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To encourage sponsor application for over-the counter naloxone, the US Food and Drug Administration (FDA) today issued a Federal Register notice, “Safety and Effectiveness of Certain Naloxone Hydrochloride Drug Products for Nonprescription Use,” that could help facilitate the development and potential approval of nonprescription naloxone drugs.

“Today’s action supports our efforts to combat the opioid overdose crisis by helping expand access to naloxone,” said FDA Commissioner Robert M. Califf, MD. “The agency will keep overdose prevention and reduction in substance use disorders as a key priority and area of intense strategic focus for action as rapidly as possible.”

The notice states that naloxone drug products up to 4 mg nasal spray and up to 2 mg autoinjector for intramuscular or subcutaneous use may be safe and effective for nonprescription use. Although this notice does not mean nonprescription/over-the-counter naloxone is immediately available, it does make application holders aware of the willingness of the FDA to consider nonprescription naloxone drug products. First, the FDA needs additional data, including product-specific data on the user interface design, such as packaging and labeling.

This is not the first step the FDA has taken to improve access to naloxone. In September, the FDA issued guidance to clarify that certain Drug Supply Chain Security Act requirements do not apply to naloxone distribution to harm reduction programs during the Opioid Public Health Emergency.

“The agency remains focused on responding to all facets of substance use, misuse, substance use disorders, overdose, and death in the US through the four priorities of the framework, including: supporting primary prevention by eliminating unnecessary initial prescription drug exposure and inappropriate prolonged prescribing; encouraging harm reduction through innovation and education; advancing development of evidence-based treatments for substance use disorders; and protecting the public from unapproved, diverted, or counterfeit drugs presenting overdose risks,” the FDA shared in a new release.

1. FDA announces preliminary assessment that certain naloxone products have the potential to be safe and effective for over-the-counter use. US Food and Drug Administration. News release. November 15, 2022. 

https://www.fda.gov/news-events/press-announcements/fda-announces-preliminary-assessment-certain-naloxone-products-have-potential-be-safe-and-effective?utm_medium=email&utm_source=govdelivery

We may be one step closer to nonprescription naloxone. 

The Road to Over-the-Counter Naloxone: FDA Releases Federal Register Notice

 covered a wide variety of psychiatric issues and industry updates, from helping employers understand traumatic brain injury to understanding—and combatting—the dangers of excessive social media usage. Here are some highlights from the week.

Expert Sheds Light on Opioid Overdose Crisis in Youth

“It’s not just an opioid crisis, it is a polysubstance crisis,” Scott Hadland, MD, MPH, MS, FAAP, told attendees of the 2022 American Academy of Pediatrics National Conference and Exhibition in Anaheim, CA. Hadland, Chief of Adolescent and Young Adult Medicine at MassGeneral Hospital for Children and Harvard Medical School, shared insights into the use and abuse of opioids in youth in the US. Hadland is triple board certification in General Pediatrics, Adolescent Medicine, and Addiction Medicine. 

Helping Employers Understand Traumatic Brain Injury: Setting Up for Success

Traumatic brain injury (TBI) is a physical trauma to the head that results in impaired function of the brain. TBI is a life-changing event not only for the individual who is injured, but also for those who surround them. A single patient’s TBI reverberates even further. Injured workers are necessarily removed from their workplace ecosystem, causing more disruption. Employers with little experience and understanding of TBI are left with the uncertainty of the individual’s recovery. 

Understanding the Long-Term Clinical Course of Comorbid SUD and ADHD

While substance use disorders (SUDs) often cooccur with attention-deficit/hyperactivity disorder (ADHD), little is known about the long-term clinical course of patients with comorbid SUD and ADHD.

The International Naturalistic Cohort Study of ADHD and SUD (INCAS) is a prospective observational cohort study of treatment-seeking individuals with SUD and comorbid adult ADHD and was designed to examine the clinical course in different treatment settings and countries. Investigators detailed treatment modalities; how age, gender, primary substance of abuse, and other psychiatric comorbidities affected treatment outcomes; and longitudinal data on a broad range of psychological measures, like cognitive symptoms. 

