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One out of seven physicians admitted consuming alcohol or controlled substances while working to cope with occupational stresses, according to a new survey.

The finding was derived from the study “State of Mental Health: American Healthcare Workers Report,” which was commissioned by Edwards, Colorado-based All Points North (APN), a recovery and rehabilitation center that specializes in treating health care workers. The survey of 1000 health care workers found that 21% of physicians—more than 1 in 5—consumed alcohol or controlled substances multiple times a day and 17% reported using at least once a day.

The results indicate “high levels of substance abuse, an acute mental health crisis, and stigma within the healthcare industry,” APN founder and CEO Noah Nordheimer said in the report.

The survey, which was conducted in July 2022, found 1 in 5 (20%) respondents had checked into a rehab or detox facility in the prior 3 months, but 14% said they did not want to admit they had a problem. Reasons for not seeking help included being overworked and not having the time (32%), concern that colleagues or family would judge them (23%), fear of getting their license revoked (23%); and not knowing where to begin and thinking the system is too difficult to navigate (20%).

The study found a difference between men and women, with 58% of male health care workers reporting they were at their breaking point or were looking for a new job because of stress, burnout, and trauma, compared with 45% of women. Male health care workers reported struggling with substance misuse more than their female counterparts. Men were more likely to use their positions in health care to acquire controlled substances than women (21% versus 4%).

Men also were more likely to consume alcohol or controlled substances while at work (18% versus 4% of women) and men were more likely to consume alcohol or controlled substances up to 12 hours before their shifts (44% versus 17% of women).

Health care experts generally agreed workers were facing dangerous levels of burnout before COVID-19 spread, but the pandemic made things worse. As such, 40% of workers said they felt anxiety or dread about going to work, 49% said they were at their breaking point or looking for new work because of job stress and trauma, and 64% said the US Supreme Court decision overturning the Roe v Wade abortion rights case increased their stress levels or caused them to feel betrayed.

“The wellbeing and mental health of health care workers has been dramatically impacted by the pandemic, with many of them seeing more pain and death than ever before,” Nordheimer said in a news release. “This frequency and intensity of exposure is causing an unprecedented amount of trauma and stress, leading to high levels of burnout. The behavioral health care industry has been slow to innovate to meet the growing need for mental health care, oftentimes treating it as an accessory to health care. We must put mental health on par with physical health and make it a basic human right, an indicator of overall health, and an industry standard.”

"We must put mental health on par with physical health and make it a basic human right, an indicator of overall health, and an industry standard.”

Survey Finds 1 in 7 Physicians Uses Alcohol or Drugs on the Job to Cope With Stress

A new study finds that mood shifts and exposure to alcohol-related cues contribute to alcohol cravings in opposite ways for men and women.

Investigators at the University of Central Florida explored how attention to alcohol-related cues and the influence of mood and biological sex affects current cravings, by gathering data from 69 college student drinkers aged 18 to 29 who did not have psychiatric disorder. Two-thirds were female and 91% were white. For up to 15 days, participants carried a digital tablet and assessed their current mood and drinking. Investigators gathered approximately 4010 assessments, which covered mood (eg, “How nervous/sad/joyful are you feeling right now?”) and alcohol craving (eg, “How strong is your urge to drink alcohol right now?”). Bias was assessed by a visual task with alcohol-related and nonalcohol-related stimuli.

Consistent with the affect regulation model, positive mood was associated with momentary alcohol cravings; however, the associations were opposite for men and women. In men, attention to alcohol cues and alcohol cravings became stronger when they experienced improved mood. In women, the association strengthened during mood declines. This is the first study to find such an association. This new data may add credit to the theory that women develop addiction-like behavioral traits more rapidly than men.

The study provides further evidence of sex differences in attention and alcohol cravings, and may be reflective of varying cognitive processing of attentional versus social cues in men and women. Interventions could potentially focus on shifting attention away from alcohol cues to reduce craving, though they may yield different results among men and women.

1. Moskal KR, Dvorak RD, Burr EK, et al. 

Attention bias and alcohol craving: differential effects via biological sex and mood.

2. Mood influences alcohol craving differently in men and women, pointing the way to alcohol use disorder treatments tailored by sex. Newswise. News release. August 24, 2022. 

https://www.newswise.com/articles/mood-influences-alcohol-craving-differently-in-men-and-women-pointing-the-way-to-alcohol-use-disorder-treatments-tailored-by-sex

A new study finds mood shifts and alcohol-related cues affect men and women differently in terms of alcohol cravings. 

Mood Shifts Have Opposite Impact on Alcohol Cravings in Men and Women

“And then they crawled out of the garbage can, dripping with blood and covered in goo. One after another, looking like little babies, except they were dead.”

Was she describing that cheesy 1970s-era horror film 

, a Times Square special about a major obstetrical mishap that self-propelled and devoured every bit of beef in the freezer? Or did this concern a later cult craze for “Garbage Pail Kids” cards, which were far more benign but nevertheless bizarre and popular enough to be known by the acronym, GPK? Or was this imagery more personal—something to discuss in a psychiatrist’s office, which is exactly where she was? The source of her concern would become obvious moments later.

