Commentary

You are on the front lines of the prevention, screening, and treatment decisions for adolescent substance use disorders. You often must choose whether to disclose information about substance use to parents and other concerned adults.

The risk of developing a substance use disorder increases dramatically the earlier an individual begins using a given substance.¹ The neurobiology behind this risk is becoming increasingly clear. Young brains are undergoing crucial developmental processes, including synaptic pruning and myelination. The brain increasingly becomes more efficient in a staggered pattern, with limbic regions preceding frontal and executive regions, so we see adolescents with “more gas than brakes.” This has wisely been identified as developmentally appropriate, and even beneficial, rather than evidence that adolescents are somehow broken.²

SolStock/Getty Images

Steve Debenport/Getty Images

In most cases, adolescents should be informed of a decision to disclose substance use to their parents. Inviting adolescents to discuss how this will be done, including if the adolescent will be present, and whether you or the adolescent will disclose the use can be an opportunity to discuss their concerns. You should seek to understand if an adolescent has specific fears related to such a disclosure including careful consideration of any history of domestic violence or abuse.

Although adolescents increasingly identify with the opinions and values of their peers, it is a mistake to assume that they therefore do not value the opinions of their parents and the concerned adults in their lives. Parents play an integral role in preventing and treating adolescent substance use disorders. Except in rare instances of severe parent-child relationship problems or abuse, parents can and should be engaged as invaluable participants

Dr. Jackson is a child and adolescent psychiatrist at the University of Vermont, Burlington.

References

1. “Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings.” NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013).

2. “The Amazing Teen Brain,” Jay N. Geidd, Scientific American, May 2016.

3. Pediatrics 2011 Oct. doi: 10.1542/peds.2011-1754.

4. Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide.

5. Pediatrics. 2016 Jul 1. doi: 10.1542/peds.2016-1211.

6. J Fam Commun. 2014 Jan 1:14(4):328-51.

7. J Clin Child Adolesc. Psychol. 2008;37(1):236-59.

8. J Child Adolesc Subst Abuse. 2015 May 4;24(3):155-65.

9. Arch Pediatr Adolesc Med. 2012;166(12):1132-9.

You are on the front lines of the prevention, screening, and treatment decisions for adolescent substance use disorders. You often must choose whether to disclose information about substance use to parents and other concerned adults.

The risk of developing a substance use disorder increases dramatically the earlier an individual begins using a given substance.¹ The neurobiology behind this risk is becoming increasingly clear. Young brains are undergoing crucial developmental processes, including synaptic pruning and myelination. The brain increasingly becomes more efficient in a staggered pattern, with limbic regions preceding frontal and executive regions, so we see adolescents with “more gas than brakes.” This has wisely been identified as developmentally appropriate, and even beneficial, rather than evidence that adolescents are somehow broken.²

SolStock/Getty Images

Steve Debenport/Getty Images

In most cases, adolescents should be informed of a decision to disclose substance use to their parents. Inviting adolescents to discuss how this will be done, including if the adolescent will be present, and whether you or the adolescent will disclose the use can be an opportunity to discuss their concerns. You should seek to understand if an adolescent has specific fears related to such a disclosure including careful consideration of any history of domestic violence or abuse.

Although adolescents increasingly identify with the opinions and values of their peers, it is a mistake to assume that they therefore do not value the opinions of their parents and the concerned adults in their lives. Parents play an integral role in preventing and treating adolescent substance use disorders. Except in rare instances of severe parent-child relationship problems or abuse, parents can and should be engaged as invaluable participants

Dr. Jackson is a child and adolescent psychiatrist at the University of Vermont, Burlington.

References

1. “Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings.” NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013).

2. “The Amazing Teen Brain,” Jay N. Geidd, Scientific American, May 2016.

3. Pediatrics 2011 Oct. doi: 10.1542/peds.2011-1754.

4. Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide.

5. Pediatrics. 2016 Jul 1. doi: 10.1542/peds.2016-1211.

6. J Fam Commun. 2014 Jan 1:14(4):328-51.

7. J Clin Child Adolesc. Psychol. 2008;37(1):236-59.

8. J Child Adolesc Subst Abuse. 2015 May 4;24(3):155-65.

9. Arch Pediatr Adolesc Med. 2012;166(12):1132-9.

You are on the front lines of the prevention, screening, and treatment decisions for adolescent substance use disorders. You often must choose whether to disclose information about substance use to parents and other concerned adults.

The risk of developing a substance use disorder increases dramatically the earlier an individual begins using a given substance.¹ The neurobiology behind this risk is becoming increasingly clear. Young brains are undergoing crucial developmental processes, including synaptic pruning and myelination. The brain increasingly becomes more efficient in a staggered pattern, with limbic regions preceding frontal and executive regions, so we see adolescents with “more gas than brakes.” This has wisely been identified as developmentally appropriate, and even beneficial, rather than evidence that adolescents are somehow broken.²

SolStock/Getty Images

Steve Debenport/Getty Images

In most cases, adolescents should be informed of a decision to disclose substance use to their parents. Inviting adolescents to discuss how this will be done, including if the adolescent will be present, and whether you or the adolescent will disclose the use can be an opportunity to discuss their concerns. You should seek to understand if an adolescent has specific fears related to such a disclosure including careful consideration of any history of domestic violence or abuse.

Although adolescents increasingly identify with the opinions and values of their peers, it is a mistake to assume that they therefore do not value the opinions of their parents and the concerned adults in their lives. Parents play an integral role in preventing and treating adolescent substance use disorders. Except in rare instances of severe parent-child relationship problems or abuse, parents can and should be engaged as invaluable participants

Dr. Jackson is a child and adolescent psychiatrist at the University of Vermont, Burlington.

References

1. “Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings.” NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013).

2. “The Amazing Teen Brain,” Jay N. Geidd, Scientific American, May 2016.

3. Pediatrics 2011 Oct. doi: 10.1542/peds.2011-1754.

4. Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide.

5. Pediatrics. 2016 Jul 1. doi: 10.1542/peds.2016-1211.

6. J Fam Commun. 2014 Jan 1:14(4):328-51.

7. J Clin Child Adolesc. Psychol. 2008;37(1):236-59.

8. J Child Adolesc Subst Abuse. 2015 May 4;24(3):155-65.

9. Arch Pediatr Adolesc Med. 2012;166(12):1132-9.

Gun violence in America is a cancer—a metastasis that must be eradicated. As a nation, we continually mourn an ever-rising toll of victims and question why this senseless, tragic loss of life is repeated year after year. What is the reason for the increasing frequency of mass shootings? How is it that we are unable to stem the spread of this plague of gun-related deaths? When will we put an end to the massacres?

All good questions. And they have once again become the hue and cry of many people in the wake of the shooting at Marjory Stoneman Douglas High School in Parkland, Florida. This particular tragedy marked the 30th mass shooting in 2018—in other words, the latest in a line of tragedies that “should have” been preventable.¹

Whatever your political stance on the issue of guns, surely we can all agree that it is a problem that more than 549,000 acts of gun violence occur each year.² In 2015 (the most recent year for which a National Vital Statistics Report is available), there were 36,252 firearm-related deaths in the US—a rate of 11.1 deaths per 100,000 population. From 2012 to 2014, nearly 1,300 children died each year from a firearm-related injury.³ These statistics support the need to change our thinking about guns and gun violence.

Thus far, the discussion about gun control has tended to focus on passing and enforcing laws. We know that the US, compared to other countries, has fairly lenient restrictions for who can buy a gun and what kinds of guns can be purchased.⁴ In fact, many Americans can buy a gun in less than an hour, while in some countries, the process takes months.⁴ Furthermore, across the nation, there is no systematic fashion of gun regulation or ownership.

The challenge of how to balance gun safety and gun rights is an ongoing, yet one-focus, approach. The debate needs to be broadened; it’s time we stop talking about just the gun. We need to address the problem of firearm injuries in the context of a public health issue.⁵

A common assumption is that mental illness or high stress levels trigger gun violence. According to data from the Sandy Hook Promise organization, most criminal gun violence is committed by individuals who lack mental wellness (ie, coping skills, anger management, and other social/emotional skills).⁶ But other statistics contradict that notion. For example, a 2011 report in The Atlantic did not support mental illness as a causative factor in gun violence.⁷ And evidence presented by the Consortium for Risk-Based Firearm Policy indicates that the majority of people with mental illness do not engage in violence against others.⁸ The Consortium noted, however, that a small group of individuals with serious mental illness does have a propensity toward violence. It is this—the risk for dangerous behavior, rather than mental illness alone—that must be the focus for preventing gun violence.

Dangerous behaviors are those that carry a high risk for harm or injury to oneself or others.⁹ Emotional problems, social conflicts, access to weapons, and altered states of mind (via alcohol and drugs) all contribute to violent and homicidal behavior in adolescents.¹⁰ A worrisome fact: A nationwide study of mass shootings from 2009 to 2016 revealed that in at least 42% of these incidents there was documentation that the attacker exhibited dangerous warning signs before the shooting.¹¹ So, in many cases of violent behavior, the perpetrator threatens others or his own life before actually carrying out his plan.¹² But surely we must be able to do more than sit and watch for warning signs.

Continue to: Might tighter gun control laws...

Might tighter gun control laws help to mitigate this crisis? Perhaps; but we must also consider the importance of mental health care reform. In order to prevent gun violence, we need to understand (and address) the cause. We therefore need funding for mental health services to assist those who are at risk for harming themselves and others.

Instead of solely viewing gun control as a yes-or-no issue, we need to examine the intersection between mental health and violence. While our mental health care system is not equipped to help everyone, we need to acknowledge that gun-related deaths are preventable—and we need to make the choice to invest in that prevention.

Thus far, the ongoing debate about gun safety has largely centered around the Second Amendment, which has a two-fold obligation: the right of US citizens to be protected from violence and the right of the people to bear arms. Proponents on both sides of this polarizing issue have rallied to support their position; this often takes the form of shouting and counter-shouting (and sometimes threats)—and we make no progress on the core issue, which is that too many people in this country die because of gun violence.

We stand at the crossroads of realizing that something must be done. Share your reasoned suggestions (no rants, please!) for how we, as a nation, can combat gun violence and gun-related deaths with me at [email protected].

Gun violence in America is a cancer—a metastasis that must be eradicated. As a nation, we continually mourn an ever-rising toll of victims and question why this senseless, tragic loss of life is repeated year after year. What is the reason for the increasing frequency of mass shootings? How is it that we are unable to stem the spread of this plague of gun-related deaths? When will we put an end to the massacres?

All good questions. And they have once again become the hue and cry of many people in the wake of the shooting at Marjory Stoneman Douglas High School in Parkland, Florida. This particular tragedy marked the 30th mass shooting in 2018—in other words, the latest in a line of tragedies that “should have” been preventable.¹

Whatever your political stance on the issue of guns, surely we can all agree that it is a problem that more than 549,000 acts of gun violence occur each year.² In 2015 (the most recent year for which a National Vital Statistics Report is available), there were 36,252 firearm-related deaths in the US—a rate of 11.1 deaths per 100,000 population. From 2012 to 2014, nearly 1,300 children died each year from a firearm-related injury.³ These statistics support the need to change our thinking about guns and gun violence.

Thus far, the discussion about gun control has tended to focus on passing and enforcing laws. We know that the US, compared to other countries, has fairly lenient restrictions for who can buy a gun and what kinds of guns can be purchased.⁴ In fact, many Americans can buy a gun in less than an hour, while in some countries, the process takes months.⁴ Furthermore, across the nation, there is no systematic fashion of gun regulation or ownership.

The challenge of how to balance gun safety and gun rights is an ongoing, yet one-focus, approach. The debate needs to be broadened; it’s time we stop talking about just the gun. We need to address the problem of firearm injuries in the context of a public health issue.⁵

A common assumption is that mental illness or high stress levels trigger gun violence. According to data from the Sandy Hook Promise organization, most criminal gun violence is committed by individuals who lack mental wellness (ie, coping skills, anger management, and other social/emotional skills).⁶ But other statistics contradict that notion. For example, a 2011 report in The Atlantic did not support mental illness as a causative factor in gun violence.⁷ And evidence presented by the Consortium for Risk-Based Firearm Policy indicates that the majority of people with mental illness do not engage in violence against others.⁸ The Consortium noted, however, that a small group of individuals with serious mental illness does have a propensity toward violence. It is this—the risk for dangerous behavior, rather than mental illness alone—that must be the focus for preventing gun violence.

Dangerous behaviors are those that carry a high risk for harm or injury to oneself or others.⁹ Emotional problems, social conflicts, access to weapons, and altered states of mind (via alcohol and drugs) all contribute to violent and homicidal behavior in adolescents.¹⁰ A worrisome fact: A nationwide study of mass shootings from 2009 to 2016 revealed that in at least 42% of these incidents there was documentation that the attacker exhibited dangerous warning signs before the shooting.¹¹ So, in many cases of violent behavior, the perpetrator threatens others or his own life before actually carrying out his plan.¹² But surely we must be able to do more than sit and watch for warning signs.

Continue to: Might tighter gun control laws...

