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

Psychopharmacologists and psychotherapists are in no way immune to the kinds of lapses in professionalism that from time to time imperil the licenses and careers of other health professionals.

 In particular, effective management of appropriate professional boundaries is an integral and ongoing task for mental health professionals throughout our careers.

 Following presentation and discussion of a fictional anecdote, I will conclude by proposing a typology for the range of professional boundary challenges.

Shots in the Dark: A Realistic Imagined Boundary Violation Anecdote

“Raquelle” and “Kobe,” two PGY-5 psychiatry fellows in a prestigious university-based mental health fellowship program, met at a poorly lit bar near the campus after work on a Friday. They were colleagues—acquaintances who were in the process of becoming work friends. As they finished up a shared half-gallon pitcher of beer, the waiter brought them each a shot of tequila that neither of them had ordered. He explained that this was a gift from a young woman seated alone at the bar. Raquelle looked up and discerned that the gift-giving bar patron appeared to be a high-functioning female graduate student who was a clinic patient under her care. She smiled and waved to the patient, and then discussed with Kobe whether or not it was appropriate for them to drink the shots. Raquelle suggested that they send the tequila back; Kobe argued that to do so was overkill: “Why kick a gift horse in the mouth? She’s already paid for the drinks anyway.” He downed the shot—was it a double, perhaps?—and then pointed out that the patient was gone. After Raquelle downed the other shot, the patient, who had been in the restroom, pulled up a chair and joined them at their table.

Kobe was buzzed, Raquelle was becoming more and more intoxicated by the minute, and her patient was clearly inebriated. Some of the free-wheeling discussion involved the patient’s frustration with being single, and at one point, she deliberately touched Kobe’s thigh. He took care to move her hand off his leg and summoned an Uber, which they took together to the patient’s apartment. They helped her negotiate her way to building’s entrance and bid her farewell. They then proceeded to Raquelle’s apartment, and Raquelle asked Kobe to help her get inside. She invited him in, and they decided to have sex. Things progressed quickly until Raquelle suddenly asked Kobe to stop. He did so immediately and left very shaken up. Raquelle did not return Kobe’s calls that weekend.

On Monday the patient cancelled all of her scheduled appointments and lodged a complaint with the clinic director. After the clinic director interviewed Raquelle and Kobe, first separately and then together, she put the 2 of them on administrative leave and contacted the HR department and legal counsel. It was decided to confer with the medical board about “a couple of young physicians who crossed some lines.”

The messy, unfortunate, and completely avoidable situation that these 2 young physicians found themselves in raises a number of important questions:

1. Is this a spurious matter that is likely to be sorted out promptly without having a negative impact on the career trajectory of these PGY-5 psychiatry fellows?

3. How does the physicians’ drinking factor into our assessment of these boundary challenges, and to what extent does this anecdote indicate a drinking problem that should likely be addressed?

4. What kind of legal exposures exist in this kind of case?

5. What lessons can be taken away from this situation? If the fellows could turn the clock back and proceed differently, what might they have changed?

Perspective of a Psychiatrist With Experience Assisting Physicians With Professionalism Challenges

From the vantage point of having assessed hundreds of physicians with professional boundary challenges, my lived professional experience suggests the following answers to the 5 questions (restated, in brief):

1. A spurious matter without a negative impact?

Not in the least! Possessing an active medical license is more of a privilege than a right, and licensed physicians are expected to face their patients, and the public, with exemplary professional behavior. When a chain of events prompted by flawed decision-making culminates in witnessed behaviors that can readily be deemed unprofessional, complaints to the licensing board, employment actions, and lawsuits may ensue. Once any or all of those “cats are out of the bag,” the involved physicians typically find themselves caught up in a complex, time-consuming, and pricey medicolegal matter that may take months or even years to resolve. In colloquial terms, it is almost impossible to get such a “cat” back in the bag. When significant professionalism concerns arise publicly, the burden of proof typically shifts to the physician, who then needs to demonstrate that they are not at risk of behaving unprofessionally in the future. It is very, very difficult to “prove a negative” to the satisfaction of risk-averse and publicity-sensitive regulatory bodies and employers.

