more frequently than prescribed
  • Taking higher doses than prescribed
  • Seeking a euphoric effect to counter physical pain
  • Experiencing excessive sleepiness or irritability

Taking these signs into account, providers can evaluate patients’ needs on an individual level to assess the magnitude of pain. If the patient is likely to develop a dependence, the providers may need to help them find an alternative treatment plan that is effective and sustainable.

Ruling out opioids altogether isn’t a realistic approach, Roberts said.

“There are still some painful injuries that will benefit from short-term opioid use,” she said.

Her key to implementing an effective treatment plan is working with the patient to assess their needs and openness to non-opioid pain medication.

Commonly Used Alternatives to Opioids

Opioids are a class of drugs that can be prescribed for pain relief but are highly addictive and illegal for consumption when not prescribed by a health care provider.

Individuals recovering from drug addiction might encounter injuries or surgical operations that require management of immediate acute pain or chronic pain in the long term. Providers can evaluate a patient’s needs when creating a treatment plan to manage that pain.

Pharmacological alternatives to opioids

Analgesics: Some of the most common painkillers can be obtained over the counter in small doses or prescribed in high doses by a health care provider. Roberts and Ogg-Gress agreed that these are the most common alternatives to opioid prescriptions.

Acetaminophen can be used for pain relief and fever reduction, but it does not reduce inflammation. It’s one of the most common pain relievers among Americans, used by roughly 23% of adults each week.

Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can treat acute pain and inflammation. A 2018 report found that NSAIDs make up 5% to 10% of all medications prescribed each year.

Gabapentinoids: This class of drugs includes gabapentin and pregabalin and has been historically used for seizure prevention. It is available by prescription to address pain but only in circumstances set by the Food and Drug Administration. While these painkillers can be an alternative to opioids, Roberts said they are not her intervention of choice because studies show there are other, more effective alternatives.

When medication isn’t appropriate or preferable, many non-pharmacological options exist to relieve pain and suffering.

“There are a lot of other nonpharmacological therapies that are available, if people are willing to try it,” Ogg-Gress said. “Providers need to educate patients regarding these pain therapies instead of the common thought of, ‘Here, take a pill, swallow it, and you’ll feel better.'”

Non-pharmacological alternatives to opioids
  • Localized numbing
  • Ice
  • Massage
  • Exercise
  • Physical therapy
  • Acupuncture
  • Relaxation

Supporting Patients in Recovery

Every patient deserves time and attention to explain their case and their needs to a provider who is listening thoughtfully. Providers treating addicted populations must keep a constant eye out for identifying drug seeking behaviors, without stereotyping or wrongly assuming a patient’s motives. A 2016 report published by the National Institutes of Health described several types of drug-seeking behaviors:

Common Drug-Seeking Behaviors
Requests and complaints
  • Describing a need for a controlled substance
  • Asking for specific opioids by brand name
  • Requesting to have a dose increased
  • Citing multiple allergies to alternative pain therapies
Inappropriate self-medicating
  • Taking more doses than recommended by the provider
  • Hoarding a controlled substance
  • Using a medication despite not being in pain
  • Injecting an oral formula instead of consuming orally
Inappropriate use of general practice
  • Visiting multiple providers for controlled substances
  • Calling clinics when providers who prescribe controlled substances are on call
  • Frequent unscheduled visits, especially for early refills
  • Consistently disruptive behavior
Patterns of resistance
  • Hesitancy to consider alternative pain treatments
  • Declining to sign controlled substances agreement
  • Resisting diagnostic workup or consultation
  • Being more interested in the medication than solving the medical problem
Illegal activity
  • Obtaining controlled drugs from family members or illicit sources
  • Using aliases or forging prescriptions
  • Pattern of lost or stolen prescriptions

Clinicians who have identified these behaviors can use electronic medical records and crossover notes from other providers to see how many times a patient has sought medication for the same problem.

“People are here for assistance, but they’re not taking personal responsibility,” Roberts said. Engaging with patients to help them understand treatment plans can build a sense of agency over their own care.

Roberts said providers can help patients identify ways to care for themselves before writing a prescription for opioids. She recommended a gradual approach to trying different types of treatment:

A Step-Wise Approach for Pain Management

  1. Get to know the patient
  2. Use analgesics to address pain symptoms
  3. Use non-pharmacological treatments as intervention for side effects
  4. Encourage patient to stop smoking and drinking alcohol
  5. Eliminate foods that irritate the stomach or digestive system
  6. Reflect on previous steps: Did you really exhaust everything?
  7. Consider opioids as a last resort, and only enough to support immediate pain relief

Nurse Practitioners who work with a multidisciplinary team are uniquely positioned to provide holistic care. Clinicians serving communities with large addicted populations have to be familiar with law enforcement, social work organizations and, in the case of making a referral outside the clinic or emergency department, recovery programs and child protective services.

Roberts also acknowledged that providers working in communities fraught with addiction are at a high risk for fatigue. “If you have three back pain patients in a row, you’re going to be pretty burned out within two hours of working your shift, so you really, truly have to look at each case individually,” she said.