Meg breathed in before she continued. She shuddered as she spoke, but she shed no tears.

She gripped the sides of her chair, her chipped nails leaving deep indentations in the well-worn leather. Her scraggly body sunk into the overstuffed armchair. She practically disappeared in the furniture.

Her disheveled appearance spoke for itself. Her half-bleached blonde hair was stringy and unkempt. Sweat beaded up on her forehead, making matters much worse.

She was scared, not sad, as she recounted the dreams that reoccurred almost every night since her last procedure. And she emphasized the word, “last,” implying that there were many more before the most recent termination of pregnancy.

It would have been easy to label her symptoms as posttraumatic stress disorder (PTSD), a result of uneasy feelings about ending a pregnancy that was never intended and never expected. She freely admitted that she was intoxicated the night that she conceived. She could remember next to nothing about the event—not even the name of the man she met that evening—but she remembered everything about the nights that followed.

Meg was only 22 years old, yet this was the third time that she terminated an unplanned pregnancy. There was 1 difference between this time and the previous abortion. Meg’s OB told her she could not in good conscience continue to treat her and perform another procedure unless Meg saw a psychiatrist and addressed her drinking. In my experience, it is unusual but admirable that this OB focused on something other than the immediate medical situation.

“And how did she know about the alcohol?” I asked. Meg did not hesitate to tell me that her liver enzymes were elevated. According to the OB, that was an ominous sign in anyone, but especially in someone so young.

Having read the paperwork that she filled out before her first appointment, I already knew that Meg (or “Margaret Mary,” as per her insurance card) was Catholic. As she disclosed during her first appointment, she was not a lapsed Catholic or an “ex-Catholic” but a practicing Catholic who sometimes attended Sunday mass and always made it to midnight mass at Christmas. So, I expected Meg to feel conflicted about a choice that contrasted with the tenets of her church, a church that she still valued. Yet I was not surprised by her choice, knowing that individuals from religions that oppose abortion are just as likely to have an abortion as those from religions that condone abortions or have no religious affiliation at all.

I also knew that Meg had recently left detox—but a little too soon. She said she signed out against medical advice when she felt well enough to walk out.

“And how did you decide upon detox?” I queried.

Again, Meg was forthcoming. She reminded me that she stopped her alcohol intake abruptly, a few days before her scheduled procedure, as she was worried that alcohol might affect the anesthesia. Someone in the recovery room at the women’s clinic saw that her hands were shaking and suspected that her tremor was more than simple anxiety. As Meg recalled, her blood pressure was high even after the anesthesia wore off. The nurse feared that Meg would enter withdrawal, so she summarily sent Meg to the hospital—not because of complications from a legal abortion performed in a safe and sterile setting, but because of the aftermath of long-standing and unchecked alcohol overuse.

It is uncommon for healthy young individuals to go into delirium tremens (DTs)—which can cause vivid and frightening hallucinosis—but it is also uncommon for a young woman to drink as much as Meg did with impunity. Meg did not know it at the time, but women develop neurotoxic symptoms from alcohol at one-third less alcohol than men. Downing a pint of vodka each night was more than her emaciated body could endure. To look at her, one would wonder if she had “alcoholorexia”-– an unofficial, non-DSM diagnosis for weight-conscious women who save their calories for alcohol and starve themselves of food.

Over the next few weeks, Meg shared more details about her life goals and lack of goals. Meg was an “on again, off again” student who worked for a local coffee chain, putting in just enough hours to get health insurance and college tuition reimbursement. Sometimes she signed up for writing classes; at other times, she filled her schedule with painting studios. She never took enough courses in a single subject to earn credit toward a college major that would make her eligible for a degree. In many ways, Meg was the opposite of her deceased father, who had been a hard-working, highly-motivated, small-town doctor—until his drinking got out of hand. In other ways, she was strikingly similar to her father, given that they each had drinking problems.

Even though Meg knew little about the man who died when she was young, she still knew details that her hometown paper published: that he was found dead, alone, lying face-down on the floor, next to an empty bottle of booze. The article wondered if his death was accidental or intentional, since he succumbed a few days before a scheduled hearing at the medical board, where he expected to lose his medical license because of a botched procedure, presumably performed while under the influence.

Meg was unfazed by her father’s fate—or by the possibility that she inherited a genetic predisposition to alcoholism that could contribute to her own downfall as well. Data suggests that 40% to 60% of alcohol problems are inheritable, so many individuals with family histories of alcohol overuse exert extra caution. Meg was not one of those prudent people. Instead, she frequented the so-called art bars in the Village when she was not working the late shift at the coffee shop. She chose that shift because she was too hungover for the early morning shift that attracted bigger tippers on their way to work.

