MedConnect

Recognizing the Connections Between Mental Health, Substance Abuse, and Responsible Prescriptions

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Sarah Manookian
5–7 minutes

Of the issues that plague our society, mental health conditions and substance use disorders are some of the most commonly talked about—and for good reason. As recently as in 2020, about a third of nonelderly American adults reported that they suffered from either. We often see reports about the two being connected, raising the question of how strong the relationship between both are. Well, according to the National Institute of Health, in 2018, 37.9% of adults with substance use disorders also had a mental health condition; conversely, 18.2% of adults with a mental health condition also had a substance use disorder. The unfortunate reality is that mental health conditions and substance use disorders are comorbidities. This can create much pain for families across the country. In 2021 alone, over 100,000 Americans died as a result of a drug overdose. Contrasting the emotional devastation of this statistic are the insensitive reactions we see throughout our society. Just think—how many times have you heard someone with a mental health disorder get called “crazy” or “a lunatic” by another person? How many times have you heard the argument that people with substance use disorders have only themselves to blame? All that such dialogues do is further ingrain the stigmas that make treating these issues more difficult. What they fail to consider is just how nuanced the relationship between the two is. From genetics to life circumstances, whether someone develops a mental health condition or a substance use disorder is not their choice. However, from the trends we’ve seen we can determine certain patterns that may indicate a predisposition to developing them. This can be a useful guide for patient care, and one instance where this applies is also quite important for aspiring physicians—namely, ordering prescriptions, especially of controlled substances.

Controlled substances, also known as controlled medications, refer to medications and chemicals that are regulated by governmental authorities due to their potential for abuse, addiction, and dependence. These drugs are divided into several classes—sometimes called schedules—according to their safety qualities, tendency for misuse, and medical uses, and are:

  • Schedule 1: Drugs without any medical use and high potential for abuse and dependency
  • Schedule 2: Drugs with medical uses, but which still hold a high potential for abuse and dependency
  • Schedule 3: Drugs with medical uses and less potential for abuse and dependency than schedule 2 drugs, but more so than schedule 4
  • Schedule 4: Drugs with medical uses and less potential for abuse and dependency than schedule 3 drugs, but more so than schedule 5
  • Schedule 5: Drugs with medical uses and the least potential for abuse and dependency

While these schedules are confusing—and problematic outside of medicine, too, in many cases—, they can provide physicians with a rough idea of what kind of a risk they pose for the average patient. While this makes for good starting points, doctors shouldn’t look only at a drug’s schedule to determine whether or not they pose a risk for a patient, and then dish out a thoughtlessly standardized prescription. The patients physicians see on a daily basis, just like the ones pre-meds will see down the line, can’t be treated as average patients. The schedules can’t say whether the patient exhibits symptoms consistent with disorders that predispose them to misuse—like mental health conditions—, or if they have a family history that may not affect them until after they begin taking the medication. This is information that doctors can only find out by getting to know their patient. However, this also goes the other way. Certain medications can have side effects that may induce symptoms consistent with mental health conditions, like anxiety or depression. Knowing whether patients are predisposed to mental health conditions can help physicians further personalize the prescription. Yet, a doctor’s job isn’t done after they send an order to the pharmacy. They need to keep up with the patient on a regular basis to make adjustments to the dosage, or even the specific medication (in some cases, one medication may need to be switched out for another that produces the same effects, but isn’t as likely to cause certain side effects), as needed. All of this becomes exacerbated by the fact that some medications may provide temporary relief from symptoms that aren’t associated with the medication being treated. For instance, opioids for post-surgical pain relief may also help patients ease their anxiety. As a result, some patients may self-medicate and take a higher dosage or with a higher frequency than they need to for their pain, seeking a break from their anxiety, too. Over the long term, this kind of misuse can create dependency. It’s something that happens with many other medications, too, and doctors should be keeping an eye out for it as they navigate through a patient’s care.

This all serves as a reminder of the responsibility that physicians hold to aid the US’s current mental health and substance use crises. Patients, at the end of the day, are people, with stories that define who they are and that influence how the rest of their lives will unfold. Medications, if prescribed without deliberate care, can upend all of that in a way that directly opposes what anyone would be seeking. Of course, though, physicians can’t be expected to develop a fool-proof treatment plan right away from the first few words that a patient says to them. Protecting their mental and physical health is a process that requires a significant amount of opening up from the patient, and this lies on a well established foundation of trust. So, although the first line of defense is always a proper prescription, building a rapport to get to know the patient is equally necessary. This comes back to the principle that every patient is a unique human being. Physicians need to treat them as such. Otherwise, details could be missed because the physician didn’t spend enough time with them, and even if a prescription cures one ailment, it could mess something else up entirely. Someone’s health is a collection of various parts that all work together, and it all depends on a fragile balance that physicians around the world work hard to maintain everyday—and one that should stay at the forefront of the minds of pre-meds like yourself as you move towards being able to prescribe controlled substances.

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