2. What professional boundaries were violated?

Drinking heavily in a public setting where crossing paths with patients may likely occur is a bad idea, because alcohol’s disinhibiting effects promote bad decision-making. When psychiatrists accept gifts of various sorts from patients, they may find themselves entering onto a slippery slope without even realizing it.

 In this case, the gift of potent drinks that raised the blood alcohol concentrations of 2 psychiatrists became extremely problematic.

Also, alcohol-fueled intimacy between current work colleagues is never a good idea and has the potential to blow up.

3. What about drinking and the role of alcohol in this professionalism lapse?

Psychoactive substance misuse should always be considered a contributing factor when evaluating unprofessional behavior in health professionals.

 The anecdote demonstrates how physicians with a casual, if not cavalier, attitude about drinking sometimes find themselves “busted” by the likes of medical leaders, HR departments, employers, organizational attorneys, and regulatory bodies. Public drinking by physicians is potentially problematic, especially when it takes place in a setting where meeting up with one’s patients is not unlikely. Free shots of high-potency alcohol were the tipping point in this anecdote, and accepting them as a gift from a patient was extremely problematic. The shots may not have been consumed if the pitcher of beer had not preceded them.

The alcohol-fueled encounter at the table was a clear boundary violation that set other problematic interactions in motion. The Uber ride with the patient and the abrupt discontinuation of treatment come immediately to mind. The culmination of this seemingly innocent attempt to “have a drink after work” was a problematic sexual encounter between 2 physicians “under the influence.” Career-derailing criminal charges sometimes emerge in situations like the one described. In some states, one or both of these physicians might be referred to the state’s physician health program, and after careful assessment, recommendations of specialized treatment and abstinence monitoring may ensue.

Physicians who behave unprofessionally, for whatever reason, may jeopardize their training and employment status, as well their ability to be credentialed and maintain a “clean” license. In this anecdote, the patient who bought the shots has the potential to assert that she was victimized by one or both psychiatrists, and a lawsuit—spurious or not—is possible. Allegations of rape are sometime made when a more intoxicated individual asserts that a less intoxicated individual took advantage of them sexually. Physicians charged with felonies, even without a conviction, find it extremely difficult to progress in their careers.

-Avoid drinking in settings close to work.

-Drink sparingly, especially when in public. Out of an abundance of caution, health professionals who are safe to consume alcohol may want to reduce the NIAAA’s recommended daily and weekly maximum drinking limits by as much as half.

-Before accepting a gift from a patient, ask yourself what could go wrong. “No thanks” is the safest default stance. Recreational substance use has no place in the relationship between mental health professionals and patients.

-Initiating sexual involvement with a colleague is a decision not to be taken lightly. It should be considered with great care and forethought. It should never take place if a power differential exists between the 2 individuals.

-Sexual involvement that is fueled by recreational substance use is fraught with complexity. It may lead to potentially catastrophic unintended consequences.

Concluding Comments on the Scope and Range of Professional Boundary Challenges

Historically, the private practice of psychiatry, psychotherapy, and psychoanalysis has at times occasioned egregious boundary violations.

 In our current hyper-technological era with an environment of rapid-paced and commodified service delivery, health professionals in all specialties and disciplines are at risk of stepping or veering out of bounds. The risk extends beyond patients; it includes colleagues, subordinates, and the public at large. Medical boards throughout the United States have investigated and disciplined physicians for serious digital boundary violations, some of which may have been “innocent” from the physician’s perspective. We are well advised to consider the boundary-violating potential of all our online communications.

Our profession calls on us to establish trust and rapport with each patient. In order to help patients, we hope that they will communicate openly with us about deeply personal situations, behaviors, thoughts, and feelings. The art of psychiatry involves mastering the ability to conduct in-depth interviews and conversations with patients in a caring and nonintrusive way. This task is inherently demanding and may even be onerous at times. Consequently, it may help us to assume that boundary challenges are in the air during each and every mental health encounter.

