Penelope P. Ziegler, MD

B. An adjustment disorder related to professional stressors

C. An acute stress reaction with underlying psychiatric symptoms

D. Medical problems that have not been diagnosed or treated

 A combination of an acute stress reaction and underlying symptoms of more persistent psychiatric issues (ie, anxiety, depression).

“Disruptive behavior” on the part of a physician in the medical workplace can include angry outbursts, harassment of hospital staff, use of vulgar or profane language, passive-aggressive refusal to complete medical records in a timely fashion or attend required meetings, and even violent acts such as throwing sharp instruments or punches in the operating suite.

The first step in providing effective and meaningful treatment involves completing a thorough evaluation to identify all sources of distress, functional impairment, and potential danger to the physician and his patients. Physicians who are willing to accept help and to participate in treatment often do well in individual psychotherapy; some may also need pharmacotherapy for depression, anxiety, or other diagnoses.

What You Need to Know When Treating Physicians: Issues, Sensitivities, and Considerations

,” by Penelope P. Ziegler, MD, on which this quiz was based.

“Burnout”: Strategies to Prevent and Overcome a Common-and Dangerous-Problem

Poll

When physicians behave disruptively in the workplace, what is the most likely cause?

Mini Quiz: Physicians as Patients

“Physicians make terrible patients.” 

This old saying has a lot of truth to it, especially if the physician who is trying to treat a colleague is not knowledgeable about the challenges, barriers, and pitfalls involved in caring for doctors. Some of these challenges are related to personality traits and behavior patterns common among physicians, while others arise out of the culture of medicine, the socialization physicians undergo during their education and training, and today’s regulatory environment.

Although physicians come in all shapes and sizes with highly variable personalities and styles, they share some character traits. In fact, premedical and medical education and the process involved in choosing candidates for medical schools and residencies select for these traits that can make doctors difficult to treat.

• Unrealistic expectations of self and others

[[{"type":"media","view_mode":"media_crop","fid":"49527","attributes":{"alt":"Â© alliance/shutterstock.com","class":"media-image media-image-right","id":"media_crop_893288982127","media_crop_h":"301","media_crop_image_style":"-1","media_crop_instance":"5997","media_crop_rotate":"0","media_crop_scale_h":"145","media_crop_scale_w":"100","media_crop_w":"208","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"Â© alliance/shutterstock.com","typeof":"foaf:Image"}}]]These traits make it difficult for the average physician to prioritize basic self-care and to seek out appropriate assistance with health maintenance activities and treatment for health-related problems when they do occur.

 As a result, physicians neglect routine health care; fail to notice early signs of dysfunction; or respond to such signs with minimization (“Well, my fever and cough are probably not that serious . . . ”), rationalization (“I need to get a flu shot, but I’m way too busy this week . . . month . . . year”), or externalization of blame (“My husband wants me to see a psychiatrist about my mood swings and temper outbursts, but if he would just stop nagging me about spending more time with the family, everything would be fine”).

Physicians who were fairly well compensated in past years are experiencing increased 

 and illnesses as they struggle to cope with the changes in health care delivery. For primary care providers and many specialists, these changes mean working longer hours for less reimbursement. Increased oversight and review mean that the doctor is likely to receive feedback from multiple sources that 

 on his or her competence, skills, and “bedside manner.”

So the physician-patient presents to a health care provider’s office with what may seem like a simple problem, illness, or symptom complex. But he is also dragging a heavy load of unresolved emotional distress, fear, and resentment. In most cases, this burden is invisible to the provider but is paramount to the physician-patient, despite his efforts to keep it out of the conversation or examination room.

Dr G is a 47-year-old family practitioner in a busy group practice. He works 65 to 70 hours every week with a night/weekend call every eighth week. He is married with 3 school-age children. His wife describes him as having had a “personality change” over the past 2 years, with unstable mood and episodes of yelling at her and the children. Last week he threw a vase across the kitchen, splashing water on the cat and frightening everyone. His wife has given him an ultimatum, stating that unless he sees a psychiatrist and gets better quickly, she is going to talk to an attorney.