Might tighter gun control laws help to mitigate this crisis? Perhaps; but we must also consider the importance of mental health care reform. In order to prevent gun violence, we need to understand (and address) the cause. We therefore need funding for mental health services to assist those who are at risk for harming themselves and others.

Instead of solely viewing gun control as a yes-or-no issue, we need to examine the intersection between mental health and violence. While our mental health care system is not equipped to help everyone, we need to acknowledge that gun-related deaths are preventable—and we need to make the choice to invest in that prevention.

Thus far, the ongoing debate about gun safety has largely centered around the Second Amendment, which has a two-fold obligation: the right of US citizens to be protected from violence and the right of the people to bear arms. Proponents on both sides of this polarizing issue have rallied to support their position; this often takes the form of shouting and counter-shouting (and sometimes threats)—and we make no progress on the core issue, which is that too many people in this country die because of gun violence.

We stand at the crossroads of realizing that something must be done. Share your reasoned suggestions (no rants, please!) for how we, as a nation, can combat gun violence and gun-related deaths with me at [email protected].

Gun violence in America is a cancer—a metastasis that must be eradicated. As a nation, we continually mourn an ever-rising toll of victims and question why this senseless, tragic loss of life is repeated year after year. What is the reason for the increasing frequency of mass shootings? How is it that we are unable to stem the spread of this plague of gun-related deaths? When will we put an end to the massacres?

All good questions. And they have once again become the hue and cry of many people in the wake of the shooting at Marjory Stoneman Douglas High School in Parkland, Florida. This particular tragedy marked the 30th mass shooting in 2018—in other words, the latest in a line of tragedies that “should have” been preventable.¹

Whatever your political stance on the issue of guns, surely we can all agree that it is a problem that more than 549,000 acts of gun violence occur each year.² In 2015 (the most recent year for which a National Vital Statistics Report is available), there were 36,252 firearm-related deaths in the US—a rate of 11.1 deaths per 100,000 population. From 2012 to 2014, nearly 1,300 children died each year from a firearm-related injury.³ These statistics support the need to change our thinking about guns and gun violence.

Thus far, the discussion about gun control has tended to focus on passing and enforcing laws. We know that the US, compared to other countries, has fairly lenient restrictions for who can buy a gun and what kinds of guns can be purchased.⁴ In fact, many Americans can buy a gun in less than an hour, while in some countries, the process takes months.⁴ Furthermore, across the nation, there is no systematic fashion of gun regulation or ownership.

The challenge of how to balance gun safety and gun rights is an ongoing, yet one-focus, approach. The debate needs to be broadened; it’s time we stop talking about just the gun. We need to address the problem of firearm injuries in the context of a public health issue.⁵

A common assumption is that mental illness or high stress levels trigger gun violence. According to data from the Sandy Hook Promise organization, most criminal gun violence is committed by individuals who lack mental wellness (ie, coping skills, anger management, and other social/emotional skills).⁶ But other statistics contradict that notion. For example, a 2011 report in The Atlantic did not support mental illness as a causative factor in gun violence.⁷ And evidence presented by the Consortium for Risk-Based Firearm Policy indicates that the majority of people with mental illness do not engage in violence against others.⁸ The Consortium noted, however, that a small group of individuals with serious mental illness does have a propensity toward violence. It is this—the risk for dangerous behavior, rather than mental illness alone—that must be the focus for preventing gun violence.

Dangerous behaviors are those that carry a high risk for harm or injury to oneself or others.⁹ Emotional problems, social conflicts, access to weapons, and altered states of mind (via alcohol and drugs) all contribute to violent and homicidal behavior in adolescents.¹⁰ A worrisome fact: A nationwide study of mass shootings from 2009 to 2016 revealed that in at least 42% of these incidents there was documentation that the attacker exhibited dangerous warning signs before the shooting.¹¹ So, in many cases of violent behavior, the perpetrator threatens others or his own life before actually carrying out his plan.¹² But surely we must be able to do more than sit and watch for warning signs.

Continue to: Might tighter gun control laws...

Might tighter gun control laws help to mitigate this crisis? Perhaps; but we must also consider the importance of mental health care reform. In order to prevent gun violence, we need to understand (and address) the cause. We therefore need funding for mental health services to assist those who are at risk for harming themselves and others.

Instead of solely viewing gun control as a yes-or-no issue, we need to examine the intersection between mental health and violence. While our mental health care system is not equipped to help everyone, we need to acknowledge that gun-related deaths are preventable—and we need to make the choice to invest in that prevention.

Thus far, the ongoing debate about gun safety has largely centered around the Second Amendment, which has a two-fold obligation: the right of US citizens to be protected from violence and the right of the people to bear arms. Proponents on both sides of this polarizing issue have rallied to support their position; this often takes the form of shouting and counter-shouting (and sometimes threats)—and we make no progress on the core issue, which is that too many people in this country die because of gun violence.

We stand at the crossroads of realizing that something must be done. Share your reasoned suggestions (no rants, please!) for how we, as a nation, can combat gun violence and gun-related deaths with me at [email protected].

The opioid epidemic continues to devastate the United States across demographic and socioeconomic groups; two-thirds of the 63,632 Americans who died of drug overdoses¹ in 2016 died of prescription or illicit opioids.

In 2015, Theodore J. Cicero, PhD, professor of psychiatry at Washington University, St. Louis, reported on a fundamental change in the nature of the ongoing opioid epidemic: What started as prescription opioid overprescribing, leading to diversion, abuse, and opioid addiction, was transitioning to illicit heroin distribution and consumption. Prescription opioids, namely, extended-release oxycodone (Oxycontin), were perceived initially as pure and safe, as they were specifically dosed and physician prescribed. In addition, filling a prescription for opioids was not associated with the shame or stigma of buying illicit drugs off the street. Because those drugs were seen as therapeutic and pharmacologically “legitimate,” many clinicians and the lay public alike were surprised to see the surge of opioid addiction and overdoses.

Dr. Cicero and others noted² that prescription opioids, whether taken originally for analgesic or recreational purposes, became a “gateway” to heroin, which already was making its way into the United States from Mexico,³ as heroin was cheap and becoming cheaper, easier to find, easy to use, and “pure.” Prescription opioids, on the other hand, were becoming more expensive, and physicians were facing increased regulations in prescribing them. Thus, as prescription opioid use became more and more stigmatized, heroin use was seen, paradoxically, as a more practical alternative. The amount of opioids prescribed in the United States has peaked; physicians are prescribing opioids less often; and the averaged dose has dropped as well, according to the Centers for Disease Control and Prevention.⁴ The first wave of deaths was attributable to prescription opioids, and the second was tied to illicitly obtained potent fentanyl analogs (manufactured in China and smuggled primarily through Mexico), which is added to heroin and sold in the United States.⁵

Many addiction experts and health policy leaders were not surprised by the increases in HIV, TB, and hepatitis B and C that followed the increasing use of intravenous opioids. However, few had experience with previous opioid epidemics in the United States, the most recent being the heroin epidemic occurring in the 1960s-1970s in the aftermath of the Vietnam War. At that time, the notion that heroin was contaminated with other psychoactive drugs, medications, fillers, and other adulterants was a foregone conclusion – though in public health and treatment discussions, this issue is hardly ever raised. We believe this to be a significant lapse in policy and planning. Surveillance by the Drug Enforcement Administration shows that acetyl fentanyl–laced heroin costs a little more on the street than regular heroin. Yet it sells, because users believe its extreme potency produces a better high, thus worth the extra cost. This phenomenon underscores an important point: Opioid addicts often are in search of a better high and will go to any lengths – even risking their lives – to get it.

The “cutting” or “adulteration” of street drugs is common practice in the manufacturing, distribution, and selling of illicit drugs, and the motive is to increase profit. The term “adulterant” generally refers to addition of substances with some psychoactive effects, such as caffeine, ephedra, or even paracetamol. These substances are cheaper than the main substance, have similar or complementary effects when added, and thus help conceal the fact that the desired substance has been cut or diluted. Substances without psychoactive properties such as lactose, other sugars, or talc, are added to a drug primarily to increase the bulk or weight of the illicit substance, or for aesthetic purposes to fool the user. Some adulterants simply are the result of the particular manufacturing process used to make the drug. For example, illicitly manufactured methamphetamine frequently is contaminated by nonstimulant impurities such as lead or mercury (extremely toxic heavy metals), or from carcinogenic solvents used in the synthesis. The local anesthetic lidocaine often is added to cocaine, and the reasons are intuitive: Both drugs are fast-acting local anesthetics.

More intriguing is the story of the antiparasitic medication levamisole. The DEA has estimated that 60%-89% of the seized street cocaine contains levamisole. Levamisole appears to be partly metabolized into an amphetamine-like compound, which could increase dopamine concentration in the reward pathway and thus activate endogenous opioids: It can mimic the effects of cocaine at a fraction of the cost. Levamisole is associated with several types of severe blood disorders, including leukopenia, agranulocytosis, multifocal inflammatory leukoencephalopathy, and neutropenia; a common presentation is vasculitis resulting in loss of limbs. Thus, a real danger in adulterants such as levamisole is their toxicity beyond those of the drug to which they are added, causing numerous medical consequences – including death.

Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, and professor of psychiatry (adjunct) at Washington University in St. Louis. He also serves as chairman of the scientific advisory boards for RiverMend Health. Dr. Srivastava is a fourth-year resident in the department of psychiatry at Washington University.

References

1 NCHS Data Brief. No. 294. December 2017.

2 N Engl J Med. 2015;373:1789-90.

3 DEA Strategic Intelligence Section. 2017 National Drug Threat Assessment: Drug Enforcement Administration, U.S. Department of Justice, 2017.

4 Centers for Disease Control and Prevention, press release. Mar 29, 2018.

5 MMWR. 2018. Mar 30;67(12):349-58.

6 Am J Public Health. 2017 Mar;107(3):430-2.

7 “Q&A: Thomas Kosten, MD: Anti-drug vaccines.” RiverMend Health.

8 “Q&A: Stacy Seikel, MD. Opioid addiction.” RiverMend Health.

9 N Engl J Med. 2018 Apr 26;378:1567-9. doi: 10.1056/NEJMp1801417.

10 Innov Clin Neurosci. 2014 Sep;11(9-10):182-90.

11 Am J Psychiatry. 187 May;144(5):563-7.

The opioid epidemic continues to devastate the United States across demographic and socioeconomic groups; two-thirds of the 63,632 Americans who died of drug overdoses¹ in 2016 died of prescription or illicit opioids.

In 2015, Theodore J. Cicero, PhD, professor of psychiatry at Washington University, St. Louis, reported on a fundamental change in the nature of the ongoing opioid epidemic: What started as prescription opioid overprescribing, leading to diversion, abuse, and opioid addiction, was transitioning to illicit heroin distribution and consumption. Prescription opioids, namely, extended-release oxycodone (Oxycontin), were perceived initially as pure and safe, as they were specifically dosed and physician prescribed. In addition, filling a prescription for opioids was not associated with the shame or stigma of buying illicit drugs off the street. Because those drugs were seen as therapeutic and pharmacologically “legitimate,” many clinicians and the lay public alike were surprised to see the surge of opioid addiction and overdoses.

Dr. Cicero and others noted² that prescription opioids, whether taken originally for analgesic or recreational purposes, became a “gateway” to heroin, which already was making its way into the United States from Mexico,³ as heroin was cheap and becoming cheaper, easier to find, easy to use, and “pure.” Prescription opioids, on the other hand, were becoming more expensive, and physicians were facing increased regulations in prescribing them. Thus, as prescription opioid use became more and more stigmatized, heroin use was seen, paradoxically, as a more practical alternative. The amount of opioids prescribed in the United States has peaked; physicians are prescribing opioids less often; and the averaged dose has dropped as well, according to the Centers for Disease Control and Prevention.⁴ The first wave of deaths was attributable to prescription opioids, and the second was tied to illicitly obtained potent fentanyl analogs (manufactured in China and smuggled primarily through Mexico), which is added to heroin and sold in the United States.⁵

Many addiction experts and health policy leaders were not surprised by the increases in HIV, TB, and hepatitis B and C that followed the increasing use of intravenous opioids. However, few had experience with previous opioid epidemics in the United States, the most recent being the heroin epidemic occurring in the 1960s-1970s in the aftermath of the Vietnam War. At that time, the notion that heroin was contaminated with other psychoactive drugs, medications, fillers, and other adulterants was a foregone conclusion – though in public health and treatment discussions, this issue is hardly ever raised. We believe this to be a significant lapse in policy and planning. Surveillance by the Drug Enforcement Administration shows that acetyl fentanyl–laced heroin costs a little more on the street than regular heroin. Yet it sells, because users believe its extreme potency produces a better high, thus worth the extra cost. This phenomenon underscores an important point: Opioid addicts often are in search of a better high and will go to any lengths – even risking their lives – to get it.