Professional boundary issues likely exist on a continuum. This is derived from the work of Gutheil and Gabbard, who distinguished between boundary crossings and violations.

Typically, we are most familiar with boundary issues that involve communications, behaviors, or actions with sexual and/or intimacy content. Outside of the interrelated realms of sexuality, intimacy, and seductiveness, there are numerous nonsexual domains where boundary challenges exist. The full range of sexual and nonsexual boundary violations, and how to prevent them, is covered in a 2008 book by Gutheil and Brodsky.

 Although some individuals’ boundary issues may be predominantly sexual or purely nonsexual, individuals with a tendency to “cross the line” may manifest boundary slippage in multiple domains. As in the anecdote we started with, it is not uncommon for slippage, crossings, and violations to occur in conjunction with substance misuse (

). PBI Education, an established professional boundary remediation program that focuses on health professionals, provides a list of boundary problems as common reasons for referral, which can be seen in the following section.

Common Reasons for Referral to a Professional Boundary Remediation Program

-Addictions (chemical, behavioral [ie, gambling, pornography, etc])

-Dual relationships (inappropriate financial, business, or nonsexual social relationships, including with coworkers or trainees; prescribing to friends, family, or coworkers)

-Failure to use a chaperone when indicated or requested

-Inappropriate use of social media, text, or email with patients/significant third parties, coworkers, or students

-Lending or borrowing money, or giving gifts to coworkers, students, or patients or their significant third parties

-Sexual boundary violations (examination of sensitive body areas without gloves, sexualized language, looks, or physical contact even if consensual with current or former patients, coworkers, students, or patients’ significant third parties)

-Supervisory issues (inadequate supervision/delegation, insubordination)

A very wise hospital attorney once advised successive classes of psychiatry residents to avoid professional jeopardy by “imagining the headline.” As we face patient after patient, encounter after encounter, and boundary challenge after boundary challenge, we are well-advised to consider the various slippery slopes that present themselves in the course of our engagement with every single person. Some might say it has never been easier to slip and find yourself at the bottom of a steep hill, bruised and unable to get right back up. It is not a small accomplishment to connect with each patient and provide the help that they need while, at the same time, staying above reproach. Do not be shy about asking for input from trusted mentors if you find yourself starting to slip.

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. Dr Adelman is on the faculty of the University of Massachusetts Medical School and serves a consultant in psychiatry in the Division of Alcohol and Drug Abuse of McLean Hospital, an affiliate of Harvard Medical School. He serves as 

Professionalism and Ethics: Q & A Self-Study Guide for Mental Health Professionals.

Boundaries, professionalism, and malpractice in psychiatry.

The price of a gift: an approach to receiving gifts from patients in psychiatric practice.

Disruptive physician behavior: use and misuse of the label.

5. US Department of Health and Human Services; National Institutes of Health; National Institute of Alcohol Abuse and Alcoholism. 

Helping Patients Who Drink Too Much: A Clinicians’ Guide. 

https://pubs.niaaa.nih.gov/publications/practitioner/cliniciansguide2005/guide.pdf

Professional boundary violations by physicians.

Professional ethics for digital age psychiatry: boundaries, privacy, and communication.

The concept of boundaries in clinical practice: theoretical and risk-management dimensions.

Preventing Boundary Violations in Clinical Practice.

10. PBI Education Professional Boundaries Course. PBI Education. Accessed August 24, 2022. 

Articles

Here’s how to stay professional in difficult situations. 

Avoid “Shots in the Dark” to Maintain Pristine Professional Boundaries 

Mark Twain fully grasped the folly of youth. He contrasted it with the humility that comes with experience in this memorable observation: “When I was a boy of 14, my father was so ignorant I could hardly stand to have the old man around. But when I got to be 21, I was astonished at how much he had learned in 7 years.” Tongue firmly in cheek, Twain is commenting that the aging process teaches us how little we really know.