Taking time to self-reflect on personal motivations for treating patients can help remind providers of why caring for others is important to them.

“It’s hard to walk in and do a good job if you’re upset about the work you’re doing,” Roberts said. “Make sure you can do this without letting your own bias get in the way.”

Please note that this article is for informational purposes only. Individuals should consult their health care professionals before following any of the information provided.

Citation for this content: [email protected], the online DNP program from the School of Nursing & Health Studies

Anti-Vaxx: a Sane Perspective on a Crazy World

Anti-Vaxx: a Sane Perspective on a Crazy World

The anti-vaccination (“anti-vaxx”) movement is a global phenomenon that has received a great deal of press, but how much do we really know about it? How do educated adults come to turn against medicines that have been saving literally millions of lives since the early days of smallpox inoculations?

Doctors prepare to vaccinate an infant.

One partial explanation is offered by health policy reporter Stuart Lyman. In a February column for STAT, he writes, “The [pharmaceutical] industry has been engaging in bad behavior for several decades, and these self-inflicted wounds have turned much of the public against it…” After reciting a horrifying litany of pharma-company scandals the public has witnessed, he concludes, “All of this has contributed to the prominent anti-pharma themes voiced by the anti-vaxx crowd.”

Anti-Vaxx is No Longer In Its Infancy

But “the anti-vaxx crowd” shows no signs of giving up their crusade anytime soon. From their original focus on parents of autistic children, they have proceeded to target orthodox Jewish communities and recently bereaved parents. Perhaps the most influential US group behind anti-vaccine campaigns is ICAN (Informed Consent Action Network). According to the Washington Post, ICAN, founded by former daytime television producer Del Bigtree, is largely funded by New York city philanthropists Bernard and Lisa Seltz, who have contributed $3 million since joining in 2012.

Lisa Seltz now serves as ICAN president, and continues to fund the organization’s message that the government and “Big Pharma” are colluding in a massive coverup regarding the hidden dangers of vaccines. Robert F. Kennedy, Jr, a nephew of the late president, runs Children’s Health Defense, his own anti-vaxx organization, and another flush-with-cash group, The National Vaccine Information Center, is run by Barbara Loe Fisher (who claims her son’s learning disabilities were the result of a 1980 DPT shot that was followed by “convulsion, collapse and brain inflammation within hours”).

Some Quick Tips from NSO’s Georgia Reiner

Considering that these wealthy and powerful organizations are finding fertile ground in today’s conspiracy-minded culture, DailyNurse interviewed Georgia Reiner, a risk specialist for Nurses Service Organization (NSO), to request a few tips for nurses who find themselves confronted by this strange controversy.

DailyNurse: What are the actual dangers posed by the anti-vaxx movement?

GR: It is important to state up front that the vast majority of people do vaccinate. However, the anti-vaccination movement has gained a lot of attention and helped foment outbreaks of largely preventable diseases that can be deadly. The anti-vaxx movement spreads misinformation and conspiracy theories online on social media, and by word-of-mouth in tight-knit, culturally isolated communities.

Anti-vaxx propagandists have helped to create pockets of unvaccinated people, which have contributed to public health issues like the measles outbreak seen recently in Orthodox Jewish communities in New York and New Jersey. These outbreaks of highly contagious diseases such as measles put vulnerable people, including newborn babies and people who have weakened immune systems, at great risk.

Outbreaks also distract and divert resources from other important public health issues, and cost state and local governments millions of dollars to contain. However, nurses are in an ideal position to counter this messaging.

DN: What are nurses doing to counter the anti-vaccination movement?

GR: Nurses are a trusted source of credible information and can have tremendous influence over the decision to vaccinate. This is true even for parents who are vaccine-hesitant. Working on healthcare’s front lines, nurses can help inform families about vaccinations and the role they play in keeping their children healthy and stopping the spread of disease. Nurses can also learn about questions parents may ask about vaccines, and how to effectively address common concerns.

DN: How can nurses cope with anti-vaxx parents?

GR: First, nurses should assume that parents will vaccinate. Research has shown that when healthcare providers use presumptive language, significantly more parents accept vaccines for their child. Then, if parents are still hesitant or express concerns, nurses should work with the treating practitioner to convey the importance of vaccines.

Nurses should listen to parents’ concerns, work to understand why they are questioning the science, and respond respectfully. Provide parents with information about vaccines and vaccine-preventable diseases, both verbally and in writing. Document parents’ questions and concerns.

If parents still decline to vaccinate, the parents should sign a Refusal to Vaccinate form. Parents should sign a new form each time a vaccine is refused so there is a record in the child’s medical file. To minimize potential legal exposure, nurses should document all discussions, actions taken, and educational material provided.

For further information, visit the American Academy of Pediatrics site document “Countering Vaccine Hesitancy.”

Listen to the Chapter Podcasts for Jonas and Kovner's Health Care Delivery in the United States

Gain a better understanding of the current state of the US health care system and how it might impact your work and life.

You have Successfully Subscribed!