At the bars, Meg cavorted with itinerant artists, writers, and musicians who also devoted more time to upping their drinking than to perfecting their crafts. She envisioned herself as the next Mary Gaitskill, an author she admired who wrote short stories about the down-and-out crowd that she hung with.

Sadly, psychoeducation about the medical hazards of alcohol overuse did not dent Meg’s denial. For sure, these visions of dead babies had scared some sense into her, but then she countered with a quote from an art instructor, who said that Jackson Pollock gained fame from dripping paint on a canvas because he was too drunk to hold a brush. “So why would I expect my work to suffer?” she retorted.

When asked about alcohol’s impact on her writing style, Meg referenced Jack Kerouac, a drinker who cavorted with the Beat Generation before he died at 47 years old. Kerouac chronicled his road travels but otherwise lived with his mother. He popped Bennies to boot.

“Sure, he died young, and, yes, because of alcohol, but the world remembers him, and that’s a lot more than I could say for most sober people,” Meg said.

It was sad to see that someone who was so quick with counterpoints was also so blind to her own self-destruction. The telling moment came when Meg asked about me to comment on her abortion. She wondered if it was the abortion that made her suffer from so many nightmares. Then she asked my opinion about when life began. I suspect that she was hoping to hear medical data that countered her church’s stance, but I swiftly sidestepped that unsolvable argument.

“I’m not an expert in theology, but I do know something about embryology and the impact of alcohol on unformed fetuses.” There was no need to mention FAS or FASD or the many other manifestations of antenatal alcohol exposure

 to Meg—not at this point. Although it was impossible for me to forget.

“I also know about the medical consequences of alcohol overuse, and in women in particular.”

I was impressed because I encountered few individuals who knew that breast cancer—among many other cancers—is promoted by alcohol.

“Does that topic interest you? You seem quite knowledgeable already.” I tossed in those motivational interviewing techniques, with the hopes of making some inroads. That topic hit home for me because I lost about 1 patient a year to breast cancer that had been promoted by past alcohol use. Saddest of all was witnessing this in individuals who had stopped drinking and become sober years before, but not until after the damage was done.

Sensing Meg’s disinterest in pursuing this discussion, I took another course. “So, Meg,” I continued. “I realize that there are endless debates about when life begins, especially when it comes to making arguments for or against abortion.”

“What’s not open to debate, in my opinion, is that life ends earlier than it should when people continue to overuse alcohol,” I added. “Sadly, women bear the brunt of this uneven distribution of medical consequences, even though alcohol overuse is typically associated with men.” I have pamphlets from NIDA [the National Institute on Drug Abuse] about women and alcohol. Would you like one? Or you can look online. I can send you a link.”

I tried another sales pitch, hoping to appeal to Meg’s artistic inclinations. “Our government really did a good job with the graphics on the NIDA website. I think you would like them.” And that was the truth.

Having said my piece, I stepped off my soapbox, waiting to hear Meg’s response. Meg responded with a blank stare, neither agreeing nor disagreeing. The fear that was in her eyes at the first visit had been replaced by a dissolute look of indifference. Still, I hoped that something I said made sense.

In my mind, it would have been tragic to turn this discussion into a political or religious debate when the most important matter at hand was protecting Meg from premature loss of her own life because of her longstanding alcohol use. Her OB had already broken barriers by convincing her to see a psychiatrist and examine the causes and consequences of her behavior. Even though Meg refused Alcoholics Anonymous, there are still ways to acquire habits that lessen the likelihood of alcohol overuse.

I felt confident that offering treatments that could decrease Meg’s alcohol cravings, rather than rebuking her for choices she made in the past, was the best way to prolong Meg’s life. If that is not a topic that everyone can agree on, then what is? Still, I wonder how many opportunities to educate patients about avoiding alcohol misuse are missed simply because people get caught up in polemics on politics.

is an assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mount Sinai in New York, New York.

1. Packer S. Jessica Jones, women, and alcohol use disorders. In Eds. Rayborn T, Keyes A. 

Jessica Jones, Scarred Superhero: Essays on Gender, Trauma, and Addiction in the Netflix Series

. McFarland & Company, Inc., Publishers; 2018.

A psychiatrist reflects on how we can educate patients about avoiding alcohol misuse without getting caught up in polemics on politics.

A Matter of Life and Death: When Abortion Wars Should Not Be Fought

Suicide Prevention Week is September 4-10. This week, we at 

 want to highlight how best to support patients, friends, family, and anyone who might be having suicidal thoughts. We sat down with Manish Mishra, MBBS, the Chief Medical Officer of the Texas Healthcare and Diagnostic Center, to discuss.

PT: What does research say the role of alcohol/substances is in suicide?

Research on the link between alcohol and substances in 

 has been driven by the prevalent involvement of alcohol and substance abuse in suicide cases. There is a multitude of factors to be considered when examining the correlation between substance abuse and suicide as independent variables with an anecdotally strong interdependent relationship.