Since I started medical school in 1977, we have witnessed dramatic advances in our understanding of neuroscience, psychopathology, and numerous psychiatric and psychotherapeutic treatment modalities. As the knowledge base of biological psychiatry has become more robust, a growing body of psychotherapy outcomes research has had a dramatic impact on the work lives of most American psychiatrists. Time-limited therapies were shown to be as effective as open-ended, longer-term psychotherapies. We also learned that mental health professionals who had not attended medical school were able to assist emotionally distressed patients as effectively as, and sometimes more effectively than, psychiatrists. As we became more biological in our orientation, episodes of care got shorter and shorter. At times, the assembly line moves too quickly and the flames and smoke of burnout may singe and choke us if we do not effectively balance caring for ourselves with caring for others.

With 1 eye on the patients and another on ourselves, we are also paying more attention, as we must, to the larger social picture. As I watched addiction psychiatry come together as a central psychiatric subspecialty that exemplifies the wisdom and intellectual vigor of our biopsychosocial orientation, we have all witnessed the limitations of a 

approach that ignores the socioeconomic determinants of mental health. Alas, the opioid epidemic rages on. Mental health parity is incomplete. Universal access to adequate care is not a reality. Far too many Americans with chronic psychiatric conditions are receiving care in the criminal justice system.

™, I hope to partner with you—psychiatrists and psychiatric nurse practitioners in different practice settings—to move the field forward. How do we leverage our knowledge and skills to optimize the biopsychosocial well-being of our patients and their families? How do we partner most effectively with our colleagues in other medical and mental health specialties? As stakeholders in a needlessly complex patchwork quilt of orthogonal health plans and reimbursement systems, what can we do about the vexing administrative complexities that interfere with patient outcomes and effective care coordination?

Although our field is atomized into many subspecialty areas, most of our patients experience challenges that cut across our categorical approach to psychopathology. Personally, I like nothing more than leaning into the complexity of patients with complicated presentations. I am currently treating 2 individuals with significant cooccurring anxiety, substance use, and personality disorders. In 1 case, I function as an integrative psychiatrist delivering all necessary care. In the other case, I am one of 3 mental health professionals working with the patient on a weekly basis, but the only psychiatrist. It is not simple figuring out how and when to flex ourselves—sometimes as a 1-person band, other times as a member, or conductor, of a small interdisciplinary collaborative group.

Thankfully, my career experiences have been rich and varied. I invite you to reach out to me through 

™ with questions or concerns regarding the following subject areas:

 What are the best protective strategies for us and our colleagues? How can we sort out the overlap between burnout and depressive disorders?

 What are the pros and cons of (1) different institutional practice settings, (2) subspecialty training and practice, and (3) private practice? What is the role of mentorship in developing your career?

 Is coaching the new psychotherapy? Should psychiatry embrace coaching or shun this nonspecific discipline that has been defined as “partnering with clients in a thought-provoking and creative process that inspires them to maximize their personal and professional potential (

Health professional health and well-being: 

How does the psychiatric treatment of independently licensed health care providers and other safety-sensitive professionals (eg, aviation, transportation) differ from the usual and customary care we provide to other patients? How do we respect patient confidentiality while ensuring the safety of the public?

Integrating medical and mental health care: 

What practice settings are most amenable to integrated and colocated mental health care? What are our options when patients constrain us from communicating with clinicians from other specialties?

What are the pros and cons of integrated care versus split treatment—from the perspective of the patient, the organization, the bottom line, and the job satisfaction of different professional disciplines?

 How can frontline mental health professionals develop their leadership skills and gain experience in mid-level and high-level leadership roles? How can we best leverage our understanding of human behavior as emerging leaders?

How can we use motivational interviewing to assist chronically mentally ill individuals who struggle with acceptance and compliance? What are the limitations of motivational interviewing in working with some communities and populations?

Problematic workplace behavior in medical and mental health settings: 

What is the role of psychiatry in assessing and treating health professionals who show up at work with “rough edges”? How can we effectively address a colleague’s problematic behavior in a mental health setting?