The Dangers of Excessive Social Media Usage

Halloween is right around the corner, and this is a time that many enjoy experiencing haunted houses, dressing up, adorning their homes with creepy decorations, and watching scary movies filled with terrifying creatures, things that are hidden in the dark, and paranormal and supernatural entities. However, as a psychiatrist, what I find scarier than any of these things is something we all deal with on a daily basis: the damage that excessive social media use is causing on our society.

Our culture glorifies celebrities and gaining exposure over various media platforms, and social media has provided the opportunity for such success to a much greater number of people. Individuals often utilize these mediums to espouse opinions and misinformation that is often consumed by users as fact. This is every mental health professional’s worst nightmare. 

. And be sure to stay up-to-date by subscribing to the 

Do you have a comment on any of these or other articles? Have a good idea for an article and want to write? Interested in sharing your perspectives? Write to us at 

From traumatic brain injury to the dangers of excessive social media usage, here are highlights from the week in Psychiatric Times.

The Week in Review: October 10-14

Thomas R. Kosten, MD, shares more about fentanyl's new look. While fentanyl previously looked like other over the counter pills, a new marketing change has arrived just in time for Halloween: Rainbow fentanyl is multicolored and looks like Skittles or jellybeans. With more than 100,000 overdose deaths a year, here's why we need to combat the opioid epidemic now more than ever.

is the Jay H. Waggoner Endowed Chair and co-founder at the Institute for Clinical and Translational Research. He is also a professor of psychiatry, neuroscience, pharmacology, and immunology at Baylor College of Medicine in Houston, Texas.

Fentanyl is now available in ways it was not before, which may lead to fatal outcomes. 

Fentanyl's Fatal Marketing Change

“It’s not just an opioid crisis, it is a polysubstance crisis,” Scott Hadland, MD, MPH, MS, FAAP, told attendees of the 

2022 American Academy of Pediatrics National Conference and Exhibition

 in Anaheim, CA. Hadland, Chief of Adolescent and Young Adult Medicine at MassGeneral Hospital for Children and Harvard Medical School, shared insights into the use and abuse of opioids in youth in the US. Hadland is triple board certification in General Pediatrics, Adolescent Medicine, and Addiction Medicine.

Addressing the issue in youth is important, Hadland explained, because data shows 2 of 3 individuals in 

 reported first use before age 25 years, and 1 in 3 reported first use before they were 18 years old. Similarly, he pointed to 2021 data from 

 that found almost 10% of high school students reported they have used prescription opioids nonmedicinally. Interestingly, data has shown a slight dip in reported opioid use during the pandemic, he said, probably because of lockdown and lack of accessibility.

between ages 14 and 18 due to opioids doubled between 2019 and 2021, Hadland said. Overdose deaths due to other substances such as cocaine, methamphetamine, and benzodiazepines also increased, but remained much lower than the approximate 4 in 100,000 rate associated with opioid overdose. 

The amount of counterfeit drugs available is partially driving the problem, Hadland said. In fact, he explained it is very difficult to purchase real prescription medications on the street, and the counterfeits are looking more and more like the real thing.

 is everywhere in this country, and it’s [availability] is not going anywhere,” he added. Hadland cited data noting approximately 75% of all overdose deaths in teens are due to fentanyl. Most deaths involve an opioid plus another substance, with cocaine, benzodiazepines, and methamphetamine being the top 3 offenders.

With this in mind, clinicians and pediatricians may be wary of prescribing opioid medications to patients with pain issues, but Hadland noted it can be safe to do so—and it should be done if needed. In fact, data has shown only about 1 in 300 youths who were prescribed opioids become addicted or overdose, he said. The key, he added, is being careful.

Long-acting opioid formulations, high daily opioid dose, and a duration of 7 days or longer are prescription-related risks associated with addiction and overdose, Hadland told attendees. He also noted family history of any addition, mental health disorders, and other substance use (eg, nicotine, alcohol, and cannabis) are patient-level risk factors.