The “cutting” or “adulteration” of street drugs is common practice in the manufacturing, distribution, and selling of illicit drugs, and the motive is to increase profit. The term “adulterant” generally refers to addition of substances with some psychoactive effects, such as caffeine, ephedra, or even paracetamol. These substances are cheaper than the main substance, have similar or complementary effects when added, and thus help conceal the fact that the desired substance has been cut or diluted. Substances without psychoactive properties such as lactose, other sugars, or talc, are added to a drug primarily to increase the bulk or weight of the illicit substance, or for aesthetic purposes to fool the user. Some adulterants simply are the result of the particular manufacturing process used to make the drug. For example, illicitly manufactured methamphetamine frequently is contaminated by nonstimulant impurities such as lead or mercury (extremely toxic heavy metals), or from carcinogenic solvents used in the synthesis. The local anesthetic lidocaine often is added to cocaine, and the reasons are intuitive: Both drugs are fast-acting local anesthetics.

More intriguing is the story of the antiparasitic medication levamisole. The DEA has estimated that 60%-89% of the seized street cocaine contains levamisole. Levamisole appears to be partly metabolized into an amphetamine-like compound, which could increase dopamine concentration in the reward pathway and thus activate endogenous opioids: It can mimic the effects of cocaine at a fraction of the cost. Levamisole is associated with several types of severe blood disorders, including leukopenia, agranulocytosis, multifocal inflammatory leukoencephalopathy, and neutropenia; a common presentation is vasculitis resulting in loss of limbs. Thus, a real danger in adulterants such as levamisole is their toxicity beyond those of the drug to which they are added, causing numerous medical consequences – including death.

Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, and professor of psychiatry (adjunct) at Washington University in St. Louis. He also serves as chairman of the scientific advisory boards for RiverMend Health. Dr. Srivastava is a fourth-year resident in the department of psychiatry at Washington University.

References

1 NCHS Data Brief. No. 294. December 2017.

2 N Engl J Med. 2015;373:1789-90.

3 DEA Strategic Intelligence Section. 2017 National Drug Threat Assessment: Drug Enforcement Administration, U.S. Department of Justice, 2017.

4 Centers for Disease Control and Prevention, press release. Mar 29, 2018.

5 MMWR. 2018. Mar 30;67(12):349-58.

6 Am J Public Health. 2017 Mar;107(3):430-2.

7 “Q&A: Thomas Kosten, MD: Anti-drug vaccines.” RiverMend Health.

8 “Q&A: Stacy Seikel, MD. Opioid addiction.” RiverMend Health.

9 N Engl J Med. 2018 Apr 26;378:1567-9. doi: 10.1056/NEJMp1801417.

10 Innov Clin Neurosci. 2014 Sep;11(9-10):182-90.

11 Am J Psychiatry. 187 May;144(5):563-7.

The opioid epidemic continues to devastate the United States across demographic and socioeconomic groups; two-thirds of the 63,632 Americans who died of drug overdoses¹ in 2016 died of prescription or illicit opioids.

In 2015, Theodore J. Cicero, PhD, professor of psychiatry at Washington University, St. Louis, reported on a fundamental change in the nature of the ongoing opioid epidemic: What started as prescription opioid overprescribing, leading to diversion, abuse, and opioid addiction, was transitioning to illicit heroin distribution and consumption. Prescription opioids, namely, extended-release oxycodone (Oxycontin), were perceived initially as pure and safe, as they were specifically dosed and physician prescribed. In addition, filling a prescription for opioids was not associated with the shame or stigma of buying illicit drugs off the street. Because those drugs were seen as therapeutic and pharmacologically “legitimate,” many clinicians and the lay public alike were surprised to see the surge of opioid addiction and overdoses.

Dr. Cicero and others noted² that prescription opioids, whether taken originally for analgesic or recreational purposes, became a “gateway” to heroin, which already was making its way into the United States from Mexico,³ as heroin was cheap and becoming cheaper, easier to find, easy to use, and “pure.” Prescription opioids, on the other hand, were becoming more expensive, and physicians were facing increased regulations in prescribing them. Thus, as prescription opioid use became more and more stigmatized, heroin use was seen, paradoxically, as a more practical alternative. The amount of opioids prescribed in the United States has peaked; physicians are prescribing opioids less often; and the averaged dose has dropped as well, according to the Centers for Disease Control and Prevention.⁴ The first wave of deaths was attributable to prescription opioids, and the second was tied to illicitly obtained potent fentanyl analogs (manufactured in China and smuggled primarily through Mexico), which is added to heroin and sold in the United States.⁵

Many addiction experts and health policy leaders were not surprised by the increases in HIV, TB, and hepatitis B and C that followed the increasing use of intravenous opioids. However, few had experience with previous opioid epidemics in the United States, the most recent being the heroin epidemic occurring in the 1960s-1970s in the aftermath of the Vietnam War. At that time, the notion that heroin was contaminated with other psychoactive drugs, medications, fillers, and other adulterants was a foregone conclusion – though in public health and treatment discussions, this issue is hardly ever raised. We believe this to be a significant lapse in policy and planning. Surveillance by the Drug Enforcement Administration shows that acetyl fentanyl–laced heroin costs a little more on the street than regular heroin. Yet it sells, because users believe its extreme potency produces a better high, thus worth the extra cost. This phenomenon underscores an important point: Opioid addicts often are in search of a better high and will go to any lengths – even risking their lives – to get it.

The “cutting” or “adulteration” of street drugs is common practice in the manufacturing, distribution, and selling of illicit drugs, and the motive is to increase profit. The term “adulterant” generally refers to addition of substances with some psychoactive effects, such as caffeine, ephedra, or even paracetamol. These substances are cheaper than the main substance, have similar or complementary effects when added, and thus help conceal the fact that the desired substance has been cut or diluted. Substances without psychoactive properties such as lactose, other sugars, or talc, are added to a drug primarily to increase the bulk or weight of the illicit substance, or for aesthetic purposes to fool the user. Some adulterants simply are the result of the particular manufacturing process used to make the drug. For example, illicitly manufactured methamphetamine frequently is contaminated by nonstimulant impurities such as lead or mercury (extremely toxic heavy metals), or from carcinogenic solvents used in the synthesis. The local anesthetic lidocaine often is added to cocaine, and the reasons are intuitive: Both drugs are fast-acting local anesthetics.

More intriguing is the story of the antiparasitic medication levamisole. The DEA has estimated that 60%-89% of the seized street cocaine contains levamisole. Levamisole appears to be partly metabolized into an amphetamine-like compound, which could increase dopamine concentration in the reward pathway and thus activate endogenous opioids: It can mimic the effects of cocaine at a fraction of the cost. Levamisole is associated with several types of severe blood disorders, including leukopenia, agranulocytosis, multifocal inflammatory leukoencephalopathy, and neutropenia; a common presentation is vasculitis resulting in loss of limbs. Thus, a real danger in adulterants such as levamisole is their toxicity beyond those of the drug to which they are added, causing numerous medical consequences – including death.

Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, and professor of psychiatry (adjunct) at Washington University in St. Louis. He also serves as chairman of the scientific advisory boards for RiverMend Health. Dr. Srivastava is a fourth-year resident in the department of psychiatry at Washington University.

References

1 NCHS Data Brief. No. 294. December 2017.

2 N Engl J Med. 2015;373:1789-90.

3 DEA Strategic Intelligence Section. 2017 National Drug Threat Assessment: Drug Enforcement Administration, U.S. Department of Justice, 2017.

4 Centers for Disease Control and Prevention, press release. Mar 29, 2018.

5 MMWR. 2018. Mar 30;67(12):349-58.

6 Am J Public Health. 2017 Mar;107(3):430-2.

7 “Q&A: Thomas Kosten, MD: Anti-drug vaccines.” RiverMend Health.

8 “Q&A: Stacy Seikel, MD. Opioid addiction.” RiverMend Health.

9 N Engl J Med. 2018 Apr 26;378:1567-9. doi: 10.1056/NEJMp1801417.

10 Innov Clin Neurosci. 2014 Sep;11(9-10):182-90.

11 Am J Psychiatry. 187 May;144(5):563-7.

The controversy over psychiatry’s “Goldwater Rule,” specifically as it applies to discussion of President Donald Trump, shows no signs¹ of abating any time soon. In an earlier commentary, we considered the problematic practice of citing a “duty to warn” about the president’s mental state to justify professional assessment from afar. We argued that the Tarasoff principle² presupposes a doctor-patient relationship in which the therapist must break confidentiality to avert imminent harm. Claiming a duty to protect against a politician’s public conduct and utterances is the proverbial square peg in a round hole.

While misapplication of the Tarasoff doctrine persists,³ some outspoken and eminent critics within the psychiatric community have since pursued another line of reasoning: that the Goldwater Rule covers only formal diagnoses and anything short of that is fair game. Here, we consider the argument that applying psychiatric labels to individuals for public consumption, absent examination and authorization, is ethically supportable so long as a definitive diagnosis is avoided. Ultimately, this justification fares no better than the misplaced duty to warn.
 

Explanation or expansion?

Nonetheless, several prominent psychiatrists charge⁵ that the APA has impermissibly broadened the Goldwater Rule since President Trump’s inauguration. These critics⁵ are referring not to any modification of Section 7.3 itself, but to an APA Ethics Committee opinion issued in March 2017 that clarified what constitutes a “professional opinion.”⁶ According to this guidance, a professional opinion includes but is not limited to a diagnosis: “... when a psychiatrist renders an opinion about the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry, the opinion is a professional one.” In an accompanying statement,⁷ then-APA President Maria A. Oquendo, MD, PhD, confirmed that the Goldwater Rule “applies to all professional opinions offered by psychiatrists, not just diagnoses.”

Among psychiatrists and other mental health professionals questioning⁸ President Trump’s fitness for office, the reaction to the ethics interpretation was swift and emphatic. Leonard L. Glass, MD, MPH, resigned from the APA in protest after more than four decades of membership. He and Bandy X. Lee, MD, MDiv, editor of a book assessing the president’s purported instability, wrote in Politico: “By fiat of the APA, the Goldwater Rule has effectively turned into a gag rule.”⁹ Dr. Glass and Dr. Lee reiterated their critique in the Boston Globe,¹⁰ and hinted that the APA’s “federal funding” should be jeopardized as a result. Meanwhile, in a New England Journal of Medicine article, Claire L. Pouncey, MD, PhD, called the APA’s interpretation a silencing mechanism whereby “psychiatrists are the only members of the citizenry who may not express concern about the mental health of the president using psychiatric diagnostic terminology.”¹¹

In light of such heated rhetoric, it is worth taking a step back to consider what, if anything, has changed. A brief historical inquiry shows that the answer is not much. Allen R. Dyer, MD, PhD, a psychiatrist and ethicist who helped draft the Goldwater Rule – and whom one of us (LHK) counts as a professional mentor – recalls originally suggesting the term “professional opinion” instead of “psychiatric diagnosis” in order “to reflect the place of ethics in defining a profession.”¹² What Dr. Dyer meant is that standards of conduct, which are the hallmark of any profession, are not intended to be legal rules, but rather normative guidelines for ethical practice.

A distinction without a difference

Putting aside the historical record, what is the substantive dispute with the APA’s ethics interpretation? In essence, the dissenters contend that even if it remains unethical to offer armchair diagnoses, it should be perfectly acceptable to call someone unstable and dangerous, and to do so as a self-identified psychiatric expert. Dr. Glass and Dr. Lee profess to be “mystified by the lack of recognition” that they aren’t formally diagnosing President Trump.¹³ Instead, they view their actions as performing a public service by illuminating the president’s dangerous psyche.

Yet legalistic parsing cannot delineate ethical boundaries for a profession. Without even addressing the issue of predictive validity when it comes to dangerousness or violence risk, it is clear to many that labeling someone as “dangerous” can be just as, if not more, hurtful than offering an unsolicited diagnosis.¹⁴ Whereas opponents of the Goldwater Rule tend to frame it as organized psychiatry’s response to professional embarrassment,¹⁵ other ethical issues are at play, the foremost being¹⁶ respect for human beings. In other words, psychiatric speculation can cause “real harm to real people.”¹⁷

As Richard A. Friedman, MD, explained long before President Trump emerged as a serious contender on the political scene, the problem with the Goldwater fiasco was not just that psychiatrists offered diagnoses, but that they gave “very specific and damaging psychiatric opinions, using the language and art of their profession, about a man whom they had not examined and who surely would not have consented to such statements.”¹⁸ Indeed, Sen. Barry Goldwater later testified to the toll that psychiatrists’ published comments about his masculinity took on his personal interactions.¹⁹

It is instructive that the survey Fact magazine sent to psychiatrists in 1964 asked20 not for diagnoses, but whether Sen. Goldwater was “psychologically fit” to be president. This question – to which nearly 2,000 psychiatrists replied in the negative – is almost exactly what some members of the profession are asking and answering about President Trump today. There is room for nuanced²¹ debate about what types of pronouncements the Goldwater Rule should cover, but there is nothing nuanced about mounting the pedestal of medical authority to brand someone as unsafe, unfit, and unstable. Doing so is disparaging to the individual and stigmatizing of mental illness in general. Ethical standards cannot condone stopping just short of malfeasance and then claiming to have clean hands.

Education vs. stigmatization

The Goldwater Rule is designed as a caveat, not a prohibition. Section 7 of the APA code affirms that psychiatrists, like all physicians,²² have a responsibility to contribute to the common good. A principal way of doing this is through civic education about mental health and illness. 


