Jordan F. Karp, MD

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(This is the last part of a 4-part series. The previous pieces provided an intro to the “Psychiatry for Non-Psychiatrists: The University of Arizona Update in Behavioral Medicine for Primary Care” conference, as well as updates on attention-deficit/hyperactivity disorder and suicide risk assessment and prevention.—Ed.)

The data on substance use disorders (SUDs) and overdose deaths are staggering and deeply concerning. According to the National Center for Drug Abuse Statistics, “165 million, or 60.2% of Americans aged 12 years or older, currently abuse drugs,” which includes illegal drugs, misusing prescribing drugs, and abusing alcohol and tobacco.

is a clinical assistant professor at the University of Arizona College of Medicine Department of Psychiatry, the department’s director of the Addiction Medicine Fellowship, and the medical director of addiction services at the Southern Arizona Veterans Affairs Health Care System. 

She developed the University of Arizona Addiction Medicine Fellowship in 2018, and, in 2020, she secured a $1.4 million Health Resources and Services Administration (HRSA) grant to expand the fellowship and further enhance the infrastructure of the program.

The Centers for Disease Control and Prevention’s National Center for Health Statistics shows that the number of overdose deaths has climbed from more than 70,000 in the 12-month period ending in January 2018 to more than 99,000 in the 12-month period ending September 2021. Preliminary reports indicate the number of drug overdose deaths in America increased 30% in 2020. In January 2021, drug overdose deaths exceeded homicides by 307%.

The positive implications for screening for and treating individuals with SUDs are vast, from preventing HIV and hepatitis in injection-drug users to improving patients’ physical health, mental health, employment, and housing.

Elisa Gumm, DO, who is presenting on “Screening for Addiction in a 20-Minute Appointment” at the “

Psychiatry for Non-Psychiatrists: The University of Arizona Update in Behavioral Medicine for Primary Care

” conference, stated that “offering addiction interventions at every level reduces the overall costs to the person and society.”

According to the National Institute on Drug Abuse publication, 

Principles of Drug Addiction Treatment: A Research-Based Guide

, “every dollar invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft. When savings related to health care are included, total savings can exceed costs by a ratio of 12 to 1.”

 Past-Year SUD and Any Mental Illness (AMI) Among Adults Aged 18 or Older, 2020

In addition, there are studies showing that addiction treatment has ripple effects and can even improve the health of family members when the patient with addiction gets treatment.

“Primary care teams should screen for addiction and assist their patients with care,” Gumm said. “When patients receive addiction treatment, comorbidities improve. It is difficult to treat medical conditions when a patient has an active substance use disorder, including nicotine and alcohol. It makes managing numerous diseases difficult and exhausting because there seems to be a hidden factor at play.”

Substance Use Among Adults Aged 18 or Older by Mental Illness Status, 2020

Primary care providers should also consider cooccurring mental health disorders, per the correlation with substance use/abuse. The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that, of adults aged 18 or older in 2020, 29% (or 74 million people) had either any mental illness (AMI) or an SUD in the past year; 14% (or 36 million people) had AMI, but not an SUD; 8% (or 21 million people) had an SUD, but not AMI; and 7% (or 17 million people) had both AMI and an SUD”(

The SAMHSA report also shows the percent of adults with mental illnesses and their substance use, as summarized in 

Gumm recommends primary care providers implement the Screening, Brief Intervention, and Referral to Treatment (SBIRT),

 as SBIRT is “proven successful in screening patients quickly and arming primary care doctors with treatment options when the screen is positive.” She also advises to, “be kind to all those involved. Soften the approach to asking patients about addiction.”

We hope you join us and Dr Gumm to learn more about helping patients with substance use disorders on Saturday, March 12. Find conference details, including the schedule, description of presenters, and registration at 

 is professor and department chair of psychiatry at the University of Arizona College of Medicine. He is an expert in the fields of geriatric psychiatry, depression treatment, and suicide prevention. He is committed to educating health care providers about the principles of psychiatry and behavioral medicine. 

 is the communication and marketing specialist for the University of Arizona College of Medicine Department of Psychiatry.

. National Center for Drug Abuse Statistics. February 19, 2022. Accessed February 25, 2022.

Vital statistics rapid release provisional drug overdose death counts

. Centers for Disease Control and Prevention. February 16, 2022. Accessed February 25, 2022.

 National Institute on Drug Abuse. January 2018. Accessed February 25, 2022.

4. Weisner C, Parthasarathy S, Moore C, et al. 

Individuals receiving addiction treatment: are medical costs of their family members reduced?