Psychiatric supervision of nonphysicians, residents, and colleagues: 

When it comes to supervision, what best practices and pitfalls should we keep in mind?

What do spirituality-informed psychiatric assessment and treatment look like? How do our own spiritual/religious histories and practices enhance or interfere with our care of patients?

 in psychiatric patients; addiction medicine; and addiction psychiatry:

 What advice should we be giving patients without substance use disorders about their use of legal and illicit psychoactive substances? As the general subspecialty of addiction medicine grows, what is happening to the American Board of Psychiatry and Neurology subspecialty of addiction psychiatry, and where do we go from here?

Traditional psychotherapy and psychiatry: 

Should all psychiatrists possess knowledge, skills, and experience in psychodynamic psychotherapy? What training and skills in nonpsychodynamic psychotherapies are essential for the practicing psychiatrist?

I look forward to contributing pieces on these and other matters in forthcoming issues of 

™. Just as I endeavor to be patient centered and client centered as a physician and coach, my goal here at 

™ is to be reader centered and learner centered. I look forward to hearing from you.

is 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. Dr Adelman is on the faculty of the University of Massachusetts Medical School and serves a consultant in psychiatry in the Division of Alcohol and Drug Abuse of McLean Hospital, an affiliate of Harvard Medical School. He serves as 

How can we—psychiatrists and psychiatric nurse practitioners—work together to move the psychiatric field forward?

Astonished by How Much There Still Is to Learn and Do

alcohol pills_ Syda Productions/Adobe Stock

The assessment and treatment of patients with comorbid 

 (SUD) can be straightforward, except when it is not. The real world of clinical practice is often not as cut-and-dry as the controlled world of clinical research that typically informs our decision-making processes. When does it make sense to prescribe an abusable medication to a patient who may also suffer from SUD? What clinical circumstances dictate prudence and, perhaps, limit-setting? In this case-based review, I will utilize a series of fictionalized clinical anecdotes to help psychopharmacologists determine how to approach prescribing stimulants to patients who may or may not be using psychoactive substances such as cannabis, alcohol, and cocaine.

A Simple Concept With Complex Implications

Daniel C. McFarland, DO; Luigi Grassi, MD; Michelle Riba, MD, MS, DFAPA, FAPM

New Directions for Insomnia and Bipolar Disorder

ADHD in school-age children is known to be a risk factor for the subsequent emergence of SUDs in young adults,

 especially when the ADHD has not been effectively treated.

 Armed with knowledge that untreated ADHD affects children adversely, many pediatricians and child psychiatrists routinely prescribe stimulant medications for children diagnosed with ADHD—to an extent that now suggests the possibility that this condition is sometimes being overdiagnosed and, consequently, overtreated.

 In the following case, trusting parents and clinicians did not detect an emerging SUD in a high school freshman.

A well-spoken boy, aged 14 years, from a “good” family was referred to a child psychiatrist by his pediatrician after failing to respond to methylphenidate extended-release (ER) for “mild ADHD.” The child psychiatrist reviewed the electronic health record, where the social history indicated “no concerns about alcohol, pot, other drugs.” The boy’s history revealed declining school performance throughout eighth grade, and he appeared distracted and unkempt during the interview. Over the next several months, increasing doses of immediate-release (IR) amphetamine/dextroamphetamine were prescribed with an equivocal response. The patient’s mother called for an early refill, stating that her son’s gym locker had been broken into. The psychiatrist met with the patient and obtained a urine drug screen, which came back with a THC level of 584 ng/mL. When confronted, the young man broke down, begged the psychiatrist not to tell his parents, and eventually admitted that he was selling some of his stimulants to pay for weed, and that he himself had crushed and snorted his amphetamine pills on at least a few occasions.

This situation is concordant with my experience in a variety of ambulatory psychiatric settings. In many real-world outpatient psychiatric settings, empirical stimulant trials to treat presumed ADHD are often undertaken, and urine drug screening may be underutilized at the outset of treatment, especially for younger patients.