He comes to see a general psychiatrist “to get my wife off my back” but denies feeling depressed or anxious; having suicidal ideation; or experiencing any physical symptoms, change in appetite, or sleep disturbance, “. . . that is when I can get any sleep if the g-damn phone quits ringing!” When the psychiatrist questions him about his relationships with his children, he begins to cry and says, “I don’t even know them anymore! They’re afraid of me.” He feels terribly ashamed about his behavior and says he wants to do something about it, but he doesn’t know what to do. He is afraid that seeking help could endanger his license and practice.

Dr R is a 27-year-old, single diagnostic radiology resident in a large teaching hospital. She has a long history of trauma-related symptoms and episodes of depression for which she’s had intensive treatment as an adolescent and college student. However, once she entered medical school, she became convinced that continuing her mental health treatment would jeopardize her chances of acceptance into a good residency.

Now that she has begun her PGY2 she is experiencing increasing anxiety and sleep disturbance. She has difficulty falling asleep and frequent nightmares. Several months ago she began using red wine and OTC sleep aids in an effort to get sufficient sleep to function; she is often late to rounds and seems “spacy” and worried. Her residency director has referred her to a psychiatrist for assessment and treatment of what seems to be an anxiety disorder. At the first visit she is very anxious and admits to being easily humiliated and terrified that her “secret will come out,” by which she means that people will learn that she was sexually abused by her stepfather from ages 7 through 13.

Dr J is a 68-year-old general surgeon, divorced, with 2 daughters and 3 small grandchildren. He has recently cut back his practice hours to spend more time with his grandchildren. However, he is struggling in the health care setting because of his difficulty with the hospital’s new electronic health record (EHR) and having to type his operative notes into the computer rather than dictating them. There have been complaints by nursing staff and his colleagues that his notes make no sense, and he has outbursts of foul language at the nursing station while trying to find his patients’ lab results on the electronic system.

The hospital’s Chief of Staff threatens to suspend Dr J’s privileges if he does not undergo evaluation to find out why he cannot “get the hang of” the EHR. He comes to the neuropsychologist with the chief complaint, “Maybe I have Alzheimer disease.”

In each of these cases there is some acute psychiatric 

 to long-standing issues that have affected each physician’s ability to handle the stresses of medical practice, relationships, and adjustment to major changes. The first step in providing effective and meaningful treatment involves completing a thorough evaluation to identify all sources of distress, functional impairment, and potential danger to the physician and his patients. Given the resistance that most physicians show in accepting the patient role, such a comprehensive evaluation needs to include extensive interviews with the physician as well as collateral information from relevant parties, including referral source(s), family/significant others, current and past treatment providers, and in some cases employers or colleagues.

The goals of an initial evaluation of a physician are to:

• Arrive at a preliminary diagnostic impression

• Determine the severity of the condition(s)

• Assess whether the person is able to carry out his professional duties with reasonable skill and safety

• Assess whether the individual presents a danger to himself or to others

• Formulate recommendations for treatment

At this stage, the biggest difference between evaluating a physician and evaluating any new patient is the issue of the doctor’s safety-sensitive occupation. Questions about safety to practice must be explored during the evaluation because of the evaluator’s ethical responsibilities and, in most states, legal obligations. Depending on the specific state’s 

, the evaluator may also want to consider whether enrollment in that program for ongoing monitoring and support would be appropriate and helpful for the physician.

Depending on the findings, the psychiatrist or other mental health professional who performs the initial evaluation may determine what continuing treatment is appropriate and acceptable to the physician-patient. Several caveats should be kept in mind when making treatment decisions.

Physician-patients present to a health care provider’s office with what may seem like a simple problem, illness, or symptom complex. But s/he is also dragging a heavy load of unresolved emotional distress

Individual office-based treatment of newly diagnosed moderate to severe substance use disorders in physicians is almost never successful and probably should not be attempted-even by providers who have expertise in substance use disorders. Such patients should be referred to the state’s Physician Health Program or to a specialized program with expertise in treating health care professionals for initial evaluation and treatment.