Key substance use and mental health indicators in the United States: results from the 2020 National Survey on Drug Use and Health (NSDUH)

. Substance Abuse and Mental Health Services Administration. Accessed February 25, 2022.

Integrating screening, brief intervention, and referral to treatment (SBIRT) into clinical practice settings: a brief review

Articles

The data on substance use disorders are staggering. What can primary care providers do to help?

Psychiatry for Primary Care: An Update on Substance Use Disorders (Part 4)

(This is the second part of a 4-part series. The next 2 pieces will discuss addiction and suicide prevention as covered in the “Psychiatry for Non-Psychiatrists: The University of Arizona Update in Behavioral Medicine for Primary Care” conference.—Ed.)

The late Paul H. Wender, MD, once wrote that “ADHD is probably the most common chronic undiagnosed psychiatric disorder in adults.”

 The primary care providers (PCPs) on our planning committee for the “

” conference unanimously favored covering this topic, and we are thrilled that Jeffrey Newcorn, MD, professor of psychiatry and pediatrics and director of the Division of ADHD and Learning Disorders at Icahn School of Medicine at Mount Sinai, will present a 30-minute lecture titled,“Diagnosis & Treatment of ADHD Across the Lifespan: A Primer for Primary Care Physicians.”

Newcorn shares with us that the main obstacle to the diagnosis and treatment of adults with attention-deficit/hyperactivity disorder (ADHD) is that most PCPs are not trained to consider it in the differential diagnosis.

“Very few physician training programs outside of psychiatry, pediatrics, and family medicine include ADHD in their curricula, yet ADHD is often present in ~4.5% of the adult population,” he said. 

is professor of psychiatry and pediatrics, director of the Division of ADHD and Learning Disorders at Icahn School of Medicine at Mount Sinai, and director of pediatric psychopharmacology for the Mount Sinai Health System. 

He is also the immediate past president of the American Professional Society of ADHD and Related Disorders (APSARD). He is a highly regarded clinician—a researcher with special expertise in the field of ADHD across the lifespan, as well as child, adolescent, and adult psychopharmacology, whose academic work spans both clinical and translational topics.

“Adults with ADHD underachieve at work and often have multiple changes in jobs. They earn less money than their non-ADHD peers—across all socioeconomic and social strata.

 Further, ADHD complicates family relationships and is associated with high rates of divorce. Moreover, a missed diagnosis of ADHD is a very common contributor to treatment failure of other disorders. Unfortunately, the vast majority of adults with ADHD who are seen for medical checkups by their primary care providers never come to psychiatric care. So, identifying ADHD in medical settings is extremely important.”

For adults with undiagnosed ADHD, the consequences can have serious implications. The National Comorbidity Survey Replication study reported a significant degree of psychiatric comorbidity among adults with ADHD: 19% had major depressive disorder, compared with 8% of those without ADHD; 47% also had a coexisting anxiety disorder (vs 20%), 38% had a mood disorder (vs 11%), and 15% had a substance use disorder (vs 6%).

Unfortunately, there are not current treatment guidelines for adult ADHD, so extrapolation from guidelines and best practices in treating adolescents is necessary. Treatments can include a combination of medication, environmental modifications, and psychosocial interventions. For medication treatment, whether to use simulants or approved nonstimulant medications, or to use them in combination, of course depends on many factors. Newcorn’s presentation will review ways to choose from among the various medications and nonmedication approaches to care.

We hope you join us and Dr Newcorn on Saturday, March 12, to learn more about how to treat your patients with ADHD. Find conference details, including the schedule, description of presenters, and registration at 

Attention-Deficit Hyperactivity Disorder in Adults

2. Biederman J, Faraone SV, Spencer TJ, et al. 

Functional impairments in adults with self-reports of diagnosed ADHD: a controlled study of 1001 adults in the community

3. Kessler RC, Adler L, Barkley R, et al. 

The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication

Being able to identify ADHD in medical settings is very important. One doctor will offer some guidelines for diagnosis and treatment.

Psychiatry for Primary Care: An Update on ADHD (Part 2)

(This is the first part of a 4-part series. The following 3 pieces will discuss ADHD, addiction, and suicide prevention as covered in the “Psychiatry for Non-Psychiatrists: The University of Arizona Update in Behavioral Medicine for Primary Care” conference.—Ed.)

Prior to the COVID-19 pandemic, the prevalence of mental illness was rising at an alarming rate. Since March 2020, it has only gotten worse.

 Between the increase in psychiatric conditions and the dearth of mental health care professionals, primary care providers (PCPs) are increasingly confronted with patients who are struggling with behavioral health conditions such as depression, attention-deficit/hyperactivity disorder (ADHD), insomnia, addiction, and suicidal ideation.