 It may appear to the addiction psychiatrist that some patient-centered clinicians possess an alarmingly low index of suspicion that SUD either may be contributing to attentional difficulties or is perhaps the primary problem. Unfortunately, many child psychiatrists receive little to no training in child and adolescent addiction psychiatry,

 despite the fact that there may be much merit in conceptualizing addiction as a pediatric disease.

 Although clear-cut ADHD in a younger child may presage the emergence of SUD in teenagers and young adults, patients like this 14-year-old may appear, at first glance, to be more straightforward than they are. This boy’s primary diagnosis may be SUD, not ADHD.

Psychopharmacologists treating adult patients should routinely endeavor to enrich the fact pattern when they are called upon to prescribe controlled substances for individuals who carry a history of ADHD. Additional assessment strategies come to mind when considering Anecdote 2.

A new male clinic patient, aged 25 years, tells his psychiatrist that he suffers from ADHD. He shows the psychiatrist a prescription bottle of prescribed stimulants (IR amphetamine/dextroamphetamine) with 3 pills left. His previous psychiatrist is known to have retired from practice a few months back. The stimulant dose is average, and he assures his new psychiatrist that he takes his medication by mouth, as prescribed. He has a negative medical history, and other than ADHD diagnosed in elementary school, he has no known psychiatric history. When asked about alcohol consumption, he acknowledges drinking “a beer or two” on weekends, but he otherwise denies substance use. He is the father of an infant who is napping in a stroller in the waiting area, tended to by the patient’s girlfriend. The patient works as a manager in a call center, and he attributes his promotion to the medication’s efficacy.

A seemingly straightforward patient with known ADHD, he is continued on the medication he received from his previous psychiatrist, and a follow-up meeting in 1 month is scheduled. He fails to keep the follow-up appointment, and when called, his girlfriend answers his phone at his bedside in the hospital. She informs the psychiatrist that he had a grand mal seizure at work on Monday morning. Later on, it becomes known that he drank nearly a full 12-pack of beer at a bachelor party over the weekend. After a thorough workup, the consulting neurologist concludes that the seizure may have resulted from a combination of alcohol withdrawal and stimulant medication. The patient’s girlfriend confirmed that his weekend binge drinking has progressed since she gave birth to their son.

Although this patient appeared “straightforward,” he did not reveal his history of binge drinking to his new psychiatrist. On the contrary, he minimized his alcohol use. This situation underscores the limitations of self-reported historical information. Denvir

 has described the not-uncommon circumstance of patients who put their best foot forward by minimizing their use of alcohol and drugs when interviewed by physicians, who often move forward quickly in taking the substance use history at face value without seeking details beyond the superficial information provided by the patient. In the case described, a recent binge, combined with a proconvulsant medication,

 had a serious and potentially catastrophic impact on the patient.

To what extent should the prescribing physician or clinician dig deep in such cases? One can readily speculate, in retrospect, about the measures the new psychiatrist might have taken. Records from the previous psychiatrist might have been obtained. Reviewing primary care records or speaking with the primary care provider often adds helpful data. In this case, information from the patient’s significant other could have been incorporated into the initial interview—she was right there in the waiting room and could have been artfully engaged in the initial evaluation session. When it comes to ruling out a current SUD, more information from multiple data sources is almost always clarifying. This takes time, but it is good medicine—good psychiatry. Because adults with ADHD are 3 times more likely to suffer from an SUD than those without ADHD,

 psychopharmacologists should routinely conduct a thorough substance use history, with multiple data inputs. This is a best practice that helps to protect patients, who may not be disclosing important information to the prescribing clinician.