The Goldwater Rule is embedded in Section 7 as one of several qualifications for psychiatrists to consider when making public forays. For example, psychiatrists should clarify whether they are speaking for themselves or an organization, avoid blanket statements on behalf of the entire profession, and differentiate between their roles as citizen and physician. Viewed in light of these other less-controversial proscriptions, it should become clear that the Goldwater Rule creates minimal barriers to public education.

Specifically, the Goldwater principle is concerned only with psychiatrists’ statements that are professional, public, and individualized. It has nothing to say about opinions that are political, private, or general.¹⁴ As an APA commentary explains, “a general discussion of relevant psychiatric topics – rather than offering opinions about that specific person – is the best means of facilitating public education.”²³ This is not a gag order but a prescription for maintaining professional integrity when exposed to the media limelight.

There are valid reasons to critique the Goldwater Rule, but they require an honest reckoning. Psychiatrists who feel compelled to assess public figures could argue that it is a matter of etiquette, not ethics, and should be left to personal discretion.²⁴

So far, the morphing rationales for contravening the Goldwater Rule fall short, because they elide the real issues at stake. Ethical behavior cannot hinge on artificial distinctions. Whereas invoking a duty to warn about presidential fitness was dubious, differentiating between a diagnosis and a professional opinion is specious.

Lt. Col. Kels practices health and disability law in the U.S. Air Force. Dr. Kels teaches and practices psychiatry at the University of the Incarnate Word School of Osteopathic Medicine in San Antonio. Opinions expressed in this article are those of the authors alone and do not necessarily reflect those of the Air Force or Department of Defense.

References

1. Psychiatric Times. Mar 19, 2018.

2. Tarasoff v. Regents of University of California, 551 P2d 334 (Cal 1976).

3.The Boston Globe. Jan 2, 2018.

4. APA Principles of Medical Ethics, 2013 ed. [7.3].

5. Psychiatric Times. Jul 20, 2017.

6. APA Opinions of the Ethics Committee. 2017 ed. [Q.7b].

7. American Psychiatric Association (APA). “APA remains committed to supporting Goldwater Rule,” Mar 17, 2017.

8. The New York Times. Feb 13, 2017.

9. Politico. Jan 10, 2018.

10. The Boston Globe. Feb 26, 2018.

11. N Engl J Med. 2018;378[5]:405-7.

12. Allen R. Dyer, MD, PhD. “Evolution of the so-called ‘Goldwater rule’: An ethical analysis,” revised Sep 23, 2017.

13. The Boston Globe. Jan 10, 2018.

14. Psychiatric Times. Feb 16, 2018.

15. J Am Acad Psychiatry Law. 2016;44[2]:226-35.

16. Psychiatric Times. Jul 20, 2017.

17. J Am Acad Psychiatry Law. 2016;45[2]:228-32.

18. The New York Times. May 24, 2011.

19. Am J Psychiatry. 2015 Aug 1;172[8]:729-30.

20. Fact. Sep-Oct 1964.

21. Psychiatric Times. Oct 7, 2016.

22. AMA Principles of Medical Ethics. 2016 ed. [VII].

23. APA Commentary on Ethics in Practice, 2015 ed. [3.4.7].

24. J Am Acad Psychiatry Law. 2016;44[2]:226-35.

The controversy over psychiatry’s “Goldwater Rule,” specifically as it applies to discussion of President Donald Trump, shows no signs¹ of abating any time soon. In an earlier commentary, we considered the problematic practice of citing a “duty to warn” about the president’s mental state to justify professional assessment from afar. We argued that the Tarasoff principle² presupposes a doctor-patient relationship in which the therapist must break confidentiality to avert imminent harm. Claiming a duty to protect against a politician’s public conduct and utterances is the proverbial square peg in a round hole.

While misapplication of the Tarasoff doctrine persists,³ some outspoken and eminent critics within the psychiatric community have since pursued another line of reasoning: that the Goldwater Rule covers only formal diagnoses and anything short of that is fair game. Here, we consider the argument that applying psychiatric labels to individuals for public consumption, absent examination and authorization, is ethically supportable so long as a definitive diagnosis is avoided. Ultimately, this justification fares no better than the misplaced duty to warn.
 

Explanation or expansion?

Nonetheless, several prominent psychiatrists charge⁵ that the APA has impermissibly broadened the Goldwater Rule since President Trump’s inauguration. These critics⁵ are referring not to any modification of Section 7.3 itself, but to an APA Ethics Committee opinion issued in March 2017 that clarified what constitutes a “professional opinion.”⁶ According to this guidance, a professional opinion includes but is not limited to a diagnosis: “... when a psychiatrist renders an opinion about the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry, the opinion is a professional one.” In an accompanying statement,⁷ then-APA President Maria A. Oquendo, MD, PhD, confirmed that the Goldwater Rule “applies to all professional opinions offered by psychiatrists, not just diagnoses.”

Among psychiatrists and other mental health professionals questioning⁸ President Trump’s fitness for office, the reaction to the ethics interpretation was swift and emphatic. Leonard L. Glass, MD, MPH, resigned from the APA in protest after more than four decades of membership. He and Bandy X. Lee, MD, MDiv, editor of a book assessing the president’s purported instability, wrote in Politico: “By fiat of the APA, the Goldwater Rule has effectively turned into a gag rule.”⁹ Dr. Glass and Dr. Lee reiterated their critique in the Boston Globe,¹⁰ and hinted that the APA’s “federal funding” should be jeopardized as a result. Meanwhile, in a New England Journal of Medicine article, Claire L. Pouncey, MD, PhD, called the APA’s interpretation a silencing mechanism whereby “psychiatrists are the only members of the citizenry who may not express concern about the mental health of the president using psychiatric diagnostic terminology.”¹¹

In light of such heated rhetoric, it is worth taking a step back to consider what, if anything, has changed. A brief historical inquiry shows that the answer is not much. Allen R. Dyer, MD, PhD, a psychiatrist and ethicist who helped draft the Goldwater Rule – and whom one of us (LHK) counts as a professional mentor – recalls originally suggesting the term “professional opinion” instead of “psychiatric diagnosis” in order “to reflect the place of ethics in defining a profession.”¹² What Dr. Dyer meant is that standards of conduct, which are the hallmark of any profession, are not intended to be legal rules, but rather normative guidelines for ethical practice.

A distinction without a difference

Putting aside the historical record, what is the substantive dispute with the APA’s ethics interpretation? In essence, the dissenters contend that even if it remains unethical to offer armchair diagnoses, it should be perfectly acceptable to call someone unstable and dangerous, and to do so as a self-identified psychiatric expert. Dr. Glass and Dr. Lee profess to be “mystified by the lack of recognition” that they aren’t formally diagnosing President Trump.¹³ Instead, they view their actions as performing a public service by illuminating the president’s dangerous psyche.

Yet legalistic parsing cannot delineate ethical boundaries for a profession. Without even addressing the issue of predictive validity when it comes to dangerousness or violence risk, it is clear to many that labeling someone as “dangerous” can be just as, if not more, hurtful than offering an unsolicited diagnosis.¹⁴ Whereas opponents of the Goldwater Rule tend to frame it as organized psychiatry’s response to professional embarrassment,¹⁵ other ethical issues are at play, the foremost being¹⁶ respect for human beings. In other words, psychiatric speculation can cause “real harm to real people.”¹⁷

As Richard A. Friedman, MD, explained long before President Trump emerged as a serious contender on the political scene, the problem with the Goldwater fiasco was not just that psychiatrists offered diagnoses, but that they gave “very specific and damaging psychiatric opinions, using the language and art of their profession, about a man whom they had not examined and who surely would not have consented to such statements.”¹⁸ Indeed, Sen. Barry Goldwater later testified to the toll that psychiatrists’ published comments about his masculinity took on his personal interactions.¹⁹

It is instructive that the survey Fact magazine sent to psychiatrists in 1964 asked20 not for diagnoses, but whether Sen. Goldwater was “psychologically fit” to be president. This question – to which nearly 2,000 psychiatrists replied in the negative – is almost exactly what some members of the profession are asking and answering about President Trump today. There is room for nuanced²¹ debate about what types of pronouncements the Goldwater Rule should cover, but there is nothing nuanced about mounting the pedestal of medical authority to brand someone as unsafe, unfit, and unstable. Doing so is disparaging to the individual and stigmatizing of mental illness in general. Ethical standards cannot condone stopping just short of malfeasance and then claiming to have clean hands.

Education vs. stigmatization

The Goldwater Rule is designed as a caveat, not a prohibition. Section 7 of the APA code affirms that psychiatrists, like all physicians,²² have a responsibility to contribute to the common good. A principal way of doing this is through civic education about mental health and illness. 


The Goldwater Rule is embedded in Section 7 as one of several qualifications for psychiatrists to consider when making public forays. For example, psychiatrists should clarify whether they are speaking for themselves or an organization, avoid blanket statements on behalf of the entire profession, and differentiate between their roles as citizen and physician. Viewed in light of these other less-controversial proscriptions, it should become clear that the Goldwater Rule creates minimal barriers to public education.

Specifically, the Goldwater principle is concerned only with psychiatrists’ statements that are professional, public, and individualized. It has nothing to say about opinions that are political, private, or general.¹⁴ As an APA commentary explains, “a general discussion of relevant psychiatric topics – rather than offering opinions about that specific person – is the best means of facilitating public education.”²³ This is not a gag order but a prescription for maintaining professional integrity when exposed to the media limelight.

There are valid reasons to critique the Goldwater Rule, but they require an honest reckoning. Psychiatrists who feel compelled to assess public figures could argue that it is a matter of etiquette, not ethics, and should be left to personal discretion.²⁴

So far, the morphing rationales for contravening the Goldwater Rule fall short, because they elide the real issues at stake. Ethical behavior cannot hinge on artificial distinctions. Whereas invoking a duty to warn about presidential fitness was dubious, differentiating between a diagnosis and a professional opinion is specious.

Lt. Col. Kels practices health and disability law in the U.S. Air Force. Dr. Kels teaches and practices psychiatry at the University of the Incarnate Word School of Osteopathic Medicine in San Antonio. Opinions expressed in this article are those of the authors alone and do not necessarily reflect those of the Air Force or Department of Defense.

References

1. Psychiatric Times. Mar 19, 2018.

2. Tarasoff v. Regents of University of California, 551 P2d 334 (Cal 1976).

3.The Boston Globe. Jan 2, 2018.

4. APA Principles of Medical Ethics, 2013 ed. [7.3].

5. Psychiatric Times. Jul 20, 2017.

6. APA Opinions of the Ethics Committee. 2017 ed. [Q.7b].

7. American Psychiatric Association (APA). “APA remains committed to supporting Goldwater Rule,” Mar 17, 2017.

8. The New York Times. Feb 13, 2017.

9. Politico. Jan 10, 2018.

10. The Boston Globe. Feb 26, 2018.

11. N Engl J Med. 2018;378[5]:405-7.

12. Allen R. Dyer, MD, PhD. “Evolution of the so-called ‘Goldwater rule’: An ethical analysis,” revised Sep 23, 2017.

13. The Boston Globe. Jan 10, 2018.

14. Psychiatric Times. Feb 16, 2018.

15. J Am Acad Psychiatry Law. 2016;44[2]:226-35.

16. Psychiatric Times. Jul 20, 2017.

17. J Am Acad Psychiatry Law. 2016;45[2]:228-32.

18. The New York Times. May 24, 2011.

19. Am J Psychiatry. 2015 Aug 1;172[8]:729-30.

20. Fact. Sep-Oct 1964.

21. Psychiatric Times. Oct 7, 2016.

22. AMA Principles of Medical Ethics. 2016 ed. [VII].

23. APA Commentary on Ethics in Practice, 2015 ed. [3.4.7].

24. J Am Acad Psychiatry Law. 2016;44[2]:226-35.

The controversy over psychiatry’s “Goldwater Rule,” specifically as it applies to discussion of President Donald Trump, shows no signs¹ of abating any time soon. In an earlier commentary, we considered the problematic practice of citing a “duty to warn” about the president’s mental state to justify professional assessment from afar. We argued that the Tarasoff principle² presupposes a doctor-patient relationship in which the therapist must break confidentiality to avert imminent harm. Claiming a duty to protect against a politician’s public conduct and utterances is the proverbial square peg in a round hole.

While misapplication of the Tarasoff doctrine persists,³ some outspoken and eminent critics within the psychiatric community have since pursued another line of reasoning: that the Goldwater Rule covers only formal diagnoses and anything short of that is fair game. Here, we consider the argument that applying psychiatric labels to individuals for public consumption, absent examination and authorization, is ethically supportable so long as a definitive diagnosis is avoided. Ultimately, this justification fares no better than the misplaced duty to warn.
 

Explanation or expansion?

Nonetheless, several prominent psychiatrists charge⁵ that the APA has impermissibly broadened the Goldwater Rule since President Trump’s inauguration. These critics⁵ are referring not to any modification of Section 7.3 itself, but to an APA Ethics Committee opinion issued in March 2017 that clarified what constitutes a “professional opinion.”⁶ According to this guidance, a professional opinion includes but is not limited to a diagnosis: “... when a psychiatrist renders an opinion about the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry, the opinion is a professional one.” In an accompanying statement,⁷ then-APA President Maria A. Oquendo, MD, PhD, confirmed that the Goldwater Rule “applies to all professional opinions offered by psychiatrists, not just diagnoses.”

