A 35-Year-Old Physician With Opioid Dependence
Authors: John R. Knight
Journal: JAMA (2004)

DR REYNOLDS: Dr L is a specialist physician in practice for several years who became addicted to hydrocodone. Dr L lives with his wife, who is also a physician, and his 2 young children. Dr L was well until several years ago, when he was grieving after a stressful life event. He began taking antidepressant medication from the sample closet in his office. He stopped taking the medications after several months because he had no relief from his symptoms. Gradually, most of his grief symptoms resolved. Some time later, Dr L became ill with an upper respiratory tract infection. Again, he self-treated his symptoms, this time with a cough syrup containing hydrocodone that he obtained from his office sample closet. The hydrocodone improved not only his cough but also his mood, and he began to take it regularly to get through the day, even after his cough resolved. It allowed him to function at a level he perceived as higher than his normal baseline: he was productive, attentive, happy, and energized. He began requiring more and more of the hydrocodone to achieve these effects. Dr L continued to use hydrocodone from his sample closet, going through numerous bottles weekly. He wrote prescriptions for the medication in tablet and liquid form so that he would have a back-up supply when the sample closet became empty. At one point, while he was out of town and away from his medication, he told his unsuspecting wife about his addiction, and he stopped using. When he had not taken hydrocodone for more than 36 hours, he experienced significant withdrawal symptoms that included anxiety, fatigue, and depression. To diminish them, he began taking hydrocodone again (without his wife’s knowledge) within a week of returning to work. At that point, he realized that he had a problem with addiction but did not seek help. Ultimately, he was taking about 200 mg per day of hydrocodone. During this entire 18-month course, Dr L did not seek medical care. Approximately 6 months later, and after about 2 months of suspicions related to observed mood changes and categorical denials that anythingwaswrong,his employerconfrontedhim abouthisdruguse.Hewasreferred to thestatephysicianhealth program by a supportive chief of staff and division head at the hospital where he had been admitting his patients. There were no issues about the quality of his care for patients during his time using hydrocodone; if anything, he reported that he had been more productive than previously. The state physician health program determined that Dr L had a substance dependence problem and the state licensing board required that he seek inpatient addiction treatment, which is where we interviewed him. If he fulfills all the goals of treatment, and the required aftercare, his license will not be suspended (it is still active), and this episode will not enter his file. Dr L is currently midway through a planned 3-month stay at an inpatient addictions center. His medical insurance will not pay for his treatment, so he is paying approximately $30000 out-of-pocket for care. He has not been diagnosed with any co-occurring psychiatric illness, such as depression. Dr L reports no history of previous addictions of any sort. He reports not misusing alcohol during college or medical school and not smoking cigarettes regularly. He has never been treated for any psychiatric illness and has no family history of addiction. At the time of his admission to the inpatient unit, Dr L had been off opioids for a number of days. He had a completely normal physical examination. Laboratory tests revealed normal blood cell counts, chemistries, and thyroid studies. His urine test was positive for tetrahydrocannabinol (THC) (91 ng/dL), but negative for all other substances.