A homeless female veteran, aged 30 years, was incarcerated after her fourth shoplifting arrest. She appeared unwell, with hypertension, tachycardia, diaphoresis, agitation, and confusion. Alcohol-withdrawal delirium was diagnosed, and she responded to benzodiazepines and supportive treatment. A toxic screen was positive for cocaine. During her 3 months of incarceration, she was seen by a mental health counselor with experience in the special education system. The inmate’s mental status and school history were consistent with a diagnosis of adult ADHD. The prison psychiatrist opted not to initiate pharmacotherapy, and the patient was discharged, while remaining on probation, to a halfway house for veterans with co-occurring disorders. An addiction psychiatrist affiliated with the Veterans Health Administration opted to treat her with methylphenidate hydrochloride ER tablets, provided she remained in the halfway house, which has daily 12-Step meetings and a robust urine drug screening program. Frequent drug random drug testing was also a condition of her probation. Within 6 months, the veteran was working gainfully and fully engaged in outpatient treatment, and she expressed a strong desire to stay on track and remain a productive member of society.

Despite the severity of this homeless veteran’s co-occurring SUDs, this case is a success story that demonstrates the efficacy of an integrated treatment approach.

 This anecdote underscores “what good looks like” when it comes to treating an individual with significant ADHD and a severe psychoactive SUD. It is saddening, but not shocking, when patients receive excellent care as a byproduct of the severity of their disorders and the extreme consequences of untreated psychopathology. In this case, arrest and incarceration allowed for a careful longitudinal assessment, including urine drug screening, and this fostered the ability of a savvy clinician to make accurate diagnoses. The need for structured postincarceration treatment was extremely clear, and the patient’s veteran status afforded her access to an appropriate residential treatment program, along with specialized services to treat co-occurring disorders. Her impressive response to structure and accountability is further promoted by her enrollment in a tightly structured monitoring program that utilizes urine drug screening to support a robust abstinence-based recovery program.

The anecdotes that have been presented and discussed demonstrate that when approaching the pharmacotherapy of ADHD in patients who may be misusing psychoactive substances, artful clinical decision-making should be evidence-based and informed by best practices that are routinely utilized by addiction professionals in the assessment and treatment of patients who suffer from SUDs. Because a history of ADHD is a risk factor for SUDs,

 it is clinically prudent to carefully assess all ADHD patients for current substance misuse. Gourlay’s

 universal precautions for treating pain (and minimizing addiction liability) have been utilized to develop “Universal Precautions for Psychiatrists” for safe, addiction-savvy treatment of anxiety disorders.

 This specific set of universal precautions is further adapted and generalized in the 

Universal Precautions for Psychiatrists (Adapted and Generalized)

These universal precautions, initially developed by Gourlay

 to facilitate the addiction-informed treatment of chronic pain and then adapted to promote the addiction-informed treatment of anxiety disorders,

 are now presented in a format that can be utilized whenever a physician or other prescribing professional is considering whether or not to prescribe a potentially abusable psychoactive medication to any patient.

 indicate that individuals with ADHD and co-occurring SUDs, with or without antisocial personality disorder, often respond positively to nonstimulant medications that are prescribed for ADHD. Some addiction psychiatrists make it a practice to begin the pharmacotherapy of ADHD with trials of nonaddictive medications. In fact, this practice may be particularly useful when a new patient presents with a sense of urgency in requesting a schedule II stimulant. When the use of stimulants clearly seems indicated, ER formulations and the prodrug lisdexamfetamine

 may be a safer first choice than IR stimulant compounds with greater abuse liability.

In conclusion, ADHD and SUDs are common conditions that frequently co-occur. A carefully conceived and executed integrated treatment plan that pays adequate attention to ADHD symptoms and also to possible psychoactive substance misuse is a universal best practice. When clinicians without addiction expertise notice problematic behaviors that may indicate that there is more going on than initially meets the eye, a subspecialty consultation may be useful in helping the patient while mitigating risk.

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

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

1. Wilens TE, Martelon M, Joshi G, et al. 

Does ADHD predict substance-use disorders? a 10-year follow-up study of young adults with ADHD

Attention-deficit/hyperactivity disorder and the substance use disorders: the nature of the relationship, subtypes at risk, and treatment issues

3. Kazda L, Bell K, Thomas R, McGeechan K, Sims R, Barratt A. 

Overdiagnosis of attention-deficit/hyperactivity disorder in children and adolescents: a systematic scoping review

Screening for substance use disorders in neurodevelopmental disorders: a clinical routine?