Historical data used to inform research suggests that across general populations, all types of 

 and substance use disorders are associated with increased risk for suicidal behaviors, including ideations, attempts, and fatalities. Substance abuse involving alcohol and illegal or prescription drugs is a much higher risk factor for suicidal mortality.

One of the reasons why alcohol and drug abuse is so strongly associated with suicide has to do with the psychological and psychosocial outcomes of untreated alcohol and drug dependence. Substance abuse and 

 often result in social isolation and marginalization, disruptions and conflicts in personal relationships, and aggravation of psychiatric symptoms such as depression and anxiety, all of which contribute to suicidal behaviors.

Another strong correlation is that alcohol and mind-altering substances are used as means of self-medication to cope with untreated mental health disorders, the symptoms of which are reciprocally exacerbated by substances. This causes a spiral effect of emotional decline and mental impairment that occurs with chronic alcohol and drug use and intoxication.

PT: People with alcohol use disorder are up 120 times more likely to commit suicide than those who are not dependent on alcohol.

 Psychoeducation on substance use and suicide for patients and their families seems to be more important than ever. In your experience, what are the best strategies for clinicians to broach this subject?

The abuse of alcohol or drugs is one of the most common risk factors for suicidal behavior. Although this is a difficult way of intervention and requires significant involvement and commitment from both patient and family members, psychoeducation has been proven to be effective in treating mental health disorders and managing the prognosis in the long run. Different strategies are used by clinicians to assess and manage symptoms and avoid remission. Some of the strategies commonly used are as follows:

1) Brief intervention to reduce suicidal behavior

These types of interventions are mostly used with postdischarge patients for follow-up. It can include postcards, letters, or even a phone call. It helps in reducing the patient’s sense of isolation contributing to decreasing future suicidal behaviors.

Brief motivational enhancement techniques to increase patients’ willingness to pursue treatment and overcome obstacles may also be an effective engagement approach. Motivational interviewing is focused on helping people work through their ambivalence about changing their behavior and explores patients’ concerns and beliefs about change.

Most important to motivational interviewing is to engage patients in a discussion that is noncoercive and nonthreatening, and to create an atmosphere that is empathic, nonjudgmental, and supportive of the patients’ concerns. Open-ended questions, affirmations, reflective listening, and summarizing are the cornerstones of this approach.

Early intervention after a suicide attempt is vital because the 3-month period after an initial attempt is when an individual is at the highest risk of additional suicidal behavior. Yet those who attempt suicide have been found to be very difficult to engage in treatment. These interventions can include outpatient or inpatient treatment depending upon the severity. Postcards and phone calls can both be used for the outpatient approach, whereas motivational interviewing has been more effective with inpatient treatment.

This strategy provides for participation in activities that exclude alcohol, tobacco, and other drug use. Constructive and healthy activities offset the attraction to, or otherwise meet the needs usually filled by, alcohol, tobacco, and other drug use, which ultimately reduces suicidal tendencies.

PT: How can mental health clinicians improve the conversation surrounding this issue beyond the office?

Part of preventing suicide is raising awareness around the topic and bringing it into conversations. The topic of suicide is surrounded by secrecy, which is one of the barriers to getting treatment for people who need it. Mental health clinicians can play a part in dispelling the secrecy and stigma around suicide, and increase social empathy by discussing it as often and openly as other mental health issues are commonly verbalized.

As subject matter experts in their fields, mental health professionals have the capacity and agency to shed light on how prevalent suicidal behaviors actually are among general populations, and help to destigmatize suicide and associated mental health disorders. This stigma is a big reason why many people do not seek help for treatable mental health conditions and preventable tragedies.

PT: Global alcohol consumption has increased in recent decades, and is linked with more than 60 types of diseases and injuries.

 Should clinicians be talking to patients about healthy alcohol consumption levels, or even abstinence?

Many people who drink to excess would not categorize themselves as being alcoholics or having an 

. Many would also not consider broaching the subject to a clinician if they think it would be irrelevant, or they do not want to be labeled as someone with an alcohol problem. Clinicians are responsible for informing their patients of the dangers and risks associated with excessive alcohol consumption, including binge drinking and chronic intoxication, as a preventative protocol—not only as a response to an immediate health concern.

Even if someone does not fit all the criteria of an alcohol use disorder, they can still be at risk of developing alcohol dependence, putting their physical and mental health at risk due to alcohol abuse. Addressing alcoholism in a clinical setting and providing recommendations about setting limits or considering abstinence can help people make informed and conscientious decisions about their alcohol consumption.

PT: When devising a safety plan with patients, how do you discuss substance use?

Safety planning is a brief intervention to help individuals survive suicidal crises by having them develop a set of steps to reduce the likelihood of engaging in suicidal behavior. Safety planning is frequently included as an element in cognitive behavioral interventions for suicide prevention and can also be used as a brief standalone intervention, typically paired with a referral for mental health treatment.

