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You are surprised when a patient of yours, a physician recovering from a substance abuse problem, tests positive for morphine. Do you believe his explanation of a false-positive result?
July 2006, Vol. XXIII, Issue 8
Dr Rick Miller, a 35-year-old internist, was just trying to be polite when he nearly ended his medical career.
Dr Miller was referred to me from a detoxification unit at a local hospital. He had been admitted a week earlier because of his oxycodone use, which developed over a 2-year period and culminated with a habit that required 600 to 800 mg of the drug daily. Dr Miller had been writing prescriptions for himself in his wife's name and using her driver's license (which he had stolen) to fill the prescriptions.
His oxycodone abuse came to an abrupt halt when he was arrested at a pharmacy. Within a few hours, he had surrendered his DEA license, stopped practicing medicine, and entered an inpatient detoxification unit. He stayed in the facility for 7 days-a short amount of time given the extent and severity of his opiate dependence-and was discharged with a prescription for paroxetine.
As part of his discharge, Dr Miller signed a 5-year chemical dependency monitoring contract with Physicians Health Services (PHS) that mandated regular check-ins with one of its associate directors, frequent and random urine drug screens, psychotherapy with a therapist of his choice (namely myself), and regular attendance at Alcoholics Anonymous meetings. Dr Miller and I have been working together for the past 7 years.
Despite feeling both depressed and shaky on his hospital discharge, Dr Miller maintained complete abstinence from opiates and other substances of abuse (with the exception of a glass of champagne at a wedding 2 years into his contract and another a year later while vacationing with friends at the beach) and came regularly to our therapy meetings. He discontinued paroxetine after about 6 months, and he resumed part-time work in a private practice group setting about a year later. Unlike before his arrest, he now genuinely seemed to enjoy his work.
Dr Miller worked hard in therapy, struggling to understand his past and its role in his substance abuse. He told me whenever he was tempted to use opiates: once a patient thrust a bottle of oxycodone toward him, telling him that he did not want it; another time a colleague handed him a bottle of hydrocodone and asked him to dispose of it. In both instances, he abstained. Because of confessions like this-as well as my general sense of how he was doing- I always felt that Dr Miller was being honest with me and was doing well in sobriety and otherwise.
I was surprised, therefore, when 3 years into our work together I received a call from a PHS associate director telling me that Dr Miller had tested positive for morphine. He also asked me whether I knew anything about this. I told him that I thought Dr Miller was doing well and that I could not explain the positive result. I hastened to add, though, that I realized I could be fooled.
When we hung up, I called Dr Miller and told him what I had just heard. He assured me he had not relapsed but could not explain the positive test result. I believed him, but in the face of the test I had some small level of doubt. We agreed to meet the next day.
When we met, Dr Miller said that since we had spoken the day before, he remembered that he had not eaten breakfast the morning before his last urine test. When he arrived in the office that day, the nurses offered him some Sociable poppy seed crackers. He ate the first cracker out of politeness. He liked it a lot, he added, and realizing his hunger, he ate half the box before heading off to his urine test. Maybe the poppy seeds in the crackers were the source of the positive test results, he surmised.
I wanted to believe him, but over the years I had seen some smart physicians who had relapsed despite intensive therapy and monitoring, so I had my suspicions. Dr Miller said he told his story to the associate director and was waiting to hear back from him. If PHS were to decide he had violated the terms of his contract, they would report the relapse to the Board of Registration in Medicine, which would jeopardize his license.
Several days passed before we heard back from PHS. When the associate director called, he told us that he was initially skeptical of Dr Miller's Sociable cracker explanation. In fact, he was so skeptical that he ate a handful of the crackers and then tested himself. He tested negative.
The following day, the associate director ate a whole box of the crackers on an empty stomach and, voilà, the test came back positive for morphine! This test satisfied him that Dr Miller was telling the truth and had not, in fact, relapsed. Case closed.
Five years later, Dr Miller continues to practice medicine well and without incident. PHS now has written into its chemical dependency contract that clients should not ingest a variety of substances that might yield false positive test results, including poppy seed crackers.
Sometimes, indeed, it's best not to be too sociable.
Dr Boyd is a lecturer in the department of psychiatry at Harvard Medical School and attending psychiatrist at Cambridge Health Alliance. He recently became an associate director at Physicians Health Services and reports no conflicts of interest regarding the subject matter of this article.