Not surprisingly, youth opioid addiction is related to a cascade of care issue, Hadland added. All youth with opioid addiction has a prevalence of about 1%, he said. Unfortunately, less than half of those individuals will receive a diagnosis; only a smaller portion will receive any treatment; a sliver of those will receive medication; and smaller slivers will remain in treatment 1 month and 6 months. The data is even more alarming for certain populations, he said. Black youth and Hispanic youth are 65% and 74% (respectively) less likely to receive treatment, he explained, and 32% and 58%, respectively, less likely to be retained short-term.

Fortunately, there are some things that can be done in the clinical trenches, Hadland said. Screening is of utmost importance, he noted, and encouraged open dialogues with patients. Overdose prevention and 

are also key to addressing the crisis. Hadland suggested warning patients to be wary of counterfeit pills and advising them to start with a little to assess the effect, avoid polysubstance use (especially benzodiazepines), not to use alone, and to call 911 in case of an emergency. He also has written prescriptions for naloxone.

Advocating for Medication for Opioid Use Disorder

Risk of Overdose with Antipsychotic and Opioid Co-Prescription

A Whirlwind Tour of OUD Treatment Strategies

Cognitive Behavior Therapy and Medication-Assisted Treatment for Opioid Use Disorder

Opioid use, addiction, and overdose in youth continue to increase. What can be done?

The National Commission on Correctional Health Care (NCCHC) and 166 national organizations recently signed a letter to Senate leadership advocating for increased access to buprenorphine, an FDA-approved medication for opioid use disorder (OUD). They urged US Senate to pass the bipartisan 

Mainstreaming Addiction Treatment (MAT) Act

“In the midst of a deadly and accelerating overdose crisis, the MAT Act is a common-sense solution that will prevent overdoses, increase access to treatment, and reduce stigma,” the letter reads.

, along with methadone and extended-release naltrexone, is 1 of 3 medications currently approved by the US Food and Drug Administration (FDA) to treat OUD and is considered the “gold standard” treatment. It also keeps individuals with OUD from returning to illicit drug use—and to jail.

 severely hinders access to buprenorphine by preventing health care providers from prescribing it. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), only about 1 in 10 people with OUD receive medications for the condition because of the X-waiver. Furthermore, the Department of Health and Human Services claims that fully 40% of US counties do not have any health care providers who can prescribe buprenorphine.

If passed, the MAT Act will eliminate the X-waiver and make buprenorphine more available and accessible for Americans with OUD.

The letter was sent to Majority Leader Chuck Schumer, Minority Leader Mitch McConnell, Chair Patty Murray, and Ranking Member Richard Burr on August 31, Overdose Awareness Day. The letter can be found 

1. NCCHC Supports Access to MOUD. National Commission on Correctional Health Care. September 9, 2022. Accessed September 21, 2022. 

https://www.ncchc.org/ncchc-supports-access-to-moud/

2. The Mainstreaming Addiction Treatment Act (“MAT Act”, S. 445 / H.R. 1384). August 31, 2022. Accessed September 21, 2022. 

https://static1.squarespace.com/static/5eb15fa07d53aa0e85b448d7/t/6317704dfeb1183bfc5ada54/1662480461791/MAT+Act+(S+445)+-+167+Organizations+Submit+Letter+to+Senate+Leadership+Urging+Passage+with+Sept.+CR+(Aug22).pdf

The NCCHC and 166 national organizations recently signed a letter to Senate leadership advocating for increased access to buprenorphine. 

Tales From the Clinic: The Art of Psychiatry

, we visit the addiction clinic to discuss accidental overdose deaths. Although death by suicide is known to greatly impact psychiatrists, the impact of overdose deaths on physicians is not well studied. Despite the best efforts exerted in treatment, patients on medications for opioid use disorder may die of accidental overdoses on opioids, having misestimated their current opioid tolerance, or overdose on other substances such as sedatives/hypnotics and stimulants. This article is dedicated to 3 patients lost in this past year—AK, EG, and AW—with heartfelt wishes to their families.