The role of the substance abuse treatment program is to provide safety for its clients: recognizing suicidality when it appears, having policies and procedures for addressing suicidal thoughts and behaviors, and ensuring that treatment for the substance use disorder is not lost in the suicidal crisis. A Treatment Improvement Protocol (TIP) developed a protocol, with the acronym GATE for discussing suicidality in patients with substance abuse. It is comprised of the following steps:

• Take action to ensure appropriate care and safety for the client.

• Extend the action beyond the immediate situation to promote ongoing treatment and safety.

PT: Why is it important for clinicians to be talking about alcohol, substance use, and suicide with teenagers and young adults specifically?

Studies have observed that people who start abusing alcohol and drugs in early adolescence greatly increase their risk of developing mental health disorders and 

 Teenagers and young adults can benefit from being made aware of the risks associated with alcohol and mind-altering substances, and how even recreational use can adversely affect their mental health and increase the risk of suicide.

Raising awareness in these age groups about the severe consequences of substance abuse and chemical dependence requires a clinical approach to young, impressionable minds that are still developing. Adolescents are exposed to a lot of misinformation and skewed perceptions of drug culture through social media and society in general. It is critical to provide them with accurate information through a lens of empathy and compassion.

PT: Finally, what resources would you recommend to clinicians that might be good to share with patients?

Three elements that are key to identifying and addressing suicidal thoughts and behaviors among individuals in substance use treatment are:

2. Safety planning, including lethal means counseling (ie, assessing the individual’s access to firearms, medications, or other potentially fatal substances or objects)

Here are a few methods and resources that can be used by clinicians which might be good to share with patients:

Community reinforcement and family training (CRAFT)

Online resources such as motivational interviewing, inspiring stories, or videos

The following are some generalized resources on substance abuse and suicide that can increase awareness and educate patients and their loved ones:

National Action Alliance Suicide Prevention 

 by the Suicide Prevention Resource Center (SPRC)

Understanding Risk and Protective Factors for Suicide

Providing patients with resources is an opportunity that clinicians should use to empower patients to take initiative in maintaining and protecting their mental health. Patients are often unaware of the resources available to them and are more likely to use them if they know where to look.

is the Chief Medical Officer of the Texas Healthcare and Diagnostic Center, and a medical reviewer for 

 where he works to provide accurate, authoritative information to those seeking help for substance abuse and behavioral health issues.

1. Alcohol and suicide. Alcohol Rehab Guide. Accessed August 24, 2022. 

https://www.alcoholrehabguide.org/resources/dual-diagnosis/alcohol-and-suicide/

2. Pompili M, Serafini G, Innamorati M, et al. 

Epidemiological evidence on the link between drug use and suicidal behaviors among adolescents.

Suicide Prevention Week is September 4-10. Are you ready? 

The Role of Alcohol and Substances in Suicide

Tales From the Clinic: The Art of Psychiatry, 

we examine the case of posttraumatic stress disorder (PTSD) in the setting of homelessness and substance use. Most homeless individuals report experiencing significant trauma at some point in their lives. This discussion examines the correlation between trauma and homelessness, and touches on vicarious trauma endured by treating physicians as well. It is easy to fall into negative perceptions of patients with homelessness, trauma, and substance use. Successful treatment hinges on remaining humane in perspective, and viewing such cases as very high in comorbidity and needing additional psychosocial support.

“Ms Harris” is a middle-aged woman with a history of PTSD and alcohol use disorders who is currently receiving 

 at a local homeless shelter. She is engaged in a substance treatment program for the first time in her life.

Ms Harris was raped by an uncle at age 12 and advised by her mother to keep the incident a secret. After the rape, she started struggling with academic performance, and then she stopped attending school at age 16. She married at age 19 and quickly had 2 children. Her husband was physically and emotionally abusive in their marriage. She started drinking alcohol to cope with the abuse. She divorced her husband after 20 years of marriage when her youngest child turned 18. She received a small financial settlement after the divorce, but after 3 years, she had exhausted her savings. She was unable to sustain employment due to her 

 and discomfort interacting with strangers. During this time, her alcohol use escalated and her relationship with her children became strained. After exhausting her financial resources, Ms Harris experienced significant alcohol withdrawal and was subsequently admitted to the medical unit for treatment. Her apartment evicted her for nonpayment while inpatient, and she was subsequently discharged to a local shelter and substance use rehabilitation program.

Ms Harris is seen by a psychiatrist after completing the first 30 days of her sobriety. She is visibly anxious with significant psychomotor agitation. She reports difficulty with sleep initiation as well as sleep maintenance. She finds interacting with her peers uncomfortable and isolates herself when possible. During the visit, she reports significant irritability, primarily triggered by her peers and loud noises. She also reports having taken escitalopram in the past with poor effect.

Distrust of others is a well-known symptom of 

. Childhood maltreatment—including emotional abuse, emotional neglect, physical abuse, physical neglect, and sexual abuse—is also associated with increased distrust as well as interpersonal threat perception in adulthood.