In response to this intersecting crisis of limited access to mental health specialists and rising rates of these disorders, the Department of Psychiatry at the University of Arizona College of Medicine in Tucson convened a committee of PCPs and psychiatrists with the charge to organize a fully virtual conference on Saturday, March 12, targeting the educational needs of physicians and allied health professionals working in primary care settings. “

” was created to provide PCPs with new and updated knowledge to enhance their clinical confidence and skills, improve comorbid medical comorbidities, and reduce the stigma of seeking treatment for mental illness.

Because the topics are wide-ranging and packed into 30- to 45-minute presentations, there are plenty of options for physicians, nurses, physician assistants, practicing psychiatrists, and resident physicians to gain valuable and applicable clinical knowledge.

In this series on the conference (for which participants may receive up to 5.5 CME hours), we will cover the presentations in 3 subsequent articles on ADHD in adults, screening for addiction, and suicide prevention.

1. Czeisler MÉ, Lane RI, Petrosky E, et al. 

Mental health, substance use, and suicidal ideation during the COVID-19 pandemic – United States, June 24-30, 2020

Primary care providers are increasingly seeing patients who are struggling with mental illness—how can they effectively assist these patients?

Psychiatry for Primary Care: A Behavioral Medicine Update (Part 1)

Rather than striving to halt, delay, or reverse disease progression or provide a cure, the goal of palliative care is to prevent and relieve suffering and to improve quality of life for people facing a serious, complex illness. Nonhospice palliative care does not depend on prognosis and is offered in conjunction with curative and all other appropriate forms of medical treatment. While any noncurative approach to treatment may be viewed as palliative, the 2 most familiar palliative approaches are pain management and hospice.

The goal of psychiatric care late in life is the remission of symptoms of mood, anxiety, cognitive, and behavioral disorders along with rehabilitation of psychosocial functioning and improved quality of life. Remission of symptoms may be viewed as a “cure” if it is sustained. In many patients, however, symptoms follow a waxing and waning course that requires a palliative care approach. For these patients and their families, cure may not be a reasonable goal of treatment; rather, a reduction in symptoms and an improved quality of life may be a more reasonable approach.

Although the concept of palliative care is not new, most physicians have traditionally concentrated on trying to cure patients. The term “palliative care” is increasingly used with regard to diseases other than cancer, such as chronic progressive pulmonary disorders, renal disease, chronic heart failure, HIV/AIDS, and progressive neurological and treatment-resistant psy-chiatric conditions.

In this article, I address 3 conditions in which psychiatrists may offer a palliative care approach to optimize the quality of life of older adults who have treatment-resistant mood disorders, pain, or moderate to advanced dementia.

Older patients with treatment-resistant mood disorders

As defined by the American College of Neuropsychopharmacology, refractory depression is the persistence of significant symptoms despite at least 2 treatment trials with drugs from different pharmacological classes, each used in an adequate dose for an adequate period.

 If combination and augmentation pharmacotherapy, other somatic interventions (electroconvulsive therapy [ECT], bright light therapy, transcranial magnetic stimulation), and psychotherapy have not led to significant resolution of symptoms, a palliative approach may be an option.

Using a palliative approach does not mean that the patient, his or her family, and the physician should give up hope that symptoms will improve. It may, however, involve a shift in the expectations of treatment outcome. In challenging cases, it may be helpful to approach the disorder as a chronic condition that requires long-term management (such as diabetes or hypertension) to maintain symptoms at a tolerable level.

Patients with such chronic conditions generally require life-long treatment with 1 or more antidepressant medications, maintenance ECT, and augmentation therapies. Targeting specific symptoms with the palliative approach may enhance quality of life for both patients and their caregivers. For example, if fatigue or sedation is a prominent symptom that is resistant to traditional pharmacological and/or behavioral interventions, trials of CNS stimulants such as methylphenidate or mixed amphetamine salts may be useful. If insomnia is recalcitrant to behavioral therapy and/or pharmacotherapy with 1 agent and obstructive sleep apnea has been excluded, the use of more than 1 hypnotic, such as a benzodiazepine, and a sedating antidepressant may be required. While we do not view these interventions as curative, they may be critical in improving quality of life. Common sense must apply regard-ing polypharmacy, adverse effects, changes in pharmacokinetics and pharmacodynamics associated with aging, and diversion of drugs of potential abuse.