“Ms Verona” was a 45-year-old female enrolled in an addictions treatment program and a mother of 7 children who struggled greatly with 

 and anxiety. She was motivated to stop her opioid use, as it was taking a toll on her health and her family. Ms Verona’s children would sense their mother’s lack of engagement with them, as she was constantly preoccupied with how to mitigate the inevitable opioid withdrawal symptoms. She was a good candidate for buprenorphine therapy, as she met criteria for severe opioid use disorder, and she preferred partial agonist therapy as opposed to naltrexone and methadone. Ms Verona was inducted onto buprenorphine, and her dose subsequently increased to 16 mg total daily in order to adequately address opioid cravings.

As treatment progressed, Ms Verona displayed a chronic tendency to arrive more than an hour late to appointments. Despite her tardiness, she would plead to still be seen, often citing traffic or lack of childcare arrangements. The psychiatrist, Dr Smith, would attempt to be flexible, given the understanding of treatment barriers stemming from social determinants of health, as well as recognizing the time-sensitive nature of 

 refills; however, these accommodations were placing Dr Smith and the treatment team under time constraints in a busy clinic. Such accommodation would either cause the psychiatrist to be late for other appointments, or it would lead to the appointment with Ms Verona feeling rushed. After the patient was accommodated for lateness over a few visits, Dr Smith became aware of his growing countertransference toward Ms Verona.

 (ADHD) may have been affecting her presentation. Ms Verona was noticeably circumstantial during sessions and required frequent redirection. She also described a childhood history with symptoms of difficulty concentrating. It was also explored whether her lateness was a manifestation of her inability to focus, organize, and prioritize. She often talked about having gotten Adderall “but not recently, doctor; I know you would not let me.” Dr Smith worked with Ms Verona in problem-solving therapy to help reduce treatment-interfering behaviors and promote punctuality. Ms Verona was also started on bupropion to target ongoing depressive symptoms and simultaneously provide a nonnarcotic option to treat attention-deficit symptoms. There was a concern for her using stimulants or other substances between appointments. Despite these treatment approaches, tardiness to her appointments continued and she appeared even sedated at times, despite negative urine drug screens.

One day, Ms Verona was more than an hour late. She was informed that she could not be seen and had to be rescheduled. She was visibly upset and opted, likely due to splitting defense mechanism, to reschedule to see a different provider in the clinic when this boundary was set. After this, Ms Verona ended up seeing a different psychiatrist for the next 6 months.

One day, Ms Verona’s former psychiatrist met with one of his active patients, Mr Kim, and the following dialog ensued:

Mr Kim: “One of my friends passed away, and I’m attending the funeral. I think you actually used to treat her before.”

Dr Smith: (Somewhat surprised) “I’m sorry to hear about the loss of your friend.”

Mr Kim: “Yea, it was sad… she (Ms Verona) said she used to see you. She was still on buprenorphine, but the suspicion was that she was taking alprazolam the whole time she was in treatment and did not tell anybody, and it is a suspected unintentional overdose. I used to see her all the time, and she would be nodding off. You didn’t hear about this?”

How Do Physicians Cope With Patient Suicide or Overdose?

Dealing with the loss of a patient due to suicide or 

 has a significant impact on the treating physician and is not often talked about. There are a variety of factors that determine how a psychiatrist will be impacted in such a situation. Younger clinicians and trainees are often affected more adversely, as they have not been exposed to the scenario and may feel more vulnerable in terms of their experience and knowledge base.

 According to literature, about 25% to 60% of psychiatrists will report having a patient who died by suicide during their career.

 The number of physicians who lose patients to overdose is not known. However, the rate of overdoses involving opioids jumped by 200% from 2000 to 2014, and between 2013 to 2019, the synthetic opioid-involved death rate increased 1040%.

 The sheer magnitude of these numbers suggest that most physicians dealing with addiction must have been exposed to patient death by overdose.

With these figures in mind, as well as the significant amount of perceived stigma and guilt surrounding disclosure of these outcomes, and with the fear of lawsuits that may occur in these situations, the overall emotional toll it can have on a clinician can be quite intense. The psychiatrist in this scenario was flooded with feelings of guilt related to potential responsibility for the outcome. In addition, there is a possibility of additional emotions of anger toward the patient who was already deceased. We hear team members often saying, “Oh, but they were doing so well,” or “So sad—they stayed off heroin but could not keep off meth.”