 This often presents a challenge to the therapeutic alliance. Engaging in the principles of trauma-informed care is critical to both establishing trust and avoiding retraumatization.

During Ms Harris’s initial visit, she is reminded that her participation in the appointment is voluntary and confidential. Prior to obtaining a trauma history, she is advised that while she may be asked about broad categories of abuse, she can decline to answer any questions that make her uncomfortable and request that no trauma history be obtained at the initial visit. She is invited to provide any details that she does feel comfortable discussing, but is reassured that she will not be asked to divulge any painful details of her past. Ms Harris discusses that she had been 

 and physically abused as an adult, but declines to provide further details during the first few visits.

During the initial interview, Ms Harris has some ambivalence about her alcohol use. While she understands that her use had escalated to an unhealthy level, she also reports that it was her primary means of coping with her anxiety. Without it, she reports a significant escalation of her symptoms. She worries about her ability to tolerate a substance use treatment program.

Ms Harris is not alone in her difficulties with alcohol use. Some studies show the prevalence of alcohol dependence of homeless patients to be upwards of 55%, and similar rates of drug dependency.

 In emergency rooms, rates of substance use were significantly higher, sometimes doubled, in homeless patients as compared to those who did not report homelessness.

 While there are many hypotheses surrounding these findings, one cannot ignore the influence of trauma. Substance use disorders and PTSD often cooccur, with one study finding that up to 46% of patients with PTSD also meet criteria for a substance use disorder.

 Successful treatment of both disorders simultaneously is critical for patient improvement.

Ms Harris is initially started on sertraline for PTSD. Given her distrust of others and perceived failure of another selective serotonin reuptake inhibitor (SSRI), considerable time is spent in psychoeducation surrounding the role and effects of medications in her treatment plan. She is also started on naltrexone for 

. Trazodone is used for sleep initiation difficulties.

In subsequent visits, the patient reveals that she is having nightmares surrounding the physical abuse from her ex-husband. She reports that the dream frequency has not changed with the initiation of her other medications. Doxazosin is added. While more research is needed in patients with comorbid PTSD and alcohol use disorder, doxazosin has had some promising results when studying these illnesses separately.

Other treatment options aimed at addressing her anxiety such as hydroxyzine and gabapentin are discussed but declined by the patient due to a fear of daytime sedation. Topiramate is also discussed, as it has shown promise in patients with cooccurring PTSD and alcohol use disorder, although additional studies are needed.

 Ultimately, this medication is also omitted from the treatment plan due to the potential for cognitive deficits, which could impair her ability to participate fully in her substance use treatment program.

The shelter helps Ms Harris remain compliant with her medications with frequent reminders and scheduled medication times. She participates in cognitive behavioral therapy (CBT)-based substance use treatment classes, as well as group and individual therapy. She engages in prolonged exposure for her traumas. Over many weeks, Ms Harris begins to trust her psychiatrist and engage in more peer support activities. Her emotional and physical reactivity improve. With the help of the shelter’s case manager, Ms Harris is able to obtain work in the retail industry. As graduation approaches, she becomes more anxious. Her psychiatrist initiates a CBT-based model aimed at addressing her cognitive distortions surrounding her ability to be successful outside of a structured setting. Ms Harris graduates from the substance treatment program and moves into an apartment.

She is followed closely by her psychiatrist after graduation. Immediately following her transition out of the shelter, the patient reports a recurrence of anxiety and sleep disturbance. In addition, she reports a relapse after being offered alcohol by a well-meaning neighbor. While initially struggling with significant shame and guilt, the patient is able to abstain from further use. Trazodone is transiently increased, and Ms Harris continues to address her anxiety in therapy with positive effect.

After many months, Ms Harris becomes romantically involved with a neighbor at her apartment complex. She reports an improvement in her anxiety and continued sobriety in the weeks following the start of their relationship. She is lost to follow up.

Ms Harris returns to the clinic after 1 year. She reports that her boyfriend did not support her use of psychiatric medications and advised her to stop them. He soon became increasingly emotionally abusive, and the patient relapsed on alcohol. Two weeks ago, he sexually assaulted her after she declined to have intercourse. She has not yet told anyone about the assault, but ended the relationship. She reports feeling fearful, as he has remained a resident in her apartment complex.

Her psychiatrist provides emotional support while also encouraging the patient to report the assault to the police and consider seeking a restraining order in accordance with state law. She is also encouraged to obtain urgent gynecologic care and is given information about a local family violence shelter center. While the patient declines to report the incident to the police or seek resources from the family violence shelter, she does agree to seek gynecologic care. The patient restarts her medications and is able to taper off alcohol as an outpatient.

Working with homeless patients can be exceedingly rewarding. Patients such as Ms Harris can and do improve at a remarkable rate with the appropriate support and treatment. However, there are also challenges facing psychiatrists who work with homeless patients, notably vicarious trauma. Psychiatrists in this area are inherently exposed to personal reports of trauma repeatedly throughout the day. One study in Canada showed rates of PTSD in helping professions related to homelessness were 2 to 3 times higher than what were found in other frontline professions such as policework and emergency services.