Addictions training in child and adolescent psychiatry fellowships

The disease of addiction: a critical pediatric prevention issue

When patients portray their conduct as normal and healthy: an interactional challenge for thorough substance use history taking

8. Brown JWL, Dunne JW, Fatovich DM, Lee J, Lawn ND. 

Amphetamine-associated seizures: clinical features and prognosis

. 2011;52(2):401-404. Published correction appears in 

9. 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

Integrating treatment for co-occurring mental health conditions

11. Jarvis M, Williams J, Hurford M, et al. 

Appropriate use of drug testing in clinical addiction medicine

Treatment strategies for co-occurring ADHD and substance use disorders

. 2007;16 Suppl 1(Suppl 1):45-56; quiz 55-56.

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

14. Adelman SA. The case for caution when prescribing benzodiazepines. 

. September 3, 2021. Accessed December 15, 2021. 

https://www.psychiatrictimes.com/view/the-case-for-caution-when-prescribing-benzodiazepines

Treatment of adult ADHD without stimulants: effectiveness in a dually diagnosed correctional population

Long-acting stimulants for treatment of attention-deficit/hyperactivity disorder: a focus on extended-release formulations and the prodrug lisdexamfetamine dimesylate to address continuing clinical challenges

How can psychopharmacologists effectively (and safely) prescribe stimulants to patients with ADHD who may be using psychoactive substances?

Helping Patients With Attentional Difficulties and Maladaptive Use of Psychoactive Substances

The opioid epidemic has grown increasingly deadly, yet it is possible that an important component has been overlooked (

). It has been estimated that concurrent use of 

 and opioids may occur in as many as 50% of opioid overdose deaths.

 Yet, more and more patients leave their doctors’ offices with prescriptions for benzodiazepine medications. Across the medical profession, the percentage of outpatient visits resulting in a benzodiazepine prescription has increased from 3.8% in 2003 to 7.4% in 2015.

 This startling statistic suggests that more cautious and conservative use and prescription of benzodiazepines has the potential to save thousands of lives per year. 

 National Drug Overdose Deaths Involving Opioids, by Benzodiazepine Involvement

During the time period studied by Agarwal et al,

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

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

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

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

 conducted a comprehensive review of studies on the combined use of opioids and benzodiazepines and concluded that “that the co-abuse of opioids and benzodiazepines is ubiquitous around the world.” They further found that benzodiazepines are utilized by those who abuse opioids to potentiate opioid intoxication, and that the co-abuse of opioid and benzodiazepines “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 is reflected in the fact that psychiatrists have paid attention, and not increased our rate of benzodiazepine prescribing. Whereas psychiatric prescriptive practices have remained stable, other physicians, especially primary care providers, are delivering nearly twice as many benzodiazepine prescriptions to patients.

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

By adhering to universal precautions in pain medicine, Gourlay et al

 suggested that physicians are able to routinize a cautious, non-stigmatizing clinical approach that facilitates their ability to limit opioid prescriptions. It might be helpful for psychiatrists to adopt a parallel set of best practices and universal precautions with regards to prescribing benzodiazepines and other psychoactive pharmaceuticals with abuse liability. (See 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 benzodiazepines.)

 8 Universal Precautions for Psychiatrists

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

 It is not surprising, then, that outpatient psychiatrists sometimes prescribe benzodiazepines to patients who may covertly be suffering from opioid use disorder. Substance use disorders (SUDs) have long been associated with behaviors that may be deemed antisocial,

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

The ease of integrating some or all of the 8 suggested universal precautions for initiating or continuing benzodiazepine 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 cooccurring psychiatric and SUDs. Integrated treatment of co-occurring disorders is the accepted standard of care for this challenging, high-risk patient population.

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

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

Patterns in outpatient benzodiazepine prescribing in the United States

Benzodiazepine use and misuse among adults in the United States

Polydrug abuse: a review of opioid and benzodiazepine combination use

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

How can the more cautious and conservative use and prescription of benzodiazepines save thousands of lives per year?

Steve Adelman, MD

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