When one is processing the suicide of a patient, one should be mindful to not isolate oneself. Efforts should be conducted to reach out to colleagues, as it is likely they would have dealt with similar experiences in the past and can normalize and validate the experience. Discussion of experiences and coping mechanisms may have therapeutic effects for physicians going through such experiences. Clinicians, as part of an organization or group practice, can utilize case conferences—a pragmatic, systematic, and therapeutic approach to exploring the case outcome in more detail. Risk management reviews or meetings could help with apprehension about any impending or perceived lawsuits. This is especially important for clinicians in private practice, who may be more isolated given their work environment structure. The message we need to hear is that a patient loss does not undo or discard the multitude of meaningful life-changing and life-preserving work done with both living and deceased patients. Support and validation go a long way in reminding us why we do what we do.

How Can We Promote Honesty About Recurrence of Substance Use?

 (SUDs), it may be helpful to try to acknowledge and normalize the fear of disclosure of relapses, as well as to emphasize the importance of honesty in recovery from the very beginning of treatment. Although feelings of guilt and internal shame are common, they are not easy to talk about for patients. Whereas the patient may perceive recurrence of use as “starting from scratch,” the clinician can reframe a recurrence of use as a learning point and a way to troubleshoot the circumstances surrounding the use. Being too harsh or strict with the patient may backfire, lead to sustain-talk, erode the therapeutic alliance, and provoke even more feelings of guilt or shame. Relapses sometimes occur because being off substances uncovers a cooccurring mental illness, or because of stress in real life, to which patients with SUDs are more susceptible.

By definition, addiction is a relapsing and remitting illness. Similarly, depression is also a relapsing and remitting illness, but no one benefits from being kicked out of treatment for having a recurrent depressive episode. Thus, patients should not be terminated from treatment for recurrence of use as if often done—they should actually receive more intense care when in a greater time of need. Although recurrence of use might have clinical significance on modifying treatment plans, patients should be informed that using is only a setback if they do not seek further treatment to address it. Patients may be relieved if asked about any internalized and unfounded fear they may have about being terminated from treatment if they divulge recurrence of use.

If a patient states that they are feeling punished for having more frequent visits during recurrence of use, it may help to first empathize with concerns and then reframe the change in treatment plans as a goal toward well-being as opposed to punishment. Utilization of motivational interviewing may be helpful if the patient is still ambivalent about recovery. It is crucial for a provider to have a nonjudgmental approach toward relapses, both past and present. Subconscious criticism, even in the form of subtle body language, can promote denial or reliance on more primitive defense mechanisms in a patient and lead to poorer treatment outcomes, especially if the patient has a harsh superego or difficulty with trusting others.

Previous recurrence of use may lead some patients to think they are a lost cause and lack the willpower and discipline that might be needed for recovery. Internalizing this belief is characteristic of patients with complicated SUD histories. It is important to modify a patient's internal process and remind them that it is not solely willpower or motivation that determines the ability to improve, but also coping and relapse prevention skills, which can be taught through any type of therapy, but especially cognitive-behavioral therapy.

How Do You Find a Balance of Boundaries With the Patient?

Finding the right balance in setting boundaries can be a challenge in a busy schedule, and it requires being mindful of the patient’s perspective while simultaneously acknowledging a patient’s subconscious need for structure to meet treatment goals.

It was important in Ms Verona’s case to validate her struggle with circumstances in her life. After all, the social determinants of health (ie, social, behavioral, and environmental factors) are a predominant influence on treatment outcomes.

 In addition, it is important to acknowledge the role of untreated ADHD (like in Ms Verona’s case) in reducing recovery success.

 At the same time, the medical ethics concept of justice should also be considered. Although justice in this situation may apply to acknowledging Ms Verona’s barriers to care, it may also expose the caveats of this approach since other waiting patients were affected by the patient’s tardiness. A provider is tasked with collectively benefiting all of their patients, treating all with equity and making accommodations where necessary, and without putting 1 patient at risk at expense of another.

