a coaching and consulting psychiatrist, is board-certified in psychiatry, addiction medicine, and coaching (BCC). He launched 

after 8 years directing Physician Health Services, Inc. On the faculty of the University of Massachusetts Medical School, he is a consultant in psychiatry in the Division of Alcohol and Drug Abuse of McLean Hospital, an affiliate of Harvard Medical School.

Steve Adelman, MD

1. Make a Diagnosis with Appropriate Differential

Patients complaining of anxiety and/or insomnia may have an underlying substance use disorder (SUD) that mimics an anxiety disorder. They may be experiencing drug side effects that may be ameliorated without adding a BZD. 

2. Comprehensive Assessment Including Risk of Substance Use Disorders and/or Chronic Pain, including Family h/o SUDs

The cornerstone of a good comprehensive assessment is a thorough and careful clinical history, including a family history of SUDs. Patient-centered urine drug screening should be the rule, along with review of the state’s prescription monitoring program. Standardized risk assessment surveys may also be utilized.

The possibility of synergistic side effects, including somnolence and respiratory depression, should routinely be covered.

The range of aberrant drug-seeking behaviors should be covered in the treatment agreement (eg, lost prescriptions, early refills), with clarity regarding the standard response to such behaviors. When patients balk at the signing of a treatment agreement regarding controlled substance use and misuse, that often represents a red flag to be kept in mind as treatment decisions are made going forward.

5. Careful Consideration of Nonpharmacological Anxiety Reduction Strategies; and, non-BZD Alternatives Without Addiction Liability

Modalities like cognitive behavioral therapy, dialectical behavioral therapy, and meditation should be considered; as should less risky pharmacological options like buspirone, selective serotonin reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors.

6. Pre- and Post-Intervention Assessment of Anxiety Symptoms and Level of Functioning

The prescription of medications with potentially dangerous side effects is meant to improve a patient’s level of functioning. If functional level is deteriorating or simply not improving, a consultation or second opinion may be called for.

7. Periodically Review All Psychiatric Diagnoses and Comorbid Conditions, Including SUDs

Early on, and throughout the course of the patient’s psychiatric treatment, the routine use of patient-centered urine drug screens, prescription monitoring program database review, and pill counts, should be emphasized as components of routine treatment.

All data that speaks to the presence or absence of active SUDs, especially opioid use disorder and aberrant use of BZDs, should be carefully documented in the medical record. Whenever possible and feasible, nonmental health providers involved with each patient should be privy to relevant data. The withholding of information from medical providers may indicate a significant current problem.

 has progressed during the past 2 decades, more and more patients have left their doctors’ offices with prescriptions for benzodiazepine medications (BZDs). Across the medical profession, the percentage of outpatient visits resulting in a BZD prescription has increased from 3.8% in 2003 to 7.4% in 2015.

 It is estimated that concurrent use of BZDs and opioids may occur in as many as 50% of 

 This shocking statistic suggests the possibility that more cautious and conservative use of BZDs by all who prescribe them has the potential to save thousands of lives per year. 

During the time period studied by Agarwal et al,

 outpatient psychiatrists manifested a stable pattern of BZD prescribing, delivering BZD prescriptions to the patient in 30% of psychiatric visits. Overall, BZD prescriptions written by psychiatrists account for approximately one-sixth of the more than 25 million prescriptions that are written each year.

 In the years 2015 and 2016, 30.6 million US adults reported BZD use in the past year; of these, 5.3 million were deemed to be misusing BZDs.

 The most common type of BZD misuse occurs when prescribed BZDs are diverted and utilized by individuals who are not receiving them for a legitimate medical indication. 

These threads of data suggest that some BZDs prescribed by psychiatrists end up being misused by individuals who are also misusing opioids, and that some of these 

opioid overdose deaths are potentiated by BZDs

 prescribed by a trusting psychiatrist. Are these BZDs that originate in mental health settings a factor in hundreds of yearly opioid overdose deaths, or in thousands? Although the magnitude of this problem is not known, it is likely that psychiatrists who exercise more caution in prescribing BZDs can play a role in doing less inadvertent harm.

 performed a comprehensive review of studies on the combined use of opioids and BZDs. They concluded that “that the co-abuse of opioids and BZDs is ubiquitous around the world,” that BZDs are utilized by many opioid abusers to potentiate opioid intoxication, and, that the co-abuse of opioid and BZDs “has negative consequences for general health, overdose lethality, and treatment outcome.”

Perhaps their 2012 conclusion that physicians should exercise more caution and vigilance in prescribing BZDs is reflected in the fact that psychiatrists have paid attention, and not increased our rate of BZD prescribing. Whereas psychiatric BZD prescriptive practices have remained stable, other physicians, especially primary care providers, are delivering nearly twice as many BZD prescriptions to patients.

