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Dr. House presents with long-term Vicodin use. It was initially prescribed for chronic pain following an infarction in his leg. His use escalated beyond any medical necessity to where he developed a tolerance, dealt with withdrawal symptoms, and compulsive use despite any negative consequences. His addiction has contributed to strained personal and professional relationships, irritability, impaired judgment, and has served as a means of avoiding emotional vulnerability and psychological distress

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Dr. Gregory House is a middle-aged man who works as a physician. He has developed chronic pain in his right leg following an infarction that left him having to use a cane to walk and dependent on Vicodin for the pain. Dr. House is often dealing with the ongoing demands of his role as a physician especially with his professional identity being tied to his ability to diagnose others. Currently, he experiences chronic pain, disrupted sleep, low mood, and irritability. Cognitively, he justifies his use by saying it helps him work and helps with his pain. Dr. House also tends to isolate himself and avoids emotional vulnerability with others which has caused him to have many strained relationships. Behaviorally, his Vicodin use has moved from alleviating pain to habitual use. He has developed a high tolerance, has had unsuccessful attempts to stop, and has continued his use despite both interpersonal and professional consequences.

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Dr. House experiences chronic pain in his right leg due to an infarction that resulted in muscle loss. He was prescribed Vicodin to deal with the pain after going through surgery. Dr. House eventually developed a dependence on the medication and would increase his dosage after also developing a high tolerance. He often experiences disruptions in his sleep and withdrawal symptoms when he makes attempts to stop his use. His physical functioning is also limited which reinforces his use.

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Dr. House has shown a pattern of avoiding emotional vulnerability. His Vicodin use has not only helped manage physical pain but also seems to numb any emotional distress that he experiences. He occasionally reports feelings of loneliness, depression, and feelings of inadequacy that he hides by being arrogant. Dr. House rationalizes his use as necessary because he says it helps him do his job and displays ambivalence towards his addiction at one point saying "I said I was an addict, I didn't say I had a problem". He has shown traits such as irritability and self-reliance which limit his openness to treatment.

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Dr. House is often isolated and in conflict whenever he is not. His closest relationships are strained because of his personality and substance use. However, they sometimes also enable his behavior by excusing his actions due to his genius ability to diagnose others. With his talent and working in a high-pressure environment, there is little external accountability for his addiction. Dr. House also reports a strained relationship with his family as his father (who he later found out was not his biological father) was abusive and his mother was emotionally distant. This has contributed to his mistrust of others, remaining emotionally guarded, and his inability to form close relationships. He has limited support outside of work and often struggles to maintain or build other relationships.

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Based on DSM-5 criteria for Opioid Use Disorder (American Psychiatric Association, 2013), Dr. House's diagnosis can be classified as severe. He demonstrates several symptoms such as:

Opioids are taken in larger amounts or over a longer period than was intended

Unsuccessful efforts to cut down or control opioid use

A great deal of time is spent in activities necessary to obtain and use of the opioid

Craving, or a strong desire or urge to use opioids

Continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids

Important social, occupational, or recreational activities are given up or reduced because of use

Recurrent use in situations in which it is physically hazardous

Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

Tolerance

A need for increased amounts to achieve intoxication or desired effect

A diminished effect with continued use of the same amount

Withdrawal

The characteristic opioid withdrawal syndrome

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"First you take a drink, then the drink takes a drink, then the drink takes you."

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"First you take a drink, then the drink takes a drink, then the drink takes you."

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F. Scott Fitzgerald was an American Author known for his depictions of the Jazz Age during the 1920s. Struggled with alcoholism throughout his career that lead to personal and health problems. Eventually passed of a heart attack at age 44.

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"It does not matter how slowly you go as long as you do not stop"

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"It does not matter how slowly you go as long as you do not stop"

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Confucius was a Chinese philosopher who taught that social harmony can be achieved through personal morality, ethical conduct, and respect for tradition and family. Emphasized that individuals can become virtuous through self-reflection, education, and emulating moral leaders.

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SMART Recovery is an evidence-based support program that is grounded in REBT and CBT that supports those facing addiction. Peer recovery support services (PRSS) such as SMART Recovery have been found to help those dealing with Opioid Use Disorder such as through improved retention in treatment, reduced misuse, and has supported remission (Gormley et al., 2021). They emphasize peer support, self-management, coping skills, and rational thinking.

