Internist's Relapse Into Drug Use Undetected

Records, obtained by The Post from a person close to the case who insisted on complete privacy, indicate that in the first years of Malakoff's treatment, when his doctors documented his purported recovery, he spent about $50,000 on bulk orders of Stadol, an opiate; fiorinal, a barbiturate; codeine, a narcotic; Xanax, an anti-anxiety drug; Ambien, a sleeping aid; and other prescription drugs.

Similarly, when Gerald Perman -- the psychiatrist on Malakoff's treatment team -- was told by a lawyer in January 2002 that Malakoff had secretly continued to order large quantities of drugs during treatment in 2001, Perman seemed unalarmed.

"There are many things in the world I don't know about, and there are many things my patients do, I'm sure, that they don't tell me about or that I don't know about," Perman is quoted as saying in legal documents related to Malakoff. He added, "It tells me that he may have felt embarrassed and ashamed about this problem."

Perman said yesterday that he could not talk about Malakoff's case but emphasized that in a situation in which he has suddenly learned that a patient in recovery is still abusing drugs, "My initial reaction would not be to express a strong emotional reaction but to sort things out in a dispassionate way."

Nonetheless, in the deposition Perman appeared less than quick to accept the news: "Even though he ordered these medications, I don't know -- we don't know if he took them or not."

What is known is that in the course of Malakoff's treatment, Richardson, the neurologist, prescribed fiorinal and codeine, two drugs that Malakoff had been abusing, with the stated aim of helping Malakoff deal with headaches and sinus pain. Malakoff's psychiatrist, Perman, added Xanax and Ambien to the mix -- two drugs Malakoff had used heavily during his times of drug dependence.

Perman said yesterday that prescribing drugs that the patient has had trouble kicking can help a physician develop a "relationship" with the patient before gradually discontinuing the drug. But he conceded that others would strongly disagree.

Those prescriptions gave Malakoff plausible deniability for his occasional positive drug tests. The real question, several doctors said, is how Malakoff managed to pass virtually all of those tests -- more than 150 of them in one stretch, according to one doctor who was monitoring his progress.

As it turns out, Stadol -- a synthetic opiate -- does not get detected on standard toxicology screening tests, which detect only naturally occurring morphine derivatives. And fiorinal is so short-acting that people can often clear the substance from their systems in time for a drug test.

Perman said that the medical society orders special tests if there is reason to believe the patient is abusing a drug not on the standard screen. Asked why a Stadol screen was apparently not included in Malakoff's tests until late in the game, when that was the drug he had been abusing from the start, Perman said: "We're fallible."

In the early years of his treatment -- the only period for which records were obtained -- Malakoff had multiple automobile accidents. Repair shop records, citations and other documents indicate he had at least 20 crashes between April 1998 and October 2001. Many of them were on the George Washington Parkway, which he would drive daily from his home in Great Falls, and several involved rental cars he had while his car was in for repairs.

The records indicate that Malakoff attributed many instances of car damage to parking garage incidents.

Staff writers Cheryl W. Thompson, Mike Allen, Henri E. Cauvin and Carol D. Leonnig and research editor Margot Williams contributed to this report.