Among psychiatrists and other mental health professionals questioning⁸ President Trump’s fitness for office, the reaction to the ethics interpretation was swift and emphatic. Leonard L. Glass, MD, MPH, resigned from the APA in protest after more than four decades of membership. He and Bandy X. Lee, MD, MDiv, editor of a book assessing the president’s purported instability, wrote in Politico: “By fiat of the APA, the Goldwater Rule has effectively turned into a gag rule.”⁹ Dr. Glass and Dr. Lee reiterated their critique in the Boston Globe,¹⁰ and hinted that the APA’s “federal funding” should be jeopardized as a result. Meanwhile, in a New England Journal of Medicine article, Claire L. Pouncey, MD, PhD, called the APA’s interpretation a silencing mechanism whereby “psychiatrists are the only members of the citizenry who may not express concern about the mental health of the president using psychiatric diagnostic terminology.”¹¹

In light of such heated rhetoric, it is worth taking a step back to consider what, if anything, has changed. A brief historical inquiry shows that the answer is not much. Allen R. Dyer, MD, PhD, a psychiatrist and ethicist who helped draft the Goldwater Rule – and whom one of us (LHK) counts as a professional mentor – recalls originally suggesting the term “professional opinion” instead of “psychiatric diagnosis” in order “to reflect the place of ethics in defining a profession.”¹² What Dr. Dyer meant is that standards of conduct, which are the hallmark of any profession, are not intended to be legal rules, but rather normative guidelines for ethical practice.

A distinction without a difference

Putting aside the historical record, what is the substantive dispute with the APA’s ethics interpretation? In essence, the dissenters contend that even if it remains unethical to offer armchair diagnoses, it should be perfectly acceptable to call someone unstable and dangerous, and to do so as a self-identified psychiatric expert. Dr. Glass and Dr. Lee profess to be “mystified by the lack of recognition” that they aren’t formally diagnosing President Trump.¹³ Instead, they view their actions as performing a public service by illuminating the president’s dangerous psyche.

Yet legalistic parsing cannot delineate ethical boundaries for a profession. Without even addressing the issue of predictive validity when it comes to dangerousness or violence risk, it is clear to many that labeling someone as “dangerous” can be just as, if not more, hurtful than offering an unsolicited diagnosis.¹⁴ Whereas opponents of the Goldwater Rule tend to frame it as organized psychiatry’s response to professional embarrassment,¹⁵ other ethical issues are at play, the foremost being¹⁶ respect for human beings. In other words, psychiatric speculation can cause “real harm to real people.”¹⁷

As Richard A. Friedman, MD, explained long before President Trump emerged as a serious contender on the political scene, the problem with the Goldwater fiasco was not just that psychiatrists offered diagnoses, but that they gave “very specific and damaging psychiatric opinions, using the language and art of their profession, about a man whom they had not examined and who surely would not have consented to such statements.”¹⁸ Indeed, Sen. Barry Goldwater later testified to the toll that psychiatrists’ published comments about his masculinity took on his personal interactions.¹⁹

It is instructive that the survey Fact magazine sent to psychiatrists in 1964 asked20 not for diagnoses, but whether Sen. Goldwater was “psychologically fit” to be president. This question – to which nearly 2,000 psychiatrists replied in the negative – is almost exactly what some members of the profession are asking and answering about President Trump today. There is room for nuanced²¹ debate about what types of pronouncements the Goldwater Rule should cover, but there is nothing nuanced about mounting the pedestal of medical authority to brand someone as unsafe, unfit, and unstable. Doing so is disparaging to the individual and stigmatizing of mental illness in general. Ethical standards cannot condone stopping just short of malfeasance and then claiming to have clean hands.

Education vs. stigmatization

The Goldwater Rule is designed as a caveat, not a prohibition. Section 7 of the APA code affirms that psychiatrists, like all physicians,²² have a responsibility to contribute to the common good. A principal way of doing this is through civic education about mental health and illness. 


The Goldwater Rule is embedded in Section 7 as one of several qualifications for psychiatrists to consider when making public forays. For example, psychiatrists should clarify whether they are speaking for themselves or an organization, avoid blanket statements on behalf of the entire profession, and differentiate between their roles as citizen and physician. Viewed in light of these other less-controversial proscriptions, it should become clear that the Goldwater Rule creates minimal barriers to public education.

Specifically, the Goldwater principle is concerned only with psychiatrists’ statements that are professional, public, and individualized. It has nothing to say about opinions that are political, private, or general.¹⁴ As an APA commentary explains, “a general discussion of relevant psychiatric topics – rather than offering opinions about that specific person – is the best means of facilitating public education.”²³ This is not a gag order but a prescription for maintaining professional integrity when exposed to the media limelight.

There are valid reasons to critique the Goldwater Rule, but they require an honest reckoning. Psychiatrists who feel compelled to assess public figures could argue that it is a matter of etiquette, not ethics, and should be left to personal discretion.²⁴

So far, the morphing rationales for contravening the Goldwater Rule fall short, because they elide the real issues at stake. Ethical behavior cannot hinge on artificial distinctions. Whereas invoking a duty to warn about presidential fitness was dubious, differentiating between a diagnosis and a professional opinion is specious.

Lt. Col. Kels practices health and disability law in the U.S. Air Force. Dr. Kels teaches and practices psychiatry at the University of the Incarnate Word School of Osteopathic Medicine in San Antonio. Opinions expressed in this article are those of the authors alone and do not necessarily reflect those of the Air Force or Department of Defense.

References

1. Psychiatric Times. Mar 19, 2018.

2. Tarasoff v. Regents of University of California, 551 P2d 334 (Cal 1976).

3.The Boston Globe. Jan 2, 2018.

4. APA Principles of Medical Ethics, 2013 ed. [7.3].

5. Psychiatric Times. Jul 20, 2017.

6. APA Opinions of the Ethics Committee. 2017 ed. [Q.7b].

7. American Psychiatric Association (APA). “APA remains committed to supporting Goldwater Rule,” Mar 17, 2017.

8. The New York Times. Feb 13, 2017.

9. Politico. Jan 10, 2018.

10. The Boston Globe. Feb 26, 2018.

11. N Engl J Med. 2018;378[5]:405-7.

12. Allen R. Dyer, MD, PhD. “Evolution of the so-called ‘Goldwater rule’: An ethical analysis,” revised Sep 23, 2017.

13. The Boston Globe. Jan 10, 2018.

14. Psychiatric Times. Feb 16, 2018.

15. J Am Acad Psychiatry Law. 2016;44[2]:226-35.

16. Psychiatric Times. Jul 20, 2017.

17. J Am Acad Psychiatry Law. 2016;45[2]:228-32.

18. The New York Times. May 24, 2011.

19. Am J Psychiatry. 2015 Aug 1;172[8]:729-30.

20. Fact. Sep-Oct 1964.

21. Psychiatric Times. Oct 7, 2016.

22. AMA Principles of Medical Ethics. 2016 ed. [VII].

23. APA Commentary on Ethics in Practice, 2015 ed. [3.4.7].

24. J Am Acad Psychiatry Law. 2016;44[2]:226-35.

Significant depressive symptoms affect approximately one in four adults with type 1 and type 2 diabetes while a formal diagnosis of depressive disorders is made in approximately 10%-15% of individuals with diabetes.¹ The combination of diabetes and depression presents a major clinical challenge because the outcomes of each condition is worsened by the presence of the other, which results in worsened quality of life, impaired diabetes self-management, and poor clinical outcomes.¹ While the costs of treatment are high for both individual patients and health economies, these costs do not necessarily result in significant improvements in disease or quality of life outcomes.¹ This raises the question, “What is the best approach to managing patients with comorbid depression and diabetes?”

• Three part-time registered nurses who had diabetes education training (certified diabetes educators), as well as training on depression management, behavioral strategies, and glycemic, hypertension, and lipid control.
• Combined support for self-care with pharmacotherapy to control depression, hyperglycemia, hypertension, and hyperlipidemia with algorithm guidance.
• Motivational and encouraging coaching for problem-solving and adherence to self-care.
• Weekly nurse supervision with a psychiatrist, primary care physician, and psychologist, with a nurse communicating recommendations back to the primary care team.

An endocrinologist/diabetologist was also incorporated for consultation when needed. After 12 months, patients in the intervention group had greater reduction in hemoglobin A_1c (0.58%), LDL cholesterol (6.9 mg/dL), systolic blood pressure (5.1 mm Hg), and depression scores than did those in the usual care group. Patients in the intervention group were also more likely to have adjustments made to insulin, antihypertensive medications, and antidepressants.

The success of this intervention, known as TEAMCare, highlights the critical need to incorporate mental health care into primary care and endocrinology practice. Currently, psychiatric and psychological care are largely administered separately from medical care for diabetes, despite evidence showing the success of an integrated care delivery model. In order to address the important interaction between mental health disorders, such as depression, and diabetes, it is critical that evaluation and treatment of mental health be integrated into medical practice.

What can we – endocrinologists and psychiatrists – do to facilitate adoption of such models? First, we can lobby our health systems to support reorganization of our health care delivery approach for patients with comorbid depression and diabetes so that endocrinologists, psychiatrists, and behavioral specialists are incorporated into primary care practices. This will facilitate better alignment of specialists and primary care providers and also enable patients to receive care in a clinical environment where they are most comfortable and have established relationships. Instead of the primary care physician referring the patient separately to psychiatry and endocrinology and awaiting feedback, which can sometimes take several weeks, the psychiatrist and endocrinologist would meet weekly with the primary care physician and nurse case manager team to review the entire patient panel, make timely adjustments in diabetes and antidepressant medications, and recommend behavioral therapy. This population health strategy would enable our two specialties to make a greater impact on a larger number of patients than we can in a half-day clinic session.

Second, our other critical role is to collaborate with payers to develop a sustainable financial reimbursement model to support the psychiatrist and endocrinologist in this novel health care delivery approach, which departs from the traditional fee-for-service model.

Dr. Golden is the Hugh P. McCormick Family Professor of Endocrinology and Metabolism and executive vice-chair of the department of medicine at Johns Hopkins University, Baltimore.

References

1. Holt RIG et al. Current Diabetes Reports. 2014;14(6):491.

2. Shojania KG et al. JAMA. 2006;296(4):427-40.

3. Katon WJ et al. N Eng J Med. 2010;363(27):2611-20.

Significant depressive symptoms affect approximately one in four adults with type 1 and type 2 diabetes while a formal diagnosis of depressive disorders is made in approximately 10%-15% of individuals with diabetes.¹ The combination of diabetes and depression presents a major clinical challenge because the outcomes of each condition is worsened by the presence of the other, which results in worsened quality of life, impaired diabetes self-management, and poor clinical outcomes.¹ While the costs of treatment are high for both individual patients and health economies, these costs do not necessarily result in significant improvements in disease or quality of life outcomes.¹ This raises the question, “What is the best approach to managing patients with comorbid depression and diabetes?”

• Three part-time registered nurses who had diabetes education training (certified diabetes educators), as well as training on depression management, behavioral strategies, and glycemic, hypertension, and lipid control.
• Combined support for self-care with pharmacotherapy to control depression, hyperglycemia, hypertension, and hyperlipidemia with algorithm guidance.
• Motivational and encouraging coaching for problem-solving and adherence to self-care.
• Weekly nurse supervision with a psychiatrist, primary care physician, and psychologist, with a nurse communicating recommendations back to the primary care team.

An endocrinologist/diabetologist was also incorporated for consultation when needed. After 12 months, patients in the intervention group had greater reduction in hemoglobin A_1c (0.58%), LDL cholesterol (6.9 mg/dL), systolic blood pressure (5.1 mm Hg), and depression scores than did those in the usual care group. Patients in the intervention group were also more likely to have adjustments made to insulin, antihypertensive medications, and antidepressants.

The success of this intervention, known as TEAMCare, highlights the critical need to incorporate mental health care into primary care and endocrinology practice. Currently, psychiatric and psychological care are largely administered separately from medical care for diabetes, despite evidence showing the success of an integrated care delivery model. In order to address the important interaction between mental health disorders, such as depression, and diabetes, it is critical that evaluation and treatment of mental health be integrated into medical practice.

What can we – endocrinologists and psychiatrists – do to facilitate adoption of such models? First, we can lobby our health systems to support reorganization of our health care delivery approach for patients with comorbid depression and diabetes so that endocrinologists, psychiatrists, and behavioral specialists are incorporated into primary care practices. This will facilitate better alignment of specialists and primary care providers and also enable patients to receive care in a clinical environment where they are most comfortable and have established relationships. Instead of the primary care physician referring the patient separately to psychiatry and endocrinology and awaiting feedback, which can sometimes take several weeks, the psychiatrist and endocrinologist would meet weekly with the primary care physician and nurse case manager team to review the entire patient panel, make timely adjustments in diabetes and antidepressant medications, and recommend behavioral therapy. This population health strategy would enable our two specialties to make a greater impact on a larger number of patients than we can in a half-day clinic session.