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SMART could help Dr. House by:

Using science-based approaches that align with Dr. House's scientific and rational mindset

Focusing on autonomy and personal responsibility

No focus on higher power

SMART supports the use of medication-assisted treatment - addresses his chronic pain

Teach practical coping skills

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Possible disadvantages of NA for Dr. House:

Requires active participation through homework and exercises given

Doesn't address complexities of those with legitimate medical needs despite supporting medication assisted treatment - gaps in treatment plan?

Too much focus on rationality?

Won't allow for him to explore deeper emotional issues

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Ongoing chronic pain can complicate treatment planning. Creates unique considerations

Cultural norms around masculinity may limit his willingness to be vulnerable

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As a physician, there could be conflicting values. Professional culture that emphasizes control and expertise

Dr. House often holds authority roles and may be resistant to being a patient. Highlights his views on relationships in treatment settings

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Stigma and shame around being a physician with an addiction

House has a job security and financial stability which reduce some of the consequences of his use but it highlights how addiction can impact different groups

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Age: middle aged (45-50)

Developmental disability: None

Disability (acquired): leg injury from an infarction that has led to chronic pain and having to use a cane for mobility

Religion: atheist

Ethnicity: White

Socioeconomic status: not stated, though has displayed job security and financial stability

Sexual orientation: straight

Indigenous heritage: not specified

National origin: U.S.

Gender: male

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Build a strong therapeutic alliance

developing trust and rapport can help with clients who have experienced stigma or betrayal

Use a biopsychosocial approach

physical, psychological, social, and environmental factors all impact lived experience

tailor interventions to the client's background

Assess for comorbidity

integrative care is often more effective than just treating addiction

Consider cultural and social context

be aware of privilege, stigma, and systemic barriers

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Tips for counselors working with Dr. House

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Tips for counselors working with Dr. House

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Build trust and respect autonomy

House values independence and would most likely benefit from a collaborative relationship

Be direct and transparent

House is a very straightforward person and responds better to honesty rather than vague communication

Address his ongoing pain alongside his addiction

Help him explore alternative coping strategies while also validating his pain

Prepare for resistance and challenges

House may be resistant to any treatment, question interventions, and possibly test boundaries

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Working with someone like Dr. House seems to be potentially really challenging because of his personality and resistance to authority. This could make establishing rapport difficult as he also tends to avoid vulnerability. I feel that I would get frustrated especially if he rejects a lot of the treatments that are suggested for him. My approach would probably have to be very collaborative to make him feel like he also still has control over this

Developing an effective treatment plan also seems like it would be challenging. Dr. House still has ongoing pain and also has access to medication given his job. Even with regulated prescriptions, he may still experience temptation/craving and his ability to access and misuse vicodin (or other medications) is also a constant risk especially with the lack of accountability. Working with him would require finding and using strategies that address both pain management and addiction

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Site that provides a directory of over 15,000 treatment facilities across the U.S. Counselors can use this to find treatment options for clients

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Recovered - Helping people to beat addiction

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At Recovered, we know that overcoming addiction is possible, but not easy to do alone. That’s why we aim to provide information about addiction and promote treatment for those that need it.

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American Society of Addiction Medicine (ASAM)

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American Society of Addiction Medicine (ASAM)

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Provides over 300 hours of accredited addiction medicine education. Topic range from advocacy, nonsubstance addiction, women, levels of care, etc.

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ASAM is the largest provider of addiction education in the country, offering Continuing Medical Education (CME) on a variety of addiction-related topics.

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Free, customizable, and evidence-based worksheets that address addictions and substance use and can be used for individual or group sessions. Some of them cover topics such as relapse prevention, trigger identification, and coping strategies.

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Substance Use Worksheets | Therapist Aid

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Download addiction and substance use therapy worksheets. Topics include relapse prevention plans, trigger identification, and more. Great for groups.

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Provides information on what addictions counseling looks like, what kind of skills counselors can teach, and includes practice demonstrations to show what sessions may look like

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Practice Demonstration - Substance Abuse Counseling

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American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5-TR). American Psychiatric Association.

Gormley, M. A., Pericot-Valverde, I., Diaz, L., Coleman, A., Lancaster, J., Ortiz, E., Moschella, P., Heo, M., & Litwin, A. H. (2021). Effectiveness of peer recovery support services on stages of the opioid use disorder treatment cascade: A systematic review. Drug and Alcohol Dependence, 229, 109123. https://doi.org/10.1016/j.drugalcdep.2021.109123