In this case, did the boundary-setting change the course of Ms Verona’s clinical treatment? Yes. Would it have been better without it? Not necessarily. Part of the treatment frame is for both physician and patient to be accessible, at a mutually convenient time. Reneging on appropriate boundaries may distort or enable certain expectations of the patient, which can undermine the patient’s perceived responsibility in treatment, reduce the patient’s ability to problem-solve, and lead to the approach that the physician drives the treatment, instead of the dyad making a shared and mutual responsibility. The physician can communicate these messages with empathy and genuine concern in the hopes that the patient will adopt that responsibility. In the case of mitigating overdoses—a poorly understood field—it is essential to know if the patient is using secondary substances outside the opioid being the target of treatment. Secondary substance use significantly increases risk of overdose.

From a larger perspective, a physician’s taking of the alternate approach can contribute to burnout and distress, and potentially adversely affecting outcomes for the other patients. Thus, boundaries can be a mechanism of protection for both the patient and the physician.

Triple Threat of Death: Suicide, Unintentional Overdoses, and COVID-19

Although there is growing literature about how patient 

 can impact physicians, there is a lack of data particularly on how substance overdose may impact a physician’s mental well-being. The lack of data on overdoses and how to cope with them is further compounded by the problem that busy schedules or shift work may inadvertently reduce the physician’s ability to access resources for support while the physician also thinks that “I must carry on.”

In addition, it would be important to differentiate how suicide and overdose are not necessarily the same. Overdoses are not always done with the intention of taking one’s life. In fact, most overdoses are accidental, but ultimately occur due to overestimated tolerance, unknown ingestion, or increasing amounts taken during stressful/inciting events. In 2014, only 12% of drug overdoses were intentional according to the Centers for Disease Control and Prevention (CDC).

 Although the percentage of intentional overdoses is the minority, another thing to consider is whether clinician perception of guilt is more intense if the overdose is intentional. A physician can be vulnerable to guilt for not effectively being able to treat a patient’s addiction or form a close enough relationship to know of their usage—even if the patient knowingly did not disclose use. Then there is the question of whether some severe addictive disorders could be considered like a “terminal illness,” where a clinician may feel that no matter how many treatment approaches have been tried, it is a matter of “not if, but when” in regards to either overdose or a chronic decompensation toward death.

Although we have seen that doctors who hear about their patients overdosing may actually reduce the amount of their opioid prescribing,

 mental health clinicians may be affected in a somewhat different capacity, as their role is also tied inevitably into also treating comorbid depression, anxiety, and suicidal ideation. The COVID-19 pandemic has further exacerbated this problem, as the estimated prevalence of suicidal ideation today is higher in comparison to the prevalence prepandemic.

If a clinician’s natural tendency to do more and become more hypervigilant following the loss of a patient, it is noteworthy to mention that most physicians suffer from burnout at one point in their life. A cross-sectional study was able to demonstrate that increases in suicidal ideation endorsement were significantly correlated with physician burnout rates.

 Considering that overdoses can be as lethal as suicides, it would be a fair but unproven assumption that it would also similarly contribute to physician burnout.

We believe further research is necessary to understand the many ways in which patient overdoses are affecting physicians, as well as developing more efficient strategies and support for dealing with the aftermath. 

is an associate professor and addiction-boarded faculty at Harris Health System in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. He is Director of Harris Health Substance Addiction Treatment Program and Associate Program Director for Baylor College of Medicine Addiction Fellowship Program. 

is currently a resident in psychiatry at Baylor College of Medicine. 

 is an associate professor in the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, as well as the Ben Taub Adult Outpatient Services director and the medical director of the Stabilization, Treatment & Rehabilitation (STAR) Program for Psychosis, also at Baylor College of Medicine. She also serves on the 

1. Ruskin R, Sakinofsky I, Bagby RM, et al. 

Impact of patient suicide on psychiatrists and psychiatric trainees.