Many physician-patients will need ongoing psychotherapy and medication management after completing the initial intensive phase of care. When prescribing medication for a physician in medication-assisted treatment (buprenorphine, methadone, naltrexone) or for co-occurring psychiatric disorders, it is important to be certain that the physician is also receiving individual and/or group therapy and toxicology monitoring and is participating in 

Most physicians who require treatment for depression, anxiety, and other stress-related problems present with a complex picture (see 

) and will need multimodal approaches that can include individual psychotherapy, couples and/or family therapy, psychopharmacological interventions, and assistance in developing a support system. A psychiatrist or therapist who treats physician-patients needs to feel comfortable making the commitment to utilize all these modalities-or needs to assemble a treatment team that can address the patient’s various needs.

When the patient is a peer/colleague, it is tempting to join with the patient’s efforts to minimize the severity of symptoms by agreeing to less frequent visits, calling in medication refills, and not addressing cancelled appointments. It is critical to keep in mind that by the time a physician reaches out for help or is referred by an outside agency, he is deeply distressed and is in need of intensive treatment.

 For these reasons, it is generally inappropriate to attempt to provide psychiatric care and/or psychotherapy to a physician with whom one has a more complicated relationship, such as a personal friendship, supervisory or subsidiary role, business relationship, family connection, or other source of potential conflict.

Managing countertransference when working with physicians can be very challenging depending on the individual patient and the points of identification. The therapist may experience intense anger when the physician-patient fails to improve, relapses, or regresses in terms of professional or family responsibilities. Marked fear and worry about possible self-destructive behavior can interfere with the therapeutic alliance. Seeking clinical supervision is strongly recommended when working with these difficult cases.

Physicians may seek psychiatric care or therapy following an incident involving a boundary violation with a patient, colleague, or co-worker. These can vary from inappropriate prescribing for family, friends, or lovers to professional sexual misconduct, defined by most states as sexual or romantic contact with a person with whom the physician (or other medical professional) has a simultaneous doctor-patient relationship. The primary concern in such cases is that, consciously or unconsciously, the physician is exploiting the power differential inherent in the doctor-patient relationship, which can cause emotional harm to the patient.

Unfortunately, many physicians have had little or no education about professional boundaries. Most have heard that “it is not a good idea to date patients,” but may not realize that it is a violation of the Medical Practice Act and, in some states, a criminal act. An in-depth discussion of the legal, professional, and treatment aspects of professional boundary violations is beyond the scope of this article.

It is critical to keep in mind that by the time a physician reaches out for help or is referred by an outside agency, he is deeply distressed and is in need of intensive treatment

Most general adult psychiatrists and psychotherapists are not equipped to offer the level of expert evaluation and treatment planning needed in such cases. A physician who seeks assistance or is sent by a hospital or medical board should be referred to a specialist or specialized program experienced in conducting this type of evaluation, formulating a comprehensive plan of treatment, and providing the forensic reports and testimony that may be required.

Some physicians are told to get help for their “disruptive behavior” in the medical workplace. This may include angry outbursts, harassment of hospital staff, use of vulgar or profane language, passive-aggressive refusal to complete medical records in a timely fashion or attend required meetings, and even violent acts such as throwing sharp instruments or punches in the operating suite. Some studies indicate that as health care delivery changes and physicians are under new levels of stress, this type of behavior is 

Physicians who are willing to accept help and to participate in treatment often do well in individual psychotherapy; some may also need pharmacotherapy for depression, anxiety, or other diagnoses. Participating in a “Distressed Physician” course can also be a helpful adjunct. Unfortunately, many physicians with “disruptive behavior” have entrenched narcissistic and obsessive-compulsive traits and are not willing to accept any responsibility for their actions. Their ability to benefit from psychotherapy is very limited.

Dr. Ziegler is Medical Director at the Professionals Resource Network, Inc in Fernandina Beach, FL. She reports no conflicts of interest concerning the subject matter of this article.

 Gabbard GO. The role of compulsiveness in the normal physician. 

 Leddy JJ, Moineau G, Puddester D, et al. Does an emotional intelligence test correlate with traditional measures used to determine medical school admission? 

 West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy. 

The Physician as Patient: A Clinical Handbook for Mental Health Professionals

. Washington, DC: American Psychiatric Publishing, Inc; 2008.

 Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. 

 Finlayson AJ, Dietrich MS, Neufeld R, et al. Restoring professionalism: the physician fitness-for-duty evaluation. 

 DuPont RL, McLellan AT, Carr G, et al. How are addicted physicians treated? A national survey of physician health programs. 