Second, our other critical role is to collaborate with payers to develop a sustainable financial reimbursement model to support the psychiatrist and endocrinologist in this novel health care delivery approach, which departs from the traditional fee-for-service model.

Dr. Golden is the Hugh P. McCormick Family Professor of Endocrinology and Metabolism and executive vice-chair of the department of medicine at Johns Hopkins University, Baltimore.

References

1. Holt RIG et al. Current Diabetes Reports. 2014;14(6):491.

2. Shojania KG et al. JAMA. 2006;296(4):427-40.

3. Katon WJ et al. N Eng J Med. 2010;363(27):2611-20.

Significant depressive symptoms affect approximately one in four adults with type 1 and type 2 diabetes while a formal diagnosis of depressive disorders is made in approximately 10%-15% of individuals with diabetes.¹ The combination of diabetes and depression presents a major clinical challenge because the outcomes of each condition is worsened by the presence of the other, which results in worsened quality of life, impaired diabetes self-management, and poor clinical outcomes.¹ While the costs of treatment are high for both individual patients and health economies, these costs do not necessarily result in significant improvements in disease or quality of life outcomes.¹ This raises the question, “What is the best approach to managing patients with comorbid depression and diabetes?”

• Three part-time registered nurses who had diabetes education training (certified diabetes educators), as well as training on depression management, behavioral strategies, and glycemic, hypertension, and lipid control.
• Combined support for self-care with pharmacotherapy to control depression, hyperglycemia, hypertension, and hyperlipidemia with algorithm guidance.
• Motivational and encouraging coaching for problem-solving and adherence to self-care.
• Weekly nurse supervision with a psychiatrist, primary care physician, and psychologist, with a nurse communicating recommendations back to the primary care team.

An endocrinologist/diabetologist was also incorporated for consultation when needed. After 12 months, patients in the intervention group had greater reduction in hemoglobin A_1c (0.58%), LDL cholesterol (6.9 mg/dL), systolic blood pressure (5.1 mm Hg), and depression scores than did those in the usual care group. Patients in the intervention group were also more likely to have adjustments made to insulin, antihypertensive medications, and antidepressants.

The success of this intervention, known as TEAMCare, highlights the critical need to incorporate mental health care into primary care and endocrinology practice. Currently, psychiatric and psychological care are largely administered separately from medical care for diabetes, despite evidence showing the success of an integrated care delivery model. In order to address the important interaction between mental health disorders, such as depression, and diabetes, it is critical that evaluation and treatment of mental health be integrated into medical practice.

What can we – endocrinologists and psychiatrists – do to facilitate adoption of such models? First, we can lobby our health systems to support reorganization of our health care delivery approach for patients with comorbid depression and diabetes so that endocrinologists, psychiatrists, and behavioral specialists are incorporated into primary care practices. This will facilitate better alignment of specialists and primary care providers and also enable patients to receive care in a clinical environment where they are most comfortable and have established relationships. Instead of the primary care physician referring the patient separately to psychiatry and endocrinology and awaiting feedback, which can sometimes take several weeks, the psychiatrist and endocrinologist would meet weekly with the primary care physician and nurse case manager team to review the entire patient panel, make timely adjustments in diabetes and antidepressant medications, and recommend behavioral therapy. This population health strategy would enable our two specialties to make a greater impact on a larger number of patients than we can in a half-day clinic session.

Second, our other critical role is to collaborate with payers to develop a sustainable financial reimbursement model to support the psychiatrist and endocrinologist in this novel health care delivery approach, which departs from the traditional fee-for-service model.

Dr. Golden is the Hugh P. McCormick Family Professor of Endocrinology and Metabolism and executive vice-chair of the department of medicine at Johns Hopkins University, Baltimore.

References

1. Holt RIG et al. Current Diabetes Reports. 2014;14(6):491.

2. Shojania KG et al. JAMA. 2006;296(4):427-40.

3. Katon WJ et al. N Eng J Med. 2010;363(27):2611-20.

Sait Ashina, MD; Kimberly Sackheim, DO; Christopher Gharibo, MD

Dr. Ashina is Clinical Associate Professor, Department of Neurology, and Director of the Headache Center at NYU Langone Medical Center, New York, NY

Dr. Sackheim is Clinical Assistant Professor, Department of Rehabilitation Medicine, NYU Langone Medical Center, New York, NY

Dr. Gharibo is Associate Professor, Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Langone Medical Center, New York, NY

Pain is one of the most prevalent medical complaints and one of the most common reasons people seek medical attention in the United States. Chronic pain has an enormous impact on the individual and is associated with high societal costs. Because of these facts, it is considered a major health problem in the United States. The pathophysiologic mechanisms of acute and chronic pain are not fully understood, and chronic pain remains poorly recognized and undertreated. However, in the past 25 years, there have been major advances in our understanding of pain. New agents, medications, and techniques for the treatment of acute and chronic pain have emerged.

Recognizing the undertreatment of pain, the Agency for Health Care Policy and Research at the US Department of Health and Human Services issued the Acute Pain Management: Operative or Medical Procedures and Trauma guidelines in 1992.¹ Subsequent years have witnessed increasing use of patient-controlled analgesia, postoperative analgesia, continuous peripheral nerve blocks, and development of new therapeutic and pharmacologic modalities. The recognition of pain medicine as a subspecialty in medicine across multiple specialties is one of the field’s major achievements. The first pain medicine fellowships were accredited in 1993. The number of programs increased to almost 100 by 1999,² and more programs are being accredited now.

References

1. Acute pain management: operative or medical procedures and trauma, part 2. Agency for Health Care Policy and Research. Clin Pharm. 1992;11(5):391-414.

2. Fishman SM, Ballantyne JC, Rathmell JP, eds. Bonica’s Management of Pain. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.

3. Woolf CJ, Salter MW. Neuronal plasticity: increasing the gain in pain. Science. 2000;288(5472):1765-1769.

4. Kissin I. The development of new analgesics over the past 50 years: a lack of real breakthrough drugs. Anesth Analg. 2010;110(3):780-789.

5. Slavin KV. Peripheral nerve stimulation for neuropathic pain. Neurotherapeutics. 2008;5(1):100-106.

6. Bicket MC, Dunn RY, Ahmed SU. High-frequency spinal cord stimulation for chronic pain: pre-clinical overview and systematic review of controlled trials. Pain Med. 2016;17(12):2326-2336.

7. Gereau RW 4th, Sluka KA, Maixner W, et al. A pain research agenda for the 21st century. J Pain. 2014;15(12):1203-1214.

8. Schou WS, Ashina S, Amin FM, et al. Calcitonin gene-related peptide and pain: a systematic review. J Headache Pain. 2017;18(1):34.

Sait Ashina, MD; Kimberly Sackheim, DO; Christopher Gharibo, MD

Dr. Ashina is Clinical Associate Professor, Department of Neurology, and Director of the Headache Center at NYU Langone Medical Center, New York, NY

Dr. Sackheim is Clinical Assistant Professor, Department of Rehabilitation Medicine, NYU Langone Medical Center, New York, NY

Dr. Gharibo is Associate Professor, Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Langone Medical Center, New York, NY

Pain is one of the most prevalent medical complaints and one of the most common reasons people seek medical attention in the United States. Chronic pain has an enormous impact on the individual and is associated with high societal costs. Because of these facts, it is considered a major health problem in the United States. The pathophysiologic mechanisms of acute and chronic pain are not fully understood, and chronic pain remains poorly recognized and undertreated. However, in the past 25 years, there have been major advances in our understanding of pain. New agents, medications, and techniques for the treatment of acute and chronic pain have emerged.

Recognizing the undertreatment of pain, the Agency for Health Care Policy and Research at the US Department of Health and Human Services issued the Acute Pain Management: Operative or Medical Procedures and Trauma guidelines in 1992.¹ Subsequent years have witnessed increasing use of patient-controlled analgesia, postoperative analgesia, continuous peripheral nerve blocks, and development of new therapeutic and pharmacologic modalities. The recognition of pain medicine as a subspecialty in medicine across multiple specialties is one of the field’s major achievements. The first pain medicine fellowships were accredited in 1993. The number of programs increased to almost 100 by 1999,² and more programs are being accredited now.

References

1. Acute pain management: operative or medical procedures and trauma, part 2. Agency for Health Care Policy and Research. Clin Pharm. 1992;11(5):391-414.

2. Fishman SM, Ballantyne JC, Rathmell JP, eds. Bonica’s Management of Pain. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.

3. Woolf CJ, Salter MW. Neuronal plasticity: increasing the gain in pain. Science. 2000;288(5472):1765-1769.

4. Kissin I. The development of new analgesics over the past 50 years: a lack of real breakthrough drugs. Anesth Analg. 2010;110(3):780-789.

5. Slavin KV. Peripheral nerve stimulation for neuropathic pain. Neurotherapeutics. 2008;5(1):100-106.

6. Bicket MC, Dunn RY, Ahmed SU. High-frequency spinal cord stimulation for chronic pain: pre-clinical overview and systematic review of controlled trials. Pain Med. 2016;17(12):2326-2336.

7. Gereau RW 4th, Sluka KA, Maixner W, et al. A pain research agenda for the 21st century. J Pain. 2014;15(12):1203-1214.

8. Schou WS, Ashina S, Amin FM, et al. Calcitonin gene-related peptide and pain: a systematic review. J Headache Pain. 2017;18(1):34.

Sait Ashina, MD; Kimberly Sackheim, DO; Christopher Gharibo, MD

Dr. Ashina is Clinical Associate Professor, Department of Neurology, and Director of the Headache Center at NYU Langone Medical Center, New York, NY

Dr. Sackheim is Clinical Assistant Professor, Department of Rehabilitation Medicine, NYU Langone Medical Center, New York, NY

Dr. Gharibo is Associate Professor, Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Langone Medical Center, New York, NY

Pain is one of the most prevalent medical complaints and one of the most common reasons people seek medical attention in the United States. Chronic pain has an enormous impact on the individual and is associated with high societal costs. Because of these facts, it is considered a major health problem in the United States. The pathophysiologic mechanisms of acute and chronic pain are not fully understood, and chronic pain remains poorly recognized and undertreated. However, in the past 25 years, there have been major advances in our understanding of pain. New agents, medications, and techniques for the treatment of acute and chronic pain have emerged.

Recognizing the undertreatment of pain, the Agency for Health Care Policy and Research at the US Department of Health and Human Services issued the Acute Pain Management: Operative or Medical Procedures and Trauma guidelines in 1992.¹ Subsequent years have witnessed increasing use of patient-controlled analgesia, postoperative analgesia, continuous peripheral nerve blocks, and development of new therapeutic and pharmacologic modalities. The recognition of pain medicine as a subspecialty in medicine across multiple specialties is one of the field’s major achievements. The first pain medicine fellowships were accredited in 1993. The number of programs increased to almost 100 by 1999,² and more programs are being accredited now.

References

1. Acute pain management: operative or medical procedures and trauma, part 2. Agency for Health Care Policy and Research. Clin Pharm. 1992;11(5):391-414.

2. Fishman SM, Ballantyne JC, Rathmell JP, eds. Bonica’s Management of Pain. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.

3. Woolf CJ, Salter MW. Neuronal plasticity: increasing the gain in pain. Science. 2000;288(5472):1765-1769.

4. Kissin I. The development of new analgesics over the past 50 years: a lack of real breakthrough drugs. Anesth Analg. 2010;110(3):780-789.

5. Slavin KV. Peripheral nerve stimulation for neuropathic pain. Neurotherapeutics. 2008;5(1):100-106.

6. Bicket MC, Dunn RY, Ahmed SU. High-frequency spinal cord stimulation for chronic pain: pre-clinical overview and systematic review of controlled trials. Pain Med. 2016;17(12):2326-2336.

7. Gereau RW 4th, Sluka KA, Maixner W, et al. A pain research agenda for the 21st century. J Pain. 2014;15(12):1203-1214.

8. Schou WS, Ashina S, Amin FM, et al. Calcitonin gene-related peptide and pain: a systematic review. J Headache Pain. 2017;18(1):34.

I was in Miami recently to give a talk on diabetes when a physician, Pablo Michel, MD, asked me whether we could address an issue that’s important to him and many of his colleagues. His question was, Do we have any suggestions about how to help “older doctors” such as himself deal with electronic health records?

One of the problems with his question was that he didn’t really look “old”; he looked like he was about 50 years of age and in good shape. This physician had come on a Saturday morning to spend 4 hours learning about diabetes, which made it clear that he cared about his patients, his craft, and staying current with the medical literature.

We now also have the advantage of well-developed medical voice recognition technology that can be used with most EHRs. Although some doctors say that the software is expensive, it can cost about $1,500 for the software and another $200-$300 for a good microphone, as well as the time to train on the software. But that expense needs to be weighed against the lost productivity of not using such software. A common complaint we hear from older doctors is that they are spending 1 to 2 hours a night completing charts. If voice recognition software could shave off half that time, decrease stress, and increase satisfaction, then it would pay for itself in 2 weeks.