2. Plakun EM, Tillman JG. The impact of patient suicide on clinicians. 

https://www.psychiatrictimes.com/view/impact-patient-suicide-clinicians

3. Rudd RA, Aleshire N, Zibbell JE, Gladden M. Increases in drug and opioid overdose deaths - United States, 2000–2014. Centers for Disease Control and Prevention. Accessed September 12, 2022. 

https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm

Trends and Geographic Patterns in Drug and Synthetic Opioid Overdose Deaths - United States, 2013-2019.

Relapse prevention and the five rules of recovery.

6. Williams N, Bossert N, Chen Y, et al. 

Influence of social determinants of health and substance use characteristics on persons who use drugs pursuit of care for hepatitis C virus infection.

Adult attention-deficit hyperactivity disorders and its correlates in patients with opioid dependence: an exploratory study.

8. Austin AE, Proescholdbell SK, Creppage KE, Asbun A. 

Characteristics of self-inflicted drug overdose deaths in North Carolina.

Opioid prescribing decreases after learning of a patient's fatal overdose.

Suicide, self-harm and suicidal ideation during COVID-19: a systematic review.

11. Menon NK, Shanafelt TD, Sinsky CA, et al. 

Association of physician burnout with suicidal ideation and medical errors.

My Patient Overdosed and Now I Feel Guilty… 

For the second year in a row, life expectancy in the United States has dropped.

 In 2020, the US experienced the largest drop life expectancy since World War II: 1.8 years.

 Now, life expectancy is yet another year lower, and declines in all individual 50 states. Declines differed significantly amongst race/ethnic groups.

Although COVID-19 obviously played a huge role in this decline, with states hardest impacted by COVID suffering larger declines, the picture is more complicated than that.

Robert Anderson, NCHS Mortality Statistics Chief, when asked about other leading causes of death that contributed to this decline, stated, “The main one is unintentional injuries, and this is mostly drug overdoses. There are some other causes that are grouped with unintentional injuries, including motor vehicle accidents and falls. But what really stands out in terms of sort of increasing mortality, and which is responsible for the decline in life expectancy, would be the drug overdose deaths. It’s second to COVID-19 in terms of its impact.”

Anderson noted that it is difficult to say whether individual overdose cases are related to pandemic stress; however, there was a flattening and even a slightly declining rate of drug overdose deaths prior to the pandemic. Now, in the wake of COVID-19, there is a steep increase in overdose deaths, with ‘unintentional injuries’ accounting for 15.9% of mortality increases. According to the NCHS data on drug overdose deaths, during the year-long period ending in March of 2022, over 109,000 overdose deaths occurred.

American Indians were amongst the race/ethnic groups most affected with a 1.9-year decline in life expectancy. “For the American Indian population, the decline was 6.6 years from 2019 to 2021. That’s just astounding,” said Anderson.

 “For the Hispanic population it was a 4.2-year decline; for the black population about a 4-year decline; for the white population 2.4 years; and for the Asian population 2.1 years.”

Read more about the overdose epidemic: “

The AMA’s 7 Recommendations for Reducing the Opioid Crisis

The Opioid Epidemic Is Alive—And Unwell

1. Arias E, Tejada-Vera B, Kochanek KD, Ahmad FB. Provisional life expectancy estimates for 2021. Centers for Disease Control and Prevention. August 2022. Accessed September 1, 2022. 

https://www.cdc.gov/nchs/data/vsrr/vsrr023.pdf

2. Life expectancy fell in 2021 for the second year in a row: interview with NCHS Mortality Statistics Chief Robert Anderson. Centers for Disease Control and Prevention. August 31, 2022. Accessed September 1, 2022. 

https://www.cdc.gov/nchs/pressroom/podcasts/2022/20220831/20220831.htm

3. Provisional Drug Overdose Death Counts. Centers for Disease Control and Prevention. Accessed September 1, 2022. 

https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm

New data shows a decrease in life expectancy in the United States. Here’s why.

The Overdose Epidemic and the “Astounding” Life Expectancy Drop

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.