 However, in view of the subsequent progression of the opioid crisis and the mounting overdose death toll, reducing the rate of BZD prescriptions in psychiatric practice may indeed be a worthwhile, life-saving consideration.

 suggest that by adhering to universal precautions in pain medicine, physicians are able to routinize a cautious, non-stigmatizing clinical approach that facilitates their ability to limit opioid prescriptions. It would likely be helpful for psychiatrists to adopt a parallel set of best practices and universal precautions with regards to prescribing BZDs and other psychoactive pharmaceuticals with abuse liability. Gourlay’s original 10 universal precautions can be found in the 

 for a list of 8 universal precautions adapted from Gourlay et al

 for use by psychiatrists faced with the decision to initiate or continue pharmacotherapy with BZDs.

Table. Gourlay’s Original 10 Universal Precautions

Epidemiological studies suggest that individuals with untreated anxiety and mood disorders may be prone to self-medicate with nonmedical use of opioids. Use and misuse of opioid drugs may themselves aggravate symptoms of anxiety.

 It is not surprising, then, that outpatient psychiatrists sometimes provide BZD prescriptions to patients who may covertly be suffering from 

. As substance use disorders (SUDs) have long been associated with behaviors that may be deemed antisocial,

 and one such behavior is deceptive communication,

 community-based psychiatrists in high-volume clinic settings may be at risk of being fooled by drug-seeking patients.

The ease of integrating some or all of the 8 suggested universal precautions for initiating or continuing BZD pharmacotherapy will vary from treatment setting to treatment setting. At the very least, this aspirational list of precautions may facilitate the ability of mental health professionals to offer a clinically sound integrated approach for the treatment of co-occurring psychiatric and SUDs. Integrated treatment of co-occurring disorders is the accepted standard of care for this challenging, high-risk patient population.

a coaching and consulting psychiatrist, and is board-certified in psychiatry, addiction medicine, and coaching (BCC). He launched

after 8 years directing Physician Health Services, Inc. On the faculty of the University of Massachusetts Medical School, he is a consultant in psychiatry in the Division of Alcohol and Drug Abuse of McLean Hospital, an affiliate of Harvard Medical School.

Patterns in outpatient benzodiazepine prescribing in the United States.

Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study.

Benzodiazepine use and misuse among adults in the United States.

Polydrug abuse: a review of opioid and benzodiazepine combination use.

Universal precautions in pain medicine: a rational approach to the treatment of chronic pain.

6. Martins SS, Fenton MC, Keyes KM, et al. 

Mood and anxiety disorders and their association with non-medical prescription opioid use and prescription opioid-use disorder: longitudinal evidence from the National Epidemiologic Study on Alcohol and Related Conditions

Natural history of male alcoholism V: is alcoholism the cart or the horse to sociopathy?

Common and challenging behaviors among individuals on long-term opioid therapy. 

Integrated treatment of substance use and psychiatric disorders.

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This week, Steve Adelman, MD, takes on the question about opioids in the US. 

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 of balancing excellent care of others with adequate self-care is not a new one. In 1902, Sir William Osler, MDCM, opined that, 

“In no relationship is the physician more derelict than in his duty to himself.”

The following year, Osler, a professor of medicine at Johns Hopkins University who was known to see as many as 50 patients per day, clarified that the dereliction of duty to self was a threat to his own wellbeing:

 “In spite of the most careful regulation of my time and health, I was often utterly ‘used up’ at the end of the week and the question was how long could I hold out at the high pressure.”

 When offered a less demanding academic position at Oxford that would allow him to downshift, his wife took charge: “Do not procrastinate, accept without delay. Better go in a steamer than a pine-box.”

 Taking her advice to heart, Osler accepted a teaching role and added another 24 years to his enduring legacy. 

The American Medical Association Sounds the Alarm

In the late 1960s, the American Medical Association’s Council on Mental Health started to reckon with the dilemma of physicians who were functioning poorly. Some were actively using psychoactive substances; others manifested psychiatric symptoms that jeopardized their ability to provide competent care to patients. In 1973, the Council published its landmark policy paper, 

“The Sick Physician: Impairment by Psychiatric Disorders, Including Alcoholism and Drug Dependence,”

The Journal of the American Medical Association

 This paper painted an alarming picture. It was noted that a “sampling of boards of medical examiners and other sources reveals a significant problem in this area.” It was acknowledged that, “Ideally, the affected physician himself should seek help when difficulties arise. Often, however, he is unable or unwilling to recognize that a problem exists.” 