Another issue is that, because the EHR enables so many things to be done from the EHR platform, many doctors find themselves doing all the work. It is important to work as a team and let each member of the team contribute to making the process more efficient. It turns out that this usually ends up being satisfying for everyone who contributes to patient care. It requires standing back from the process periodically and thinking about areas of inefficiency and how things can be done better.

One clear example is medication reconciliation: A nurse or clinical pharmacist can go over medicines with patients, and while the physician still needs to review the medications, it takes much less time to review medications than it does to enter each medication with the correct dose. Nurses also can help with preventive health initiatives. Performing recommended preventive health activities ranging from hepatitis C screening to colonoscopy can be greatly facilitated by the participation of nursing staff, and their participation will free up doctors so they can have more time to focus on diagnosis and treatment. Teamwork is critical.

Finally, if you don’t know something that is important to your practice – learn it! We are accustomed to going to CME conferences and spending our time learning about diseases like diabetes, asthma, and COPD. Each of these disease accounts for 5%-10% of the patients we see in our practice, and it is critically important to stay current and learn about them. We use our EHR for 100% of the patients we see; therefore, we should allocate time to learning about how to navigate the EHR and work more efficiently with it.

These issues are real, and the processes continue to change, but by standing back and acknowledging the challenges, we can thoughtfully construct an approach to maximize our ability to continue to have productive, gratifying careers while helping our patients.

Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington Jefferson Health. Follow him on twitter @doctornotte.

References

1. Medscape Physician Lifestyle Report 2015. Accessed April 27, 2018. https://www.medscape.com/slideshow/lifestyle-2015-overview-6006535#1.

2. Sinsky C et al. Ann Intern Med. 2016;165(11):753-60.

I was in Miami recently to give a talk on diabetes when a physician, Pablo Michel, MD, asked me whether we could address an issue that’s important to him and many of his colleagues. His question was, Do we have any suggestions about how to help “older doctors” such as himself deal with electronic health records?

One of the problems with his question was that he didn’t really look “old”; he looked like he was about 50 years of age and in good shape. This physician had come on a Saturday morning to spend 4 hours learning about diabetes, which made it clear that he cared about his patients, his craft, and staying current with the medical literature.

We now also have the advantage of well-developed medical voice recognition technology that can be used with most EHRs. Although some doctors say that the software is expensive, it can cost about $1,500 for the software and another $200-$300 for a good microphone, as well as the time to train on the software. But that expense needs to be weighed against the lost productivity of not using such software. A common complaint we hear from older doctors is that they are spending 1 to 2 hours a night completing charts. If voice recognition software could shave off half that time, decrease stress, and increase satisfaction, then it would pay for itself in 2 weeks.

Another issue is that, because the EHR enables so many things to be done from the EHR platform, many doctors find themselves doing all the work. It is important to work as a team and let each member of the team contribute to making the process more efficient. It turns out that this usually ends up being satisfying for everyone who contributes to patient care. It requires standing back from the process periodically and thinking about areas of inefficiency and how things can be done better.

One clear example is medication reconciliation: A nurse or clinical pharmacist can go over medicines with patients, and while the physician still needs to review the medications, it takes much less time to review medications than it does to enter each medication with the correct dose. Nurses also can help with preventive health initiatives. Performing recommended preventive health activities ranging from hepatitis C screening to colonoscopy can be greatly facilitated by the participation of nursing staff, and their participation will free up doctors so they can have more time to focus on diagnosis and treatment. Teamwork is critical.

Finally, if you don’t know something that is important to your practice – learn it! We are accustomed to going to CME conferences and spending our time learning about diseases like diabetes, asthma, and COPD. Each of these disease accounts for 5%-10% of the patients we see in our practice, and it is critically important to stay current and learn about them. We use our EHR for 100% of the patients we see; therefore, we should allocate time to learning about how to navigate the EHR and work more efficiently with it.

These issues are real, and the processes continue to change, but by standing back and acknowledging the challenges, we can thoughtfully construct an approach to maximize our ability to continue to have productive, gratifying careers while helping our patients.

Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington Jefferson Health. Follow him on twitter @doctornotte.

References

1. Medscape Physician Lifestyle Report 2015. Accessed April 27, 2018. https://www.medscape.com/slideshow/lifestyle-2015-overview-6006535#1.

2. Sinsky C et al. Ann Intern Med. 2016;165(11):753-60.

I was in Miami recently to give a talk on diabetes when a physician, Pablo Michel, MD, asked me whether we could address an issue that’s important to him and many of his colleagues. His question was, Do we have any suggestions about how to help “older doctors” such as himself deal with electronic health records?

One of the problems with his question was that he didn’t really look “old”; he looked like he was about 50 years of age and in good shape. This physician had come on a Saturday morning to spend 4 hours learning about diabetes, which made it clear that he cared about his patients, his craft, and staying current with the medical literature.

We now also have the advantage of well-developed medical voice recognition technology that can be used with most EHRs. Although some doctors say that the software is expensive, it can cost about $1,500 for the software and another $200-$300 for a good microphone, as well as the time to train on the software. But that expense needs to be weighed against the lost productivity of not using such software. A common complaint we hear from older doctors is that they are spending 1 to 2 hours a night completing charts. If voice recognition software could shave off half that time, decrease stress, and increase satisfaction, then it would pay for itself in 2 weeks.

Another issue is that, because the EHR enables so many things to be done from the EHR platform, many doctors find themselves doing all the work. It is important to work as a team and let each member of the team contribute to making the process more efficient. It turns out that this usually ends up being satisfying for everyone who contributes to patient care. It requires standing back from the process periodically and thinking about areas of inefficiency and how things can be done better.

One clear example is medication reconciliation: A nurse or clinical pharmacist can go over medicines with patients, and while the physician still needs to review the medications, it takes much less time to review medications than it does to enter each medication with the correct dose. Nurses also can help with preventive health initiatives. Performing recommended preventive health activities ranging from hepatitis C screening to colonoscopy can be greatly facilitated by the participation of nursing staff, and their participation will free up doctors so they can have more time to focus on diagnosis and treatment. Teamwork is critical.

Finally, if you don’t know something that is important to your practice – learn it! We are accustomed to going to CME conferences and spending our time learning about diseases like diabetes, asthma, and COPD. Each of these disease accounts for 5%-10% of the patients we see in our practice, and it is critically important to stay current and learn about them. We use our EHR for 100% of the patients we see; therefore, we should allocate time to learning about how to navigate the EHR and work more efficiently with it.

These issues are real, and the processes continue to change, but by standing back and acknowledging the challenges, we can thoughtfully construct an approach to maximize our ability to continue to have productive, gratifying careers while helping our patients.

Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington Jefferson Health. Follow him on twitter @doctornotte.

References

1. Medscape Physician Lifestyle Report 2015. Accessed April 27, 2018. https://www.medscape.com/slideshow/lifestyle-2015-overview-6006535#1.

2. Sinsky C et al. Ann Intern Med. 2016;165(11):753-60.

This is the ninth in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.

There is growing awareness of the importance of supporting patient self-management as part of a comprehensive approach to caring for people with chronic conditions. This is in part the recognition that 15 minutes with a provider every few months contributes less to patient outcomes than what the patient does every day. This month’s article describes some elements of AHRQ’s Self-Management Support Resource Library, a collection of materials and tools produced by AHRQ and others.

Dr. Genevro is a health scientist at AHRQ. Dr. Ganiats is director of the National Center for Excellence in Primary Care Research at AHRQ.

This is the ninth in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.

There is growing awareness of the importance of supporting patient self-management as part of a comprehensive approach to caring for people with chronic conditions. This is in part the recognition that 15 minutes with a provider every few months contributes less to patient outcomes than what the patient does every day. This month’s article describes some elements of AHRQ’s Self-Management Support Resource Library, a collection of materials and tools produced by AHRQ and others.

Dr. Genevro is a health scientist at AHRQ. Dr. Ganiats is director of the National Center for Excellence in Primary Care Research at AHRQ.

This is the ninth in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.

There is growing awareness of the importance of supporting patient self-management as part of a comprehensive approach to caring for people with chronic conditions. This is in part the recognition that 15 minutes with a provider every few months contributes less to patient outcomes than what the patient does every day. This month’s article describes some elements of AHRQ’s Self-Management Support Resource Library, a collection of materials and tools produced by AHRQ and others.

Dr. Genevro is a health scientist at AHRQ. Dr. Ganiats is director of the National Center for Excellence in Primary Care Research at AHRQ.

Digestive Disease Week^® (DDW) is approaching rapidly. One might say, with strong justification, that the overarching theme for DDW is a celebration of diversity. We are entering the era of “omics” and current research suggests a microbiome rich in diversity is associated with health, while a less-diverse biome is associated with digestive disorders – inflammatory bowel disease for example. Multiple abstracts and presentations will be related to research into microbiome alterations in disease. In nature, diversity is a key to survival.

Farmers know the value of diversity and the devastating effects of restricted diversity. When fields are restricted to a single crop year after year, artificial fertilizers must be used to restore fertility. Organic farmers understand the need for diversity in the form of crop rotation. No forest can survive for long without rich biological diversity. Even cancer reminds us of the importance of diversity. Restricted diversity in the form of cellular monoclonality is one of the hallmarks of malignant growth.

DDW, our annual hallmark meeting, emphasizes our need for diverse thoughts and intellectual discourse as we advance the science of gastroenterology, endoscopy, hepatology, and surgery. Biology does not tolerate restrictions on diversity for long. Diversity makes DDW great.

In this month’s issue of GI & Hepatology News, we are reassured that PPIs are not linked to cognitive decline. Sessile serrated polyps, often missed at colonoscopy and CT colography might be detected with noninvasive testing as the field of blood-based cancer screening advances. Pay attention to the exciting bleeding-edge technology emerging from the AGA Tech Summit – especially technologies to treat obesity. Read about some of the continuing barriers to CRC screening in underserved populations – if we are to achieve 80% screening rates we must focus on people challenged to access our health care system.

Finally, consider the AGA Clinical Practice Update about Barrett’s esophagus. I spent a morning with Joel Richter, MD, last month and he reminded me that our current surveillance system is failing to impact annual incidence of esophageal adenocarcinoma. Perhaps we should focus on a one-time screen for those most at risk, catching prevalent disease at an early stage.
 

John I. Allen, MD, MBA, AGAF
Editor in Chief

Digestive Disease Week^® (DDW) is approaching rapidly. One might say, with strong justification, that the overarching theme for DDW is a celebration of diversity. We are entering the era of “omics” and current research suggests a microbiome rich in diversity is associated with health, while a less-diverse biome is associated with digestive disorders – inflammatory bowel disease for example. Multiple abstracts and presentations will be related to research into microbiome alterations in disease. In nature, diversity is a key to survival.

Farmers know the value of diversity and the devastating effects of restricted diversity. When fields are restricted to a single crop year after year, artificial fertilizers must be used to restore fertility. Organic farmers understand the need for diversity in the form of crop rotation. No forest can survive for long without rich biological diversity. Even cancer reminds us of the importance of diversity. Restricted diversity in the form of cellular monoclonality is one of the hallmarks of malignant growth.

DDW, our annual hallmark meeting, emphasizes our need for diverse thoughts and intellectual discourse as we advance the science of gastroenterology, endoscopy, hepatology, and surgery. Biology does not tolerate restrictions on diversity for long. Diversity makes DDW great.

In this month’s issue of GI & Hepatology News, we are reassured that PPIs are not linked to cognitive decline. Sessile serrated polyps, often missed at colonoscopy and CT colography might be detected with noninvasive testing as the field of blood-based cancer screening advances. Pay attention to the exciting bleeding-edge technology emerging from the AGA Tech Summit – especially technologies to treat obesity. Read about some of the continuing barriers to CRC screening in underserved populations – if we are to achieve 80% screening rates we must focus on people challenged to access our health care system.

Finally, consider the AGA Clinical Practice Update about Barrett’s esophagus. I spent a morning with Joel Richter, MD, last month and he reminded me that our current surveillance system is failing to impact annual incidence of esophageal adenocarcinoma. Perhaps we should focus on a one-time screen for those most at risk, catching prevalent disease at an early stage.
 

John I. Allen, MD, MBA, AGAF
Editor in Chief

Digestive Disease Week^® (DDW) is approaching rapidly. One might say, with strong justification, that the overarching theme for DDW is a celebration of diversity. We are entering the era of “omics” and current research suggests a microbiome rich in diversity is associated with health, while a less-diverse biome is associated with digestive disorders – inflammatory bowel disease for example. Multiple abstracts and presentations will be related to research into microbiome alterations in disease. In nature, diversity is a key to survival.

Farmers know the value of diversity and the devastating effects of restricted diversity. When fields are restricted to a single crop year after year, artificial fertilizers must be used to restore fertility. Organic farmers understand the need for diversity in the form of crop rotation. No forest can survive for long without rich biological diversity. Even cancer reminds us of the importance of diversity. Restricted diversity in the form of cellular monoclonality is one of the hallmarks of malignant growth.

DDW, our annual hallmark meeting, emphasizes our need for diverse thoughts and intellectual discourse as we advance the science of gastroenterology, endoscopy, hepatology, and surgery. Biology does not tolerate restrictions on diversity for long. Diversity makes DDW great.