•For some older adults with treatment-resistant mood and anxiety disorders, advanced cognitive decline, and chronic pain, cure may not be the goal of treatment. Rather, a reduction in symptoms and an improved quality of life may be a more reasonable approach.

•  Effective use of a palliative care approach often requires a multidisciplinary approach.

• When treating a patient with dementia, among the psychiatrist’s most important functions are to advocate for the patient and his or her family, to manage behavioral and mood disturbances, and to minimize caregiver burden.

Psychiatrists caring for older adults evaluate and treat patients with persistent pain in the office, nursing home, psychiatric hospital, and medical hospital. Consistent with the principles of palliative care, the psychiatric approach to persistent pain is not disease modification; rather, the goal is to reduce symptom severity and improve quality of life. Given that up to 50% of community-dwelling seniors experience pain that interferes with normal function and 45% to 80% of nursing home residents have daily pain, care of these patients should, at the least, involve routine assessment for pain severity and pain-related disability.

Although some psychiatrists who work with the elderly are comfortable prescribing oral and topical analgesics and collaborating with primary care physicians and physical and occupational therapists, the majority of psychiatrists feel little “ownership” of or comfort with this area of medicine. For all psychiatrists, however, knowledge about the typical presentation and differential diagnosis of pain conditions (

) will assist in precise and effective transdisciplinary communication and will allow for treatment recommendations.

In the specialized setting in which I practice, I routinely assess for and assist in the management of both the psychiatric and pain conditions of elderly patients. I have found the following steps useful when assessing a patient:

• Introduce yourself and let the patient know that you are a psychiatrist with an interest in pain management

• Take a full pain history that includes a chart review; an etiology and a description of the pain; past treatments; and the degree to which pain interferes with activities, relationships, independence, and sleep

• Assess the psychiatric chief complaint and history of the psychiatric illness

• Pay attention to psychiatric comorbidity, sleep problems, and suicidal ideation, because patients with chronic pain and psychiatric disorders are at higher risk for these conditions

Most of the prescriptions that I write are for antidepressants, anticonvulsants, benzodiazepines, stimulants, and hypnotics; however, to properly care for patients has required that I be comfortable prescribing both oral (eg, acetaminophen, opioids) and topical (eg, lidocaine patch, capsaicin, compounded creams) analgesics. When opioids are required, I usually prescribe tramadol; hydrocodone; oxycodone; or a longer-acting morphine derivative, such as the transdermal fentanyl patch. Although I occasionally prescribe NSAIDs, given their potential GI and cardiovascular toxicity, I usually leave the prescribing of these agents to pain physicians or primary care physicians. Their use, however, frequently goes into my consultation reports as treatment recommendations.

Because pain is a multifactorial phenomenon, including sensory, emotional, and cognitive components, there is no one-size-fits-all treatment. Thus, to effectively care for patients and provide palliative care, I work closely with a multidisciplinary team of psychologists (who specialize in cognitive-behavioral therapy), rehabilitation specialists (physical and occupational therapists), and pain medicine physicians. We are fortunate to have all of these services under one roof. However, psychiatrists can create their own network of specialists by cultivating professional relationships with colleagues from these disciplines.

Because of the multiple components of pain (sensory, emotional, cognitive), each patient requires an individualized management plan that can integrate analgesics, rehabilitation therapies, psychological interventions, and a variety of somatic treatments (eg, injections, surgery, complementary and alternative medicine). All older patients, however, should be counseled that:

• Chronic pain is a syndrome with many potential contributors, all of which require treatment for optimal clinical outcome

• Chronic pain can be treated but not cured; improvement is the rule, not the exception

• Improvement in functional ability is often greater than the reduction in pain severity

It may be helpful to refer patients to a pain clinic for more intensive treatment if pain is the primary complaint, if the pain is not diminishing (or is worsening), or if “serial referrals” to specialists have been unsuccessful. There are different types of pain clinics, including single-modality clinics (eg, a nerve block clinic), syndrome-oriented clinics (eg, for low back pain or headaches), and multidisciplinary clinics that treat a variety of pain syndromes.

There are no established recommendations for when to refer a patient or who should be referred to a pain clinic. In general, though, a referral is usually appropriate between 4 and 6 months after severe symptom onset in patients who also have evidence of related physical or psychosocial deterioration.

 In addition to reduction in pain severity and pain “bothersomeness,” treatment outcome parameters for older adults include the degree to which pain interferes with performance of basic, instrumental, and discretionary activities of daily living. Other relevant outcomes include the effect of pain on the patient’s mobility/activity, energy, appetite, sleep, mood and irritability, interpersonal functioning, attention and concentration, and frequency of as-needed dosing of an analgesic.