The Council cited a number of small studies that consistently found high rates of alcoholism and drug problems in physicians, going so far as to mention “addiction as an occupational hazard.” A note of alarm was sounded in comments indicating that physicians with substance use disorders “come before disciplinary bodies with relatively high frequency,” and that other mental disorders occur “with perhaps greater frequency among physicians.” Sick physicians, specifically those suffering from conditions that are typically treated by psychiatrists and other mental health professionals, were depicted as nothing less than a triple threat—to the physicians themselves, to their patients, and to the medical profession. 

The Council’s level of concern was compounded by its observation that, “Experience in such situations is often disappointing as the physician-patient denies he is ill, lacks insight into his problem, avoids medical assistance, and minimizes his problem outright. Therefore, an element of coercion is often necessary.”

The Council’s 1973 “Sick Physician” paper proposed a solution to this worrisome state of affairs. They surveyed medical societies across the United States and its territories, finding that very few of them had an active committee or standardized approach to assisting doctors who were ill. The Council went on to recommend that each state or county medical society convene a committee with the specific task of determining “whether the physician is suffering from a disorder to a degree that interferes with his ability to practice medicine.” These peer committees should include, but not be limited to, “psychiatrists and neurologists.” In 1973, only 7 such committees were known to exist. In 2021, the number approaches 50. 

, most psychiatrists will care for other physicians. However, interactions between treating psychiatrist and state physician health programs occur infrequently. As a psychiatrist who directed the Massachusetts physician health program (Physician Health Services, Inc) for 8 years, I discovered that most psychiatrists deeply appreciate gaining a more nuanced understanding of the physician health program (or PHP), and its delicate interactions with practicing physicians and the regulatory board that licenses them. Doing so can help you provide the best possible care to your physician patients.

State Physician Health Programs—Commonalities and Differences

Today we recognize medicine as an inherently stressful profession that may engender personal and 

 The visibility of physician suicides and the COVID-19 pandemic have brought additional attention to the health and well-being of physicians and other health professionals. Most physicians are now employed by large corporate entities, and some of the leading health systems in the United States now employ 

Accreditation Council for Graduate Medical Education

 now requires all accredited training programs to furnish accessible 24/7 mental health services to all residents.

When compared to the stoic doctors of yesteryear, contemporary physicians appear somewhat less reluctant to acknowledge and address mental health and substance misuse challenges. Although concerns about stigma and licensure still deter some from getting help, it is abundantly clear to PHP professionals, as well as to licensing boards, that the impaired work performance caused by illness, not the treatment of illness per se, is the greater threat to the well-being and careers of physicians.

Although many PHPs make efforts to promote physician health and wellness, these small organizations spend most of their limited resources assessing, addressing, and monitoring physicians who have come to the attention of employers and regulatory bodies (like state medical boards and the Drug Enforcement Agency) as a result of immediate concerns that are suggestive of current or imminent impairment due to a mental health or substance use disorder. Sadly, the “sick physicians” described in 1973

 still exist. They are the ones who have failed to effectively address significant health conditions in a timely and proactive fashion.

Some practicing psychiatrists tend to view PHPs as harsh, punitive programs that are an extension of state medical boards. However, by gaining a more nuanced view of the modus operandi of your state’s PHP, you may discover ways in which a thoughtful partnership with the PHP can help your physician patient recover faster and more completely, while reducing the likelihood of recurrent symptoms that may have a deleterious impact on patient care, as well as on the career of the physician.

As a psychiatrist caring for a physician with significant mental health challenges, the following information may help you make more effective use of your state’s PHP.

Should I reveal my patient’s identity to the PHP?

 Never reveal the identity of a physician patient to the PHP without possessing a comprehensive understanding of the relationship of the PHP with the licensing board. Proceeding with caution is vitally important, because in some (but not all) states, the PHP may be hard-wired to the licensing board. Although this is not a best-practice arrangement, it is, in fact, sometimes a reality. The downside of a hard-wired connection between the PHP and licensing board is the unintended consequence that an informational query may turn into an inadvertent medical board report that has the potential to rupture your therapeutic alliance with your physician patient. To guard against this, carefully review the details of your PHP’s relationship with your state’s medical board. You can ascertain this by reviewing your PHP’s website (see 

 for links to each state PHP), speaking to knowledgeable individuals in your state medical society or state chapter of the APA, or calling the medical director of the PHP and posing hypothetical questions about client confidentiality and the PHP’s relationship to the licensing board.

Can PHPs be helpful to treating psychiatrists even when they are ‘hard-wired’ to the medical board?