 Therefore, it is imperative that those working with this patient population actively engage in their personal wellness and ensure they are receiving support from their institution.

is assistant professor at the Meninger Department of Psychiatry and Behavioral Sciences at the Baylor College of Medicine in Houston, Texas. She specializes in homeless populations with cooccurring psychiatric illnesses and serves as the Departmental Lead Medical Students Elective Officer and Associate Clerkship Director.

Childhood maltreatment in associated with distrust and negatively biased emotion processing.

Borderline Personal Disord Emot Dysregul. 

Trauma-Informed Care in Behavioral Health Services. 

Treatment Improvement Protocol (TIP) Series 57. Substance Abuse and Mental Health Services Administration; 2014.

The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis.

4. Doran KM, Rahai N, McCormack RP, et al. 

Substance use and homelessness among emergency department patients.

5. Pietrzak R, Goldstein R, Southwick S, Grant B. 

Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: results from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions.

6. Back SE, Flanagan JC, Jones JL, et al. 

Doxazosin for the treatment of co-occurring PTSD and alcohol use disorder: design and methodology of a randomized controlled trial in military veterans.

7. Flanagan JC, Korte KJ, Killeen TK, Back SE. 

Concurrent treatment of substance use and PTSD.

PTSD symptoms, vicarious traumatization, and burnout in front line workers in the homeless sector.

More than 80% of homeless individuals report having experienced life-altering trauma at some point in their lives.

“I Have No One”: Understanding Homelessness and Trauma

Doctors and health care professionls are having a difficult time right now. Even before the COVID-19 pandemic, our rates of 

 were steadily rising to the point that half of physicians have at least 1 symptom of burnout. We have one of the highest suicide rates of any profession, with female physicians being particularly vulnerable. A quarter to one-third of our students and trainees are reported to be suffering from clinical depression. The pandemic has exacerbated all the stressors that are fueling these tragic statistics.

A related issue that is not discussed nearly as thoroughly or as openly as it should be is that of physicians and 

. Physicians become addicted to drugs or alcohol at least as commonly as the general population does. It is thought that 10% to 14% of physicians suffer from addiction to drugs or alcohol during their careers.

I suspect that the rates are higher, as our current system of addressing this problem is punitive and dehumanizing. It incentivizes physicians hiding their addiction and avoiding unwanted attention that comes from seeking help. Most individuals will not ask for help if they receive punishment and judgment as a result. After 2 years of a pandemic during which physicians and nurses absorbed the brunt of the stress, with rates of all types of addiction in other populations skyrocketing across the country, it is difficult to imagine that this problem of physicians and addiction has not become even more prevalent.

Personally, I am 14 years into recovery from a severe and, toward the end, all-consuming addiction to prescription opioids. During my addiction, and my halting steps toward recovery, I learned about the challenges and obstacles that face physicians who struggle with substance use disorders. As is my 

, I learned about these things the hard way: I had the state police and the US Drug Enforcement Administration (DEA) in my office; received 3 felony drug charges leading to several years probation; stayed in an out-of-state rehabilitation facility for 3 months; lost my medical license for 3 years; and had to donate about 20 gallons worth of urine for drug testing over a period of 5 years.

Once it was deemed I was in stable recovery, I was invited to become an associate director of our state’s physician health program (PHP). In this role, I sat at the exact same table I did 10 years previously, now on the other side of where I had been sitting during my early addiction when I began getting in trouble and realized I needed help. Now I was being offered the privilege of helping other physicians. Having participated in this issue from both sides, I have insight into how physicians become addicted, how they are treated, what they go through, and how they try to heal.

I also understand how stressful it is when someone realizes that a colleague is impaired and the agonizing decisions that can come with this realization. Finally, I feel as if I have some insight into the problems that predispose us toward these dangerous addictions.

Are all types of physicians afflicted to the same extent? According to a 2014 article from the 

“Emergency medicine physicians, psychiatrists, and anesthesiologists are at higher risk for developing a substance use disorder compared with other doctors, perhaps because of their knowledge of and access to certain legal drugs.”

Other research suggests that anesthesiology residents have a high risk of developing substance use disorders—often to injectable fentanyl—as well as a higher risk of subsequent relapse during their professional career.

 When I was an associate director at the PHP, debates often took place on whether it was safe to let anesthesiologists who were addicted to injectable opioids return to work, as both relapse and death were not uncommon outcomes.

Findings from some older studies may be enlightening. For example, according to research from 1992 and 2011 based on data from an anonymous survey of 5426 doctors, some medical specialties were associated with higher use of certain substances than others. Anesthesiologists used more opiates, emergency medicine physicians used more illicit drugs, and psychiatrists used more benzodiazepines; surgeons and pediatricians had comparatively low rates of drug use, with the exception of tobacco.