 Gendel MH. Treatment adherence in physicians. Prim Psychiatry. 2005;12:48-54.

 Brooks E, Gendel MH, Early SR, et al. Physician boundary violations in a physician’s health program: a 19-year review. 

 Rosenstein AH. Physician disruptive behavior: five-year progress report. 

Articles

The very traits that define a good physician make it difficult for most doctors to prioritize basic self-care. Many fail to notice early signs of dysfunction.

Addiction to alcohol and other drugs is a complex disorder that has been shown to cause modifications in the structure and function of the brain's reward system. These changes are apparent during active drug use, and they persist to some extent for long periods after a person stops using drugs. Because of these persistent changes, as well as established patterns of behavior, patients with substance use disorders-whether actively using or in recovery-are vulnerable to reactivating or complicating their addiction. They can relapse to using the original drug of choice, or an addiction can develop to other chemicals not used in the past. Persons addicted to opioids are at great risk for becoming re-addicted when similar drugs are introduced to their vulnerable brains.

Nevertheless, conditions associated with severe pain can and do develop in persons who have an active addiction or who are in remission from an addictive disease, and these patients may require treatment for pain relief. This presents a challenge to clinicians: how do we help patients manage pain without exacerbating or reactivating the addictive disorder? There is little research data on this topic, but experiential and anecdotal reports collected over the past 3 decades indicate that there are safe and effective approaches to pain management in these patients.


For acute pain syndromes such as pain that occurs following an operation, trauma, or extensive dental work, the use of opioids may be indicated to control severe pain and to achieve optimal pain relief. Many but not all patients recovering from a substance use disorder have an increased tolerance to the effects of opioid drugs and may require higher than average doses for appropriate effect. Despite this, the treating physician or dentist, in a well-meaning but misguided attempt to prevent complications related to addiction, will often reduce the dosage of opioids administered. However, this is contrary to the effective approach, which is to give as large a dose as needed to achieve good pain control. Untreated pain is a trigger for relapse-a trigger that can be as powerful as exposure to an intoxicant.

Since patients with substance use disorders who are in pain often have difficulty discriminating between the need for pain relief and the craving for more drug, it is best to administer the analgesics on a fixed schedule rather than on an as-needed basis. Personally controlled analgesia is not recommended for most persons with a history of substance use addiction.

An additional recommendation for preventing problems with craving is to designate a "medication administrator" who will hold the supply of pills and give them to the patient on schedule. If possible, this will be a person who cannot be manipulated easily by the patient. As soon as possible, the analgesic should be switched from an opioid to an NSAID and/or acetaminophen. In some cases, this may require gradual detoxification from the opioid.

If the patient has an active addiction to alcohol, sedatives, or opioids at the time when the trauma or surgery necessitates pain control, postoperative care may be complicated by the need to manage a more complex detoxification. In addition, clinicians should initiate a discussion about plans for further addiction treatment following recovery. An addiction psychiatrist would be helpful in designing a pharmacologic plan to manage pain and withdrawal symptoms and for follow-up referrals.

If the patient is receiving agonist treatment for opioid dependence with either methadone or buprenorphine, the physician who is prescribing the agonist therapy should be contacted and involved in the pain-management plan.

Maintenance medication will not cover the patient's need for acute pain control.

 Maintenance methadone should be continued as before, and short-acting opioid medication should be given in addition to the maintenance drug on a standing dosage schedule.

 For example, immediately after surgery, a patient receives his or her usual dosage of methadone, 90 mg/d, and also receives meperidine, 100 mg q4h, intramuscularly for pain. Since buprenorphine is a partial agonist with a high affinity for the µ-receptor, it will need to be discontinued in order for the short-acting opioid pain medication to be effective. Once the patient no longer requires opioids for pain management, the patient can be re-induced on buprenorphine for continued opioid agonist treatment.

During a bout with acute pain, a patient recovering from a substance use disorder will need increased support from his ongoing recovery program. Strengthening the support system may make all the difference in preventing a relapse. The abstinent patient without an ongoing program of recovery is at high risk for relapse when exposed to opioid pain medications or sedative muscle relaxants.


