David’s Story: Beyond the Dose

Narrative

When I first met David, he was just 25 years old, sitting in my office with a hollow look in his eyes and a desperate plea for help.

I admitted him to the methadone clinic that day, explaining exactly what I was planning to do. I explained the expectations he could have and the expectations we would have. I talked about how methadone worked, what it will do, can do, and won't do. I told him how it could help steady his life. At first, he was hopeful, but his battle was relentless. David persistently requested higher doses, explaining that he couldn't feel normal without more. I raised his dose to what I considered a safe and effective level, but his cravings persisted. As I raised his dose, I did blood work to make sure we had a therapeutic level of methadone in him. I went higher on his dose and got to a blood level considered a blocking dose; a dose high enough that using heroin would not cause a sensation of being high. But he needed more. Ultimately, I ordered the highest dose of methadone I had ever prescribed someone. Because of his dose, I checked his blood levels, both peak and trough, often and even ordered an EKG. His latest blood test revealed I was close to a toxic dose of methadone in him, but he continued to use and insist he needed more. He told me he was using less heroin than before, though he could never articulate exactly how much. His vague answers and the inconsistent pattern of use worried me deeply. I continued the high dose of methadone and implored him to go to counseling three days a week and attend group meetings at least once a week, as well as attend 12-step meetings daily, or as often as possible.

One evening, I got the call every addiction physician dreads: David had overdosed. When I arrived at the hospital, I found him on a ventilator. The Intensive Care Unit (ICU) staff told me he was lucky to be alive. His brain had been deprived of oxygen, and they didn't know for how long.

For four weeks, David lay in that hospital bed, machines doing the work his body could not. Against all odds, he woke up—lucid and intact, a miracle. Yet those four weeks had erased even the small progress we'd made. Deprived of methadone or any opioids, his body was starting from scratch. Many people believe if you can just remove the drugs from the patient's body, you can cure the patient and claim success. Physicians know better. Removing drugs from a patient's system is only the first base camp on the journey to the summit.

When David was finally extubated, I restarted his methadone, this time with the highest initial dose I'd ever prescribed. Still, David insisted it wasn't enough. Before I even told him what dose I was going to order, he said, "It's too low, Doc. It won't work."

I adjusted his dose as quickly as I could, but his cravings outpaced my interventions. I usually increase a patient's dose once a week. With David I increased his dose every day or at least every other day. And every day, he told me it wasn't enough. Less than one week later, the second call came. This time, there was no ventilator, no miracle. Three years after we had met, at the age of 28, David was gone.

The day of the funeral, I stood in front of a mirror, straightening my tie with trembling hands. My wife placed a steadying hand on my shoulder. "You don't have to go," she said softly.

"I do," I replied. "But I'm scared."

Since the time I began practicing medicine as a family physician I have gone to my patient's funerals. I believed it was my responsibility to care for my patients from cradle to grave. I took that philosophy with me when I left Family Medicine to specialize in Addiction Medicine. I believe that being present at my patients' funeral is a way I can show respect and recognize my patient's humanity. But today's funeral was different; my treatment of David failed. Sometimes with death comes guilt. I will second guess myself for the rest of my life, wondering what if I had done things just a little differently. Sometimes family members feel guilty or become angry as they look for blame to ease their pain and loss. I didn't know if I'd be welcomed or confronted with grief-fueled rage.

My wife nodded. "If anything happens, I'll be right there with you."

At the funeral home, the air was heavy with grief. As I approached David's casket, his father spotted me. His gaze was intense, and my heart raced. This was the moment I'd dreaded. Would he scream at me, accuse me of failing his son, or something worse? He walked toward me with his jaw and fists clenched. I braced myself as he got closer.

Then, to my astonishment, he opened his arms and relaxed. For a moment, I hesitated, unsure of what to expect. But then, he pulled me into a firm embrace.

"I tried," I choked out, tears spilling over.

"We all tried," he said, his voice also breaking.

"David tried too," I added.

We stood there, holding each other, united in sorrow. In that moment, there were no accusations, no anger—only the raw silence of shared grief and the weight of a battle we had all fought together, but ultimately lost.

Despite our best efforts and the use of every tool we have—medications, therapy, compassion, and persistence—some battles with addiction still end in tragedy. It is not always a failure of medicine or will, but often the immense power of the disease. Healing sometimes comes not from saving a life, but from standing beside a grieving family and honoring the person who fought so hard.

Optional Author Reflection

Sometimes healing is not restoring life but honoring effort and accepting humanity amid loss. Writing David's story is a way to acknowledge the complexity of addiction and the limits of medicine, while preserving dignity and compassion.