Case Study: Robert, a 35-year-old teacher

Considering Treatment Options

The patient is a 35-year-old school teacher. He has been injecting heroin on and off since he was 16. He has never been arrested. He has been through many episodes of heroin detoxification, mostly outpatient methadone detoxification but has also been in three inpatient drug treatment programs. The last inpatient program was a 28-day, drug-free recovery program, and he remained both heroin and alcohol free for about 6 months following treatment. He teaches math at a junior high school and is in some difficulty because of “calling in sick too much.”

Robert’s wife in in recovery as well and insisted that he return to treatment after discovered he was taking large quantifies of codeine pills from several doctors for a back injury following an automobile accident. She is unaware that he is also injecting heroin at least once daily. He has been alcohol abstinent for the past two years. His only current medical problem is that he is hepatitis C positive and has been for at least 10 years.


He states, “Doc, I know I’m an addict. My wife cleaned up when she was pregnant with our daughter and she just got her 12-year chip. She moved on with her life, but I’m stuck. My back injury threw me into a tailspin. At first I really needed the codeine, but now I’m just using them to stave off heroin withdrawal. I really need your help. If my wife finds out I’m back on the needle she’ll leave me this time.

Questions for Discussion

1. Does the patient meet DSM-IV criteria for opioid dependence?

2. What are the treatment options for this patient?

3. How would you assess the need for pharmacotherapy for this patient?

4. Is this patient a candidate for buprenorphine?

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