These days, there is less emphasis on rehab and more focus on intensive outpatient programs, in which one can receive plenty of group therapy, counseling, and care from specialists. 

 is what I say: I spend about 50 pages in 

 discussing how unscientific, expensive, religiously oriented, and generally useless I found rehab. We mostly repeated slogans from the “Big Book” of Alcoholics Anonymous, written in 1937, all day long. I do not know of any independently verified evidence that rehab, 

, actually helps individuals with their addictions. We can do much better for our addicted physicians.

Physicians who work with their PHPs and successfully compete their contracts generally have a good outcome, with 70% to 80% of doctors achieving stable recovery and being able to go back to work.

 Part of this is due to the leverage that is used against doctors like a blunt instrument. I was essentially told, “If you keep flunking drug tests, you will not go back to practicing medicine.” 

It worked. The success also has to do with the resources doctors have to throw at their problems and the long-term, coherent follow-up. According to 1 study, “Over the course of 5 years of care, 78% never had a single positive drug or alcohol test result and 72% were able to return to practice.”

Not all doctors make it. Two of my colleagues overdosed and died lonely deaths, locked in bathrooms—both were anesthesiologists, as it happens. I know several other physicians who are homeless and many who have never made it back to clinical work.

For the sake of fairness and completeness, it is important to mention that PHPs have recently been criticized for having too much power over physicians and for having little to no independent oversight. Physicians cannot appeal the PHP’s decisions. If and when the PHPs make mistakes, such as sending a thriving medical cannabis patient to rehab for “cannabis use disorder,” 

. You simply do what they say even if you think you are not addicted to cannabis or alcohol or are not suffering from whatever it is they have labeled you with—or you do not get your medical license back. This clearly needs to improve with openness and transparency.

In a 2019 article called “Practicing What We Preach—Ending Physician Health Program Bans on Opioid-Agonist Therapy,”

 several colleagues of mine called out the cruelty and hypocrisy of PHPs denying doctors access to buprenorphine (Suboxone). When used for opioid use disorder, buprenorphine leads to a 50% reduction in overdosages and deaths. The rationale for denying doctors buprenorphine was that they would be “impaired” if they took it—but there is no good evidence for this claim. One might reasonably point out that, as doctors are allowed to use alcohol, Ambien or benzodiazepines, sedating antihistamines, gabapentinoids, and muscle relaxants, why not buprenorphine? 

This merely represented an internalization of society’s stigma against addiction, and it has been jeopardizing the lives of physicians. “Sunlight is the best disinfectant,” and, as such, this policy has since purportedly been modified (it is difficult to monitor because of confidentiality).

How Can We Prevent Addiction in Physicians?

Physicians who become addicted represent a profession-wide call for help. What can we do to lessen or prevent this problem? How can we best care for our caregivers?

To start, doctors have to be recognized as individuals who struggle with the same challenges and problems as everyone else does. We need all the institutions that we deal with to take this into account. For example, the medical boards snoop for mental illness and often include in their renewal forms questions such as, “Have you taken a leave of absence in the last several years?” If a doctor can practice safely, this is none of the board’s business.

Next, the entire ecosystem of physician health has to become more supportive and nurturing and less punitive. Doctors need to be empowered to ask for help and have reasonable assurances that, by doing so, they (1) will get good help and (2) will not damage their careers beyond repair. A physician who is getting help and is being carefully monitored by their PHP is perfectly safe for patient care. What is not safe is when people are afraid to get help for common, yet deadly, problems.

Finally, we need to address the mental health challenges of our entire profession. If medical students and residents need time for therapy appointments, 

 we need to grant this. If individuals need time off to deal with crises, this must be granted. We need to encourage individuals to ask for help—no more “Physician, heal thyself.”

We need to acknowledge the pressure that we are all under and find ways to alleviate it, such as unchaining us from the EMRs. We need to push back against the crumbling social contract in which we give more and more of ourselves, and society gives us less and less in return every year. Increasingly, doctors are commodified and flat-out exploited; many are leaving the profession and it is taking a devastating toll on those of us who decide to stay.

“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.”

Opioid Related Disorders