Sidebar. Eight Universal Precautions for Psychiatrists
1. Make a Diagnosis with Appropriate Differential
Patients complaining of anxiety and/or insomnia may have an underlying substance use disorder (SUD) that mimics an anxiety disorder. They may be experiencing drug side effects that may be ameliorated without adding a BZD.
2. Comprehensive Assessment Including Risk of Substance Use Disorders and/or Chronic Pain, including Family h/o SUDs
The cornerstone of a good comprehensive assessment is a thorough and careful clinical history, including a family history of SUDs. Patient-centered urine drug screening should be the rule, along with review of the state’s prescription monitoring program. Standardized risk assessment surveys may also be utilized.
3. Informed Consent
The possibility of synergistic side effects, including somnolence and respiratory depression, should routinely be covered.
4. Treatment Agreement
The range of aberrant drug-seeking behaviors should be covered in the treatment agreement (eg, lost prescriptions, early refills), with clarity regarding the standard response to such behaviors. When patients balk at the signing of a treatment agreement regarding controlled substance use and misuse, that often represents a red flag to be kept in mind as treatment decisions are made going forward.
5. Careful Consideration of Nonpharmacological Anxiety Reduction Strategies; and, non-BZD Alternatives Without Addiction Liability
Modalities like cognitive behavioral therapy, dialectical behavioral therapy, and meditation should be considered; as should less risky pharmacological options like buspirone, selective serotonin reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors.
6. Pre- and Post-Intervention Assessment of Anxiety Symptoms and Level of Functioning
The prescription of medications with potentially dangerous side effects is meant to improve a patient’s level of functioning. If functional level is deteriorating or simply not improving, a consultation or second opinion may be called for.
7. Periodically Review All Psychiatric Diagnoses and Comorbid Conditions, Including SUDs
Early on, and throughout the course of the patient’s psychiatric treatment, the routine use of patient-centered urine drug screens, prescription monitoring program database review, and pill counts, should be emphasized as components of routine treatment.
All data that speaks to the presence or absence of active SUDs, especially opioid use disorder and aberrant use of BZDs, should be carefully documented in the medical record. Whenever possible and feasible, nonmental health providers involved with each patient should be privy to relevant data. The withholding of information from medical providers may indicate a significant current problem.