INTERNIST'S RELAPSE INTO DRUG USE UNDETECTED

Cheney Was Aware of His Doctor's Problem

For years after Vice President Cheney's personal internist, Gary
Malakoff, had supposedly quit abusing prescription painkillers, the
team of doctors monitoring his recovery remained oblivious to the fact
that the high-profile doctor was still drug-dependent, according to
legal papers and medical records obtained by The Washington Post.

Records show that treatment team members at George Washington
University Medical Center, who conducted frequent medical and
psychiatric examinations to watch for signs of relapse, may even have
facilitated Malakoff's problem by their deferential treatment, raising
questions about the suitability of having medical center doctors
overseeing one of their own.

The psychiatrist and neurologist overseeing care for Malakoff -- then
the director of the medical center's internal medicine division --
repeatedly prescribed the drugs the internist was known to have been
abusing, medical charts show.

And when the neurologist, Perry Richardson, needed to document
Malakoff's progress to the local medical society, he let Malakoff
craft the letter, Richardson acknowledged in a deposition.

"I have no concerns about his thought processes or judgment," Malakoff
wrote about himself for Richardson's signature. "I truly believe that
he is stable enough to see and take care of patients as well as teach
our medical students and residents."

The documents, along with interviews of doctors familiar with the
case, paint a picture of an insular and ineffective system of
oversight in which Malakoff's doctors accepted his assurances of
well-being at face value while he continued to order thousands of
dollars of drugs on the Internet, repeatedly crashed his car and
managed to bamboozle scores of urine tests.

By doing so, the records show, Malakoff's physicians effectively, if
unwittingly, protected him from further disciplinary action by the
District's medical licensing board.

The Malakoff case also has spotlighted the role of the Medical Society
of D.C., the nonprofit physician organization that monitored his treatment.

Peter J. Cohen, the physician who chairs the committee that watches
over impaired doctors, said the medical society took immediate steps
when it discovered this spring that Malakoff was still using drugs.

"When we found out about this, because we knew his history, we acted
very quickly," Cohen said. "The first thing we did was notify the
hospital, and he stopped practicing immediately. . . . We did not
coddle him. We did not hide him."

It is not clear, however, why earlier periods of ongoing drug use by
Malakoff were not picked up by drug tests demanded by the medical
society. Malakoff "has had some relapses" during his nearly five years
of oversight by the medical society, Cohen said.

One thing that became clear yesterday is that Cheney has known about
Malakoff's problems for some time. Jonathan Reiner, director of GWU's
cardiac catheterization laboratory, said in an interview that Cheney
"has known for years" about Malakoff's drug dependence, although he
would not be specific.

"Dr. Malakoff had frank discussions with the vice president for quite
a period of time about this," Reiner said. "This was not just recent
news. He has kept him apprised."

Reiner said he had "no concern" that Malakoff's problems affected
Cheney's care, saying that Malakoff was "a member of a team of
doctors" that made collective decisions.

Cheney's press secretary, Kevin Kellems, would not comment on when the
vice president learned about Malakoff's problems but said Cheney had
no concerns about the care he received.

Several doctors and medical administrators said Malakoff's story is
emblematic of a larger problem of the difficulties doctors face in
applying the tough love their impaired colleagues need.

"My experience over the last 30 years is that in any setting,
physicians are very cautious and conservative about correcting and
monitoring their fellow colleagues," said Thomas W. Chapman, former
chief executive at the medical center and now president of the HSC
Foundation, which helps special-needs children. "It's a very important
thing obviously, because you're dabbling around with someone's career.
It's a very thin line. It's complicated."

Several doctors suggested that GWU's medical center is in a
particularly difficult position because of its affiliation with the
White House -- a relationship that adds significantly to its
reputation and which the medical center has not been shy about.

"It's the president's hospital," said Robert Stillman, medical
director at the Shady Grove Fertility Reproductive Science Center in
Rockville and a former director of GWU's fertility program. "You
parlay that in the community, and it's an appropriate thing to do. You
say, 'Who trusts us? Well, the president of the United States and the
Secret Service.' "

But the flip side, doctors said, is that GWU's medical center has more
to lose from an open admission of wrongdoing by a staff physician.

"Remember all those men in their white coats at the Cheney news
conference with their chests all pumped up? They knew that if they
blew the whistle on Gary, it would hurt the center," said a physician
with close ties to the case who spoke on the condition of anonymity
out of fear of repercussions. As a result, the physician said,
overseers either intentionally or unconsciously "turned a blind eye to
someone in need of help."

Malakoff is not the first doctor caught in this dilemma at GWU's
medical center, which prides itself on its Capitol Hill clientele. In
D.C. Superior Court papers filed in 1999 relating to a different
doctor also under treatment for drug abuse, that doctor's attorney
explicitly sought to seal the court record "by virtue of the status of
his many prominent patients."

Center spokeswoman Barbara Porter declined to answer questions about
how the institution deals with impaired doctors. "We have decided not
to have any further comment on the story," she said.

Malakoff continued to treat patients from the fall of 1999 -- when he
was first caught using other doctors' names to prescribe drugs for
himself -- until this May, when the medical society determined he was
failing to stay clear of drugs and insisted he stop practicing or face
possible action by the District's medical licensing board.

For several weeks, Malakoff has been in "intensive therapy" at an
inpatient treatment program, Cohen said.

Much in Malakoff's treatment record supports the view that his doctors
were not inclined, at least initially, to define him as addicted and
were less than aggressive about finding out whether he was truly off
drugs, as he said he was.

In an April 2000 retrospective he wrote as part of his treatment,
describing his drug habits leading up to being caught in 1999,
Malakoff wrote: "The medication made me feel better and I kept using
more. . . . I found myself trying to do anything to avoid interrupting
taking and getting the medication. . . . Daily use of the medication
became necessary."

Yet according to a deposition by GWU's chief of medicine, Alan
Wasserman, an initial evaluation of Malakoff by the medical center's
then-chief of psychiatry David Mrazek concluded that Malakoff "did not
have an addiction problem" but rather had a problem of
"self-medicating."

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.