 Yes! If it is possible that your physician patient is unable to practice medicine with reasonable skill and safety, then you, as the psychiatrist, are ethically bound to address the problem at hand so as to prevent patients from being harmed. Beyond the ethical obligation, the state where you are licensed may require you to report potentially impaired physicians to the medical board. Utilizing the services of your state’s PHP can help you navigate these trying and complex clinical issues in ways that may protect patients, enhance your efficacy as a psychiatrist, and improve your patient’s prognosis, both short-term and long-term. In such trying circumstances, calling the PHP before communicating to the medical board may benefit all parties.

How can a PHP help you improve your care of a physician patient?

 Informational conversations with a PHP may help you identify physician-savvy evaluative and therapeutic resources that will help you to deliver the best care to your physician patient. If a medical leave of absence is called for, the PHP may be able to facilitate this critical step by drawing on its rich experience. This can be reassuring to everyone: physician patients, their employers, and involved clinicians. Over and over again, PHPs have assisted seriously ill physicians in getting the help they need. This helps them to stabilize and regain the ability to practice medicine competently. In many situations, the PHP will recommend ongoing monitoring for recovering physicians returning to the practice of medicine.

How does involvement with the PHP improve a physician patient’s prognosis?

 In 2017, Thomas McLellan, PhD, an eminent addiction scientist as well as the cofounder and CEO of the Treatment Research Institute, delivered the Massachusetts Medical Society’s annual meeting educational program lecture on “The Winding Road of Addiction: Hope on the Horizon.” McLellan began his lecture by asserting that “we know how to effectively treat addiction in this country.” He explained that state physician health programs represent a best practice for the treatment of addiction, as they utilize highly structured accountability and monitoring structures to promote long-term abstinence and prevent relapse. Indeed, 75% to 80% of the physicians enrolled in these aftercare programs maintain 

 Fewer than 10% become symptomatic to the point of not being able to practice medicine. Even high-risk groups like 

 with a history of intravenous opioid use disorder are able to recover successfully, often returning to the high-risk practice of anesthesia, thanks to the meticulous orchestration of assessment, triage, and monitoring services by state physician health programs.

To what extent do PHPs provide assistance to distressed physicians who are not misusing psychoactive substances?

 This varies from state to state and from PHP to PHP. Most PHPs can provide assessment, referral, and monitoring assistance for doctors with major psychiatric conditions like bipolar disorder, major depression, and obsessive-compulsive disorder. In some states, PHPs are able to guide doctors (along with their psychiatrists and other involved mental health professionals) with challenges in some of the following domains: anger management, communication, burnout, teamwork, organization, professional boundaries, and adverse outcome stress. As outpatient psychiatrists are well-advised to steer clear of making fitness-for-duty determinations of their physician patients, your PHP can often help you navigate through some of the complex and problematic requests that emerge when you have been treating a physician with significant, potentially-impairing psychiatric conditions.

In summary, state PHPs are important resources that can be carefully and strategically utilized by psychiatrists who treat physicians with substance use challenges and/or other mental disorders. Before engaging the PHP to be of service to you and a specific physician patient, it is important to clarify the rules of engagement, including the PHP’s relationship with your state’s medical board. When you know how and when to make use of a state PHP, it can be an extremely valuable resource, one that may help you take better care of physicians. It is very satisfying when these efforts trickle down to patients who are being effectively cared for by a recovering physician. 

Osler: Inspirations from a Great Physician

2. Bryan CS. Caring carefully: Sir William Osler on the issue of competence vs compassion in medicine. 

Baylor University Medical Center Proceedings

4. American Medical Association’s Council on Mental Health. 

The sick physician: impairment by psychiatric disorders, including alcoholism and drug dependence.

5. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. 

Taking action against clinician burnout: a systems approach to professional well-being.

Reframing clinician distress: moral injury not burnout.

7. Brower KJ, Brazeau CMLR, Kiely SC, et al. 

The evolving role of the chief wellness officer in the management of crises by health care systems: lessons from the COVID-19 pandemic

NEJM Catalyst Innovations in Care Delivery.

8. Accreditation Council for Graduate Medical Education. Improving physician well-being, restoring meaning in medicine. Accessed August 5, 2021. 

https://www.acgme.org/what-we-do/initiatives/physician-well-being/

9. DuPont RL, McLellan AT, White WL, et al. 

Setting the standard for recovery: Physicians’ Health Programs.

Anesthesiologists with substance use disorders: a 5-year outcome study from 16 state physician health programs. 

How can State Physician Health Programs guide your care of physician patients?

Steve Adelman, MD

Articles

The Case for Caution When Prescribing Benzodiazepines

Fighting the Opioid Crisis

Partnering With State Physician Health Programs