BG is a 47-year-old married plumber with a long history of alcohol and cocaine dependence who has been abstinent and attending Alcoholics Anonymous (AA) for 3 years. While installing new bathroom fixtures, he fell from a ladder and fractured his right tibia and fibula, requiring open reduction. In the emergency department, he told the orthopedic surgeon about his addiction history and expressed a fear that the pain medication would cause him to relapse. Postoperatively, his surgeon decided to use lower doses of meperidine than usual in order to avoid any possible complications with BG's addiction recovery. However, BG was in severe pain and unable to sleep for several days.

Within hours of being discharged from the hospital with no prescription pain medication, BG began drinking heavily. His wife called the surgeon, who decided to obtain an addiction medicine consultation. BG was admitted to the hospital detoxification unit under the care of Dr J, an addiction psychiatrist, and was started on an alcohol detoxification protocol and prescribed appropriate dosages of oxycodone with acetaminophen for pain control. Dr J, with BG's permission, also contacted his AA sponsor and arranged for him to visit the patient.

After 3 days, BG was discharged from the unit with a plan for the AA group to bring meetings to his home and for his wife to hold the pain medications and administer the prescribed dose every 6 hours. By week's end, BG's pain was being managed with ibuprofen, and he reported no craving for alcohol or other drugs.


Chronic pain syndromes present very different management issues in the patient who has a substance use disorder. The first step in developing a plan for safe pain management is to conduct a thorough assessment of all aspects of the patient's physical and emotional health and his recovery. This includes a comprehensive physical and psychiatric history and examination; a review of the patient's records from previous and current care providers; collateral contacts with significant persons in the patient's life, such as a spouse or significant other, parents, children, involved relatives, friends, coworkers, and current health care providers. The evaluation should also include a urine toxicology screening that tests for a range of substances, including synthetic opioids; agonist/antagonist opioids; short-acting benzodiazepines and barbiturates; and over-the-counter substances, such as diphenhydramine, ephedrine, and phenylpropanolamine.

The drug history needs to explore alcohol use patterns; use of illicit, prescription, and over-the-counter drugs; and use of herbal preparations and food supplements, including energy drinks, natural sleep aids, and other tonics.

Three drugs that are frequently prescribed for patients with chronic pain deserve special mention because of the high risk of addiction. Carisoprodol is a muscle relaxant that is metabolized to meprobamate, a tranquilizer similar to diazepam. Butalbital is a short-acting barbiturate that is often combined with acetaminophen or a combination of acetaminophen and caffeine. Tramadol is a µ-receptor agonist that also appears to inhibit reuptake of serotonin and norepinephrine. Often viewed as "benign" by practitioners because they are not scheduled by the US Drug Enforcement Agency, these drugs' pharmacologic actions trigger the same receptors as other, more obvious offenders and should be avoided if possible.

For the person recovering from a substance use disorder who has a chronic or recurring pain syndrome and who is not currently taking opioids or sedatives, the safest treatment approach is for the clinician and patient to develop a pain management plan that effectively controls pain without the use of these substances. Most persons with substance use disorders who are involved in a recovery program are motivated to work with a pain treatment physician to prevent re-addiction and will have at least a vague understanding that certain drugs can be risky for them. A written treatment protocol can provide a structure and framework that will decrease the patient's anxiety and give family members and other caregivers a guideline to follow in times of crisis (

Nonopioid pain treatments vary widely in their efficacy and appropriateness, depending on the type of pain the patient is experiencing, his overall state of health, and the availability of support systems and resources.

In addition to nonspecific pain relievers including anti-inflammatory drugs, syndrome-specific drugs are available for many types of chronic pain (

). New (and often off-label) uses for older drugs are also available, including tricyclic antidepressants

Nonpharmacologic approaches are also an important part of managing chronic pain. The following are some examples:

Relaxation, meditation, and imagery techniques

Electrostimulation, including transcutaneous electrical nerve stimulation

Expressive therapies, such as art therapy, movement therapy, and music therapy

Many patients with chronic pain who are recovering from an addiction have additional psychiatric disorders that require treatment in order for the pain management strategy to be successful. Some common comorbid illnesses include depression, anxiety disorders (including posttraumatic stress disorder); somatoform disorders; personality disorders; and adjustment disorders, which may or may not be directly related to the pain syndrome itself. Commonly, the pain is found to have both physical and psychological components, and aggressive treatment of comorbid psychiatric illness can decrease the severity of the pain; improve the patient's adherence to the pain management strategy; and improve the patient's participation in, and the benefit from, his addiction recovery program.