 And, according to data from a 1991 study, psychiatrists seem to be at higher risk of self-prescribing sleeping pills and/or tranquilizers than their peers.

However, it is important to note that addiction can affect any physician regardless of specialty, gender, race, or life circumstances.

In addition to the usual conditions that predispose individuals to addiction—family history, trauma history, undertreated anxiety and depression, poor distress tolerance—physicians have extra stressors that greatly enhance our risk. No one would argue that we have little anxiety in our professional lives. When you think about it, we have the same stressors as everyone (eg, depression, divorces, caring for older family members, illnesses, financial problems, troubles with our children), plus we have the added stress of trying to be good doctors in a profoundly broken system. Many of us face moral injury daily as we try to do what is right for our patients in the face of hospital and insurance policies that undermine us. We click on the electronic medical records (EMRs) late into the evening, trying to catch up, after our children fall asleep. This is not healthy or sustainable.

We also have knowledge about and access to easily abusable prescription opioids and sedatives. The mixture of additive stress and open access to medications is a perfect storm for addiction (which is why I called my memoir 

). It starts slowly, and before you know it, you are withdrawing, afraid to get help, and feeling trapped. To ask for help is to risk bringing the medical board crashing down on your head. Who would do this voluntarily? The culture of medicine dictates we are supposed to be strong and independent and are viewed as (and feel) weak or substandard if we ask for help further worsens this situation.

How to Recognize Addiction in a Colleague

Unfortunately, sometimes you cannot and may not recognize it. Do not blame yourself. Doctors are great at hiding their addictions, especially from themselves. Usually there is no “smoking gun,” ie, someone smelling of alcohol, slurring words, nodding off, or getting caught injecting in a bathroom, or swigging on a flask between patients. However, there are signs that something is wrong, be it addiction, depression, psychosis, or some other problem.

One might notice a relatively rapid decrease in a colleague’s competence at work, newfound tardiness, irritability, and/or deteriorating personal hygiene. A once-affable colleague might be isolating themselves, pushing others away, being quarrelsome, and keeping odd hours in the hospital. When I was addicted, I would return to my office to snort oxycodone by myself. In retrospect, it was lonely and miserable, but I could not stop. Anyone who saw me in the office would have assumed I was just working late—but why would a primary care physician with small children be in his office at 11 at night?

What Do You Do if You Suspect Addiction in a Colleague?

According to the letter of the law, we are mandated reporters—we must report a colleague who is impaired to the medical board of our state, or to the PHP, which is the legal equivalent in terms of discharging our mandated reporter duties. Many PHPs have “diversionary” programs in which, if there are no criminal charges or allegations of patient harm, physicians can get treatment without the board necessarily finding out about it. (In reality, however, the board often does find out because, if anything goes wrong—if there is even a paperwork problem—physicians can be reported to the board. This obviously defeats the purpose of the “diversionary” program.)

There are other pathways. I truly believe it is in the spirit of the law to confront a colleague, with empathy, and to tell them, “I suspect you are impaired, and if you do not get help, I will have to report you. Let’s work on getting you help.” This can be done with your supervisor, to give it more weight, if your colleague denies there is a problem. If your colleague truly will not get help, you may be forced to take the nuclear option, which is then to actually report them. However, this is often not my first step unless they pose an imminent danger to patients or to themselves.

What Are the Consequences of Addiction in Physicians?

Addictions tend to get worse, especially in high-stress professions. As they say in recovery lore, addictions usually end in “jails, institutions, or death.” I can tell you from vast experience that this is largely true for physicians who do not acknowledge that they have a problem and accept help. 

Addicted physicians can also harm patients—something that is exceedingly difficult to come to terms with for the rest of your life (and which can result in a devastating lawsuit). They can get into criminal difficulty, usually via illegal diversion of medications. We have all heard horror stories about this happening, such as when doctors or nurses steal fentanyl.

What I tell medical students and doctors is this: You 

get help for your addiction. It is merely a question of whether you get help 

 (ie, put yourself in a program that you choose, consult with an addiction psychiatrist, or report yourself to a PHP; you get a lot of “points” for self-reporting, although you are in their clutches once you do so)—or 

, as I did. These terms tend to be much more destructive, harsh, and painful, such as my experience of having the state police and the DEA visit my office and having the medical board shoot first and ask questions later.

If you are struggling, the best thing you can do is find a trusted colleague or manager, confide in them, ask for help, and arrange to get the help you need.

PHPs generally monitor and oversee treatment, and the treatment preferences are evolving. It used to be that everyone was sent to rehab for 90 days, in addition to a longitudinal program of support group meetings, drug testing, therapy, and work with an addiction psychiatrist. Doctors are “monitored” for 3 to 5 years and are eventually let back to work if the medical board feels they are in stable recovery and pose no threat to patient care.

“Doctors are great at hiding their addictions, especially from themselves... However, there are signs that something is wrong—be it addiction, depression, psychosis, or some other problem.”

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