Older patients with moderate to advanced dementia

To date there are no disease-modifying or preventive medications for dementia, of which Alzheimer disease is the most common. In addition to memory and other cognitive deficits, the majority of patients with moderate to advanced dementia have a range of neuropsychiatric and behavioral disorders, such as depression, anxiety, disordered sleep, apathy, agitation, and psychosis.

The goal is not cure but a palliative reduction in symptom burden and an enhancement of quality of life. An important function of the psychiatrist is to teach families and caregivers about the most distressing neuropsychiatric symptoms and behaviors that can be expected, such as repetitive behavior, restlessness, incontinence, lack of inhibition, sleep problems, and suspiciousness. 

 lists practical recommendations for coping with these behaviors. In addition, it is important to educate patients and their caregivers so that they have reasonable expectations about dis-ease progression and management options and to provide information about services, entitlements, and options (eg, nursing home placement, respite care, hospice, and geriatric case managers).

In working with elderly patients with dementia and their families, patient preferences regarding type and level of care should be ascertained (

). This is especially useful if premorbid preferences for care in late life (when capacity to make decisions is less likely to be challenged) have been documented.

The ability of families to care for loved ones with dementia in the home varies. It is a standard of care to consistently assess caregivers for burnout and depression to ensure that their quality of life is maintained and that proper care can be provided to the patient. Minimizing patients’ neuropsychiatric and behavioral symptoms can prolong the time they can stay in their homes and can maximize the amount of meaningful time they can spend with loved ones.

Hospice is an option for severely demented patients. Key clinical indicators for hospice include:

• Progressive decline in status despite curative treatments

• Progressive/profound weakness and fatigue

• Shortness of breath with or without oxygen

• Profound dependency (decrease in activities of daily living)

A patient may leave hospice care if his condition improves and reenter if the condition worsens. The goal of hospice, consistent with palliative care, is to keep the patient’s pain and suffering to a minimum. Hospice care can be delivered at home or in a hospital, nursing home, or private hospice facility. Hospice can provide companionship, spiritual care, transferral of the patient from home care to inpatient care, respite care for caregivers, family conferences, after-death services, and bereavement care.

Because pain management and symptom control may be difficult with dementia, many patients are cared for in nursing homes. The final stage can last from months to years. Medicare allows hospice care for 2 periods of 90 days, followed by an unlimited number of 60-day periods, as long as the physician recertifies that the patient is not getting better and is still terminal. Patients remain eligible for hospice services if their decline is measurable (from month to month) and their prognosis can be recertified by their primary care physician. Ways to enhance hospice enrollment for patients with advanced dementia include:

• Educating nursing homes about the appropriate time to suggest hospice services

• Educating families and physicians that dementia is terminal and about the disease process

• Increasing the comfort of physicians to certify that a patient has 6 months (or less) to live, although some patients may actually live longer

• Identifying and controlling pain symptoms in cognitively impaired patients

The palliative approach described in this article is no less aggressive in hastening treatment outcome than that used in a curative treatment model. Indeed, the imperative for symptom reduction and enhanced quality of life may be more pressing given both the urgency (eg, pain) or the terminal nature (eg, end-stage dementia) of these conditions and the profound effect on families and caregivers.

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Psychopharmacology: The Fourth Generation of Progress

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 Helme RD, Gibson SJ. The epidemiology of pain in elderly people.

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 Onen SH, Onen F, Courpron P, Dubray C. How pain and analgesics disturb sleep.

 Bair MJ, Wu J, Damush TM, et al. Association of depression and anxiety alone and in combination with chronic musculoskeletal pain in primary care patients.

 Weiner DK. Office management of chronic pain in the elderly.

 Nicholas MK. When to refer to a pain clinic.

• Caring Connections. Living with an illness. http://www.caringinfo.org. Accessed June 24, 2010.
• Family Caregiver Alliance. National Center on Caregiving. http://www.caregiver.org. Accessed June 24, 2010.
• Hospice Foundation of America. Hospice information center for families, friends, and professionals. 

. Accessed June 24, 2010.
• JAMA Patient Page: Palliative care. 

http://jama.ama-assn.org/cgi/reprint/296/11/1428.pdf

The goal of palliative care is to prevent and relieve suffering and to improve quality of life for people facing a serious, complex illness.

Jordan F. Karp, MD

Articles

Psychiatry for Primary Care: An Update on Substance Use Disorders (Part 4)

Psychiatry for Primary Care: An Update on ADHD (Part 2)

Psychiatry for Primary Care: A Behavioral Medicine Update (Part 1)

Palliative Care in Older Adults