When the pain is not responsive to such approaches and opioids are required to control the patient's pain, it is essential that a structured plan of treatment be in place. In such cases, a clear written agreement such as the one that is shown in the Figure can be very helpful.


CA is a 28-year-old single mother who is currently working as a receptionist in an attorney's office. She was actively addicted to heroin between ages 17 and 22 years, when she became pregnant. She entered a methadone treatment program for pregnant women and after giving birth to her daughter, spent 2 years in a drug-free therapeutic community for women with children. She has been abstinent from street drugs and alcohol since that time, and she has completed her degree at a local community college.

Since her pregnancy, CA has had migraine headaches 2 or 3 times per month. Initially, she managed the headaches with over-the-counter medication, but in the past year, the headaches have become more severe. CA discussed the headaches with her family doctor but did not reveal her addiction history. Her physician prescribed hydrocodone, which was ineffective, and then oxycodone and butalbital with codeine. CA began escalating the dosages, asking for early refills, and making frequent visits to the emergency department. She was having headaches almost daily, despite the increased dosages of medication. When a trial of fentanyl patches was not beneficial, CA admitted that she was addicted and told her physician about her addiction history.

She entered a buprenorphine treatment program under the care of an addiction psychiatrist and was given topiramate daily for migraine prophylaxis and sumatriptan therapy for breakthrough headaches. A structured treatment protocol, including a weekly pain management group, a weekly addiction group, and 3 weekly Narcotics Anonymous meetings, was essential in managing her occasional cravings to take heroin. Her medications were not covered by insurance but were obtained through a prescription assistance program.


In general, the pain treatment regimen for a person recovering from an addiction involves the use of long-acting opioids, such as sustained-release oxycodone, methadone, or buprenorphine, administered on a fixed dosage schedule, with another person holding the medication. Unlike addiction treatment protocols, which usually employ once-daily dosing schedules, methadone and buprenorphine are divided into 2 or 3 daily doses for better pain control. For methadone, dosages can range from 60 to 200 mg or more daily; with buprenorphine, dosages of 4 to 32 mg/d are common.

 In addition, a "rescue" dose of a short-acting opioid such as oxycodone or hydromorphone may be available, again held by the participating family member or caregiver, with clear guidelines for when it is to be used.

Other aspects of the protocol include the involvement of a single physician who writes prescriptions weekly at first with no refills, until the patient demonstrates his ability to safely adhere to the protocol. As in the nonopioid protocol, all prescriptions are filled at the same pharmacy, and no prescriptions are called in by phone; lost, stolen, or damaged prescriptions or pills are not replaced. Although controlled research to demonstrate the effectiveness of this approach in preventing substance misuse is lacking, more than 75% of pain specialists currently use some form of agreement with their patients with chronic pain.

Urine drug screening should be done randomly but regularly to determine whether other substances are being ingested and to ensure that prescribed medications are being taken. The current use of illicit substances indicates a need for additional substance abuse treatment for the patient and may predict misuse of opioid pain medications.

When approached as a joint effort between the physician and the patient, a structured treatment plan gives the patient a strong investment in determining his own pain management strategy. Throughout the development of the protocol, it should be emphasized that the purpose of the plan is to provide maximal pain relief while protecting the recovering patient's sobriety against the insidious reactivation of his disease.

In addition to the written agreement and consistent expectations and responses on the part of the treating psychiatrist, all clinical staff need to be trained in both addiction and pain, using experiential (eg, films, group discussions) as well as didactic methods. Staff should be aware that patient behaviors arise from symptoms of their disease; despite their behavior they deserve to be treated with dignity and respect. Since clinicians ask patients to adhere to their treatment agreements, we need to keep our end of the bargain by being kind, patient, forthright, and on time.

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How do we help patients manage pain without exacerbating or reactivating an addictive disorder?

Author | Penelope P. Ziegler, MD

Articles

Mini Quiz: Physicians as Patients

What You Need to Know When Treating Physicians: Issues, Sensitivities, and Considerations

Safe Treatment of Pain in the Patient With a Substance Use Disorder