In this month’s issue of GI & Hepatology News, we are reassured that PPIs are not linked to cognitive decline. Sessile serrated polyps, often missed at colonoscopy and CT colography might be detected with noninvasive testing as the field of blood-based cancer screening advances. Pay attention to the exciting bleeding-edge technology emerging from the AGA Tech Summit – especially technologies to treat obesity. Read about some of the continuing barriers to CRC screening in underserved populations – if we are to achieve 80% screening rates we must focus on people challenged to access our health care system.

Finally, consider the AGA Clinical Practice Update about Barrett’s esophagus. I spent a morning with Joel Richter, MD, last month and he reminded me that our current surveillance system is failing to impact annual incidence of esophageal adenocarcinoma. Perhaps we should focus on a one-time screen for those most at risk, catching prevalent disease at an early stage.
 

John I. Allen, MD, MBA, AGAF
Editor in Chief

As the end of the academic year approaches, I always think of one last message to send to the freshly minted psychiatrists who will complete their 4 years of post-MD training. This year, I thought of emphasizing the principles of psychiatric practice, which the graduates will deliver for the next 4 to 5 decades of their professional lives. Those essential principles are coded in the DNA of psychiatric practice, just as the construction of all organs in the human body is coded within the DNA of the 22,000 genes that comprise our 23 chromosomes.

So here are the principles of psych­iatry that I propose govern the relationship of psychiatrists with their patients, encrypted within the DNA of our esteemed medical specialty:

• Provide total dedication to helping psychiatric patients recover from their illness and regain their wellness.
• Maintain total and unimpeachable confidentiality.
• Demonstrate unconditional acceptance and respect to every patient.
• Adopt a nonjudgmental stance toward all patients.
• Establish a strong therapeutic alliance as early as possible. It is the center of the doctor–patient relationship.
• Provide the same standard of care to all patients—the same care you would want your family members to receive.
• Provide evidence-based treatments first, and if no response, use unapproved treatments judiciously, but above all, do no harm.
• Educate patients, and their families, about the illness, and discuss the benefits and risks of various treatments.
• Do not practice “naked psychopharmacology.” Psychotherapy must always be provided side-by-side with medications.
• Support the patient’s family. Their burden often is very heavy.
• Emphasize adherence as a key patient responsibility, and address it at every visit.
• Do not hesitate to consult a seasoned colleague about your complex clinical cases.
• Deal effectively with negative countertransference. Recognize it, and refer the patient to another colleague if you cannot resolve it.
• Always inquire about thoughts of harming self or others and act accordingly.
• Always ask about alcohol and substance use, and about over-the-counter drugs as well. They all can complicate your patient’s treatment course and outcome.
• Never breach boundaries with your patient, and firmly guide the patient about breaching boundaries with you.
• Uphold the medical tenet that all “mental” disorders of thought, mood, affect, behavior, and cognition are generated by disruptions of brain structure and/or function, whether molecular, cellular, or connectomic, caused by various combinations of genetic and/or environmental etiologies.
• Check your patients’ physical health status, including all treatments they received from other specialists, and always rule out iatrogenesis and disruptive pharmacokinetic interactions that may trigger or exacerbate psychiatric symptoms.
• Learn and use clinical rating scales to quantify symptom severity and adverse effects at baseline and at each visit. Measuring the severity of psychosis, depression, or anxiety in psychiatry is like measuring fasting glucose, triglycerides, or blood pressure in internal medicine.
• Use rational adjunctive and augmentation therapies when indicated, but avoid irrational and hazardous polypharmacy.
• Document your clinical findings, diagnosis, and treatment plan conscientiously and accurately. The medical record is a clinical, billing, legal, and research document.
• Advocate tirelessly for psychiatric patients to increase their access to care, and fight the unfair and hurtful stigma vigorously until it is completely erased. A psychiatric disorder should have no more stigma than a broken leg or peptic ulcer, and insurance parity must be identical as well.
• Establish collaborative care for each of your patients and link them to a primary care provider if they do not already have one. Disorders of the body and the brain are bidirectional in their effects and psychiatric patients often suffer from multiple organ diseases.
• Do some pro bono care for indigent or uninsured patients, and actively ask companies to provide free drugs to patients who cannot afford the medication you believe they need.
• Recognize that every treatment you use as the current standard of care was at one time a research project. Know that the research of today is the treatment of tomorrow. So support the creation of new medical knowledge by referring patients to FDA clinical trials or to National Institutes of Health–funded biologic investigations.
• No matter how busy you are, write a case report or a letter to the editor about an unusual response or adverse effect. This generates hypotheses that researchers can pursue and test.
• Volunteer to serve as a clinical supervisor for medical students and residents from your local medical school. Most academic departments of psychiatry appreciate their community-based volunteer faculty.

You, the readers of Current Psychiatry, include thousands of experienced psychiatrists with years of practice in the real world. I invite you to add to this list of principles by writing to me at [email protected]. Join me in providing the freshly minted psychiatrists words of wisdom about the DNA of psychiatry to guide them before they embark on their careers as psychiatric physicians.

As the end of the academic year approaches, I always think of one last message to send to the freshly minted psychiatrists who will complete their 4 years of post-MD training. This year, I thought of emphasizing the principles of psychiatric practice, which the graduates will deliver for the next 4 to 5 decades of their professional lives. Those essential principles are coded in the DNA of psychiatric practice, just as the construction of all organs in the human body is coded within the DNA of the 22,000 genes that comprise our 23 chromosomes.

So here are the principles of psych­iatry that I propose govern the relationship of psychiatrists with their patients, encrypted within the DNA of our esteemed medical specialty:

• Provide total dedication to helping psychiatric patients recover from their illness and regain their wellness.
• Maintain total and unimpeachable confidentiality.
• Demonstrate unconditional acceptance and respect to every patient.
• Adopt a nonjudgmental stance toward all patients.
• Establish a strong therapeutic alliance as early as possible. It is the center of the doctor–patient relationship.
• Provide the same standard of care to all patients—the same care you would want your family members to receive.
• Provide evidence-based treatments first, and if no response, use unapproved treatments judiciously, but above all, do no harm.
• Educate patients, and their families, about the illness, and discuss the benefits and risks of various treatments.
• Do not practice “naked psychopharmacology.” Psychotherapy must always be provided side-by-side with medications.
• Support the patient’s family. Their burden often is very heavy.
• Emphasize adherence as a key patient responsibility, and address it at every visit.
• Do not hesitate to consult a seasoned colleague about your complex clinical cases.
• Deal effectively with negative countertransference. Recognize it, and refer the patient to another colleague if you cannot resolve it.
• Always inquire about thoughts of harming self or others and act accordingly.
• Always ask about alcohol and substance use, and about over-the-counter drugs as well. They all can complicate your patient’s treatment course and outcome.
• Never breach boundaries with your patient, and firmly guide the patient about breaching boundaries with you.
• Uphold the medical tenet that all “mental” disorders of thought, mood, affect, behavior, and cognition are generated by disruptions of brain structure and/or function, whether molecular, cellular, or connectomic, caused by various combinations of genetic and/or environmental etiologies.
• Check your patients’ physical health status, including all treatments they received from other specialists, and always rule out iatrogenesis and disruptive pharmacokinetic interactions that may trigger or exacerbate psychiatric symptoms.
• Learn and use clinical rating scales to quantify symptom severity and adverse effects at baseline and at each visit. Measuring the severity of psychosis, depression, or anxiety in psychiatry is like measuring fasting glucose, triglycerides, or blood pressure in internal medicine.
• Use rational adjunctive and augmentation therapies when indicated, but avoid irrational and hazardous polypharmacy.
• Document your clinical findings, diagnosis, and treatment plan conscientiously and accurately. The medical record is a clinical, billing, legal, and research document.
• Advocate tirelessly for psychiatric patients to increase their access to care, and fight the unfair and hurtful stigma vigorously until it is completely erased. A psychiatric disorder should have no more stigma than a broken leg or peptic ulcer, and insurance parity must be identical as well.
• Establish collaborative care for each of your patients and link them to a primary care provider if they do not already have one. Disorders of the body and the brain are bidirectional in their effects and psychiatric patients often suffer from multiple organ diseases.
• Do some pro bono care for indigent or uninsured patients, and actively ask companies to provide free drugs to patients who cannot afford the medication you believe they need.
• Recognize that every treatment you use as the current standard of care was at one time a research project. Know that the research of today is the treatment of tomorrow. So support the creation of new medical knowledge by referring patients to FDA clinical trials or to National Institutes of Health–funded biologic investigations.
• No matter how busy you are, write a case report or a letter to the editor about an unusual response or adverse effect. This generates hypotheses that researchers can pursue and test.
• Volunteer to serve as a clinical supervisor for medical students and residents from your local medical school. Most academic departments of psychiatry appreciate their community-based volunteer faculty.

You, the readers of Current Psychiatry, include thousands of experienced psychiatrists with years of practice in the real world. I invite you to add to this list of principles by writing to me at [email protected]. Join me in providing the freshly minted psychiatrists words of wisdom about the DNA of psychiatry to guide them before they embark on their careers as psychiatric physicians.

As the end of the academic year approaches, I always think of one last message to send to the freshly minted psychiatrists who will complete their 4 years of post-MD training. This year, I thought of emphasizing the principles of psychiatric practice, which the graduates will deliver for the next 4 to 5 decades of their professional lives. Those essential principles are coded in the DNA of psychiatric practice, just as the construction of all organs in the human body is coded within the DNA of the 22,000 genes that comprise our 23 chromosomes.

So here are the principles of psych­iatry that I propose govern the relationship of psychiatrists with their patients, encrypted within the DNA of our esteemed medical specialty:

• Provide total dedication to helping psychiatric patients recover from their illness and regain their wellness.
• Maintain total and unimpeachable confidentiality.
• Demonstrate unconditional acceptance and respect to every patient.
• Adopt a nonjudgmental stance toward all patients.
• Establish a strong therapeutic alliance as early as possible. It is the center of the doctor–patient relationship.
• Provide the same standard of care to all patients—the same care you would want your family members to receive.
• Provide evidence-based treatments first, and if no response, use unapproved treatments judiciously, but above all, do no harm.
• Educate patients, and their families, about the illness, and discuss the benefits and risks of various treatments.
• Do not practice “naked psychopharmacology.” Psychotherapy must always be provided side-by-side with medications.
• Support the patient’s family. Their burden often is very heavy.
• Emphasize adherence as a key patient responsibility, and address it at every visit.
• Do not hesitate to consult a seasoned colleague about your complex clinical cases.
• Deal effectively with negative countertransference. Recognize it, and refer the patient to another colleague if you cannot resolve it.
• Always inquire about thoughts of harming self or others and act accordingly.
• Always ask about alcohol and substance use, and about over-the-counter drugs as well. They all can complicate your patient’s treatment course and outcome.
• Never breach boundaries with your patient, and firmly guide the patient about breaching boundaries with you.
• Uphold the medical tenet that all “mental” disorders of thought, mood, affect, behavior, and cognition are generated by disruptions of brain structure and/or function, whether molecular, cellular, or connectomic, caused by various combinations of genetic and/or environmental etiologies.
• Check your patients’ physical health status, including all treatments they received from other specialists, and always rule out iatrogenesis and disruptive pharmacokinetic interactions that may trigger or exacerbate psychiatric symptoms.
• Learn and use clinical rating scales to quantify symptom severity and adverse effects at baseline and at each visit. Measuring the severity of psychosis, depression, or anxiety in psychiatry is like measuring fasting glucose, triglycerides, or blood pressure in internal medicine.
• Use rational adjunctive and augmentation therapies when indicated, but avoid irrational and hazardous polypharmacy.
• Document your clinical findings, diagnosis, and treatment plan conscientiously and accurately. The medical record is a clinical, billing, legal, and research document.
• Advocate tirelessly for psychiatric patients to increase their access to care, and fight the unfair and hurtful stigma vigorously until it is completely erased. A psychiatric disorder should have no more stigma than a broken leg or peptic ulcer, and insurance parity must be identical as well.
• Establish collaborative care for each of your patients and link them to a primary care provider if they do not already have one. Disorders of the body and the brain are bidirectional in their effects and psychiatric patients often suffer from multiple organ diseases.
• Do some pro bono care for indigent or uninsured patients, and actively ask companies to provide free drugs to patients who cannot afford the medication you believe they need.
• Recognize that every treatment you use as the current standard of care was at one time a research project. Know that the research of today is the treatment of tomorrow. So support the creation of new medical knowledge by referring patients to FDA clinical trials or to National Institutes of Health–funded biologic investigations.
• No matter how busy you are, write a case report or a letter to the editor about an unusual response or adverse effect. This generates hypotheses that researchers can pursue and test.
• Volunteer to serve as a clinical supervisor for medical students and residents from your local medical school. Most academic departments of psychiatry appreciate their community-based volunteer faculty.

You, the readers of Current Psychiatry, include thousands of experienced psychiatrists with years of practice in the real world. I invite you to add to this list of principles by writing to me at [email protected]. Join me in providing the freshly minted psychiatrists words of wisdom about the DNA of psychiatry to guide them before they embark on their careers as psychiatric physicians.