Citation Nr: 21022495 Decision Date: 04/16/21 Archive Date: 04/16/21 DOCKET NO. 04-04 098 DATE: April 16, 2021 ORDER Entitlement to service connection for cocaine addiction, to include as related to the postoperative residuals of nasal bone fracture with scarring is denied. FINDINGS OF FACT 1. Service connection is currently in effect for the postoperative residuals of nasal bone fracture, with scarring. 2. The competent and credible evidence does not show that it is at least as likely as not that the Veteran’s cocaine addiction was caused by the topical administration of cocaine and Lidocaine during an inservice surgery to repair the Veteran’s nasal bone fracture, alone or in combination with the administration of Tylenol #3 for postoperative pain relief, with the result that the competent evidence preponderates against the Veteran’s claim. 3. The Veteran’s cocaine abuse in-service was due to his own willful misconduct. CONCLUSION OF LAW The criteria for entitlement to service connection for cocaine addiction, to include as related to the postoperative residuals of nasal bone fracture with scarring have not been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.301, 3.303, 3.304 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September1986 to June 1988. The Veteran testified before the undersigned Veterans Law Judge at a December 2005 hearing that was held at the Regional Office (RO). A transcript is of record. The Board acknowledges that this appeal has a rather complex procedural history and has been back and forth to the United States Court of Appeals for Veterans Claims (Court) several times. Most recently, in July 2020, the Board remanded the appeal for additional evidentiary development. It has since been returned to the Board for further consideration. Entitlement to service connection for cocaine addiction, to include as related to the postoperative residuals of nasal bone fracture with scarring Legal Principles The Veteran seeks entitlement to service connection for cocaine addiction, to include as related to the service-connected postoperative residuals of nasal bone fracture with scarring. Essentially, he contends that his longstanding addiction to cocaine is the direct result of the topical administration of cocaine and Lidocaine during an in-service surgery to repair the Veteran’s nasal bone fracture, alone or in combination with the administration of Tylenol #3 for postoperative pain relief. In that regard, service connection may be established for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131 (2012). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in-service. 38 C.F.R. § 3.303. In order to establish direct service connection for a claimed disability, there must be competent evidence of that disability; medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and competent evidence of a nexus between the claimed inservice disease or injury and the current disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); see also Hickson v. West, 12 Vet. App. 247, 253 (1999). However, primary drug or alcohol abuse are not disabilities for which service connection may be granted. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.301(c)(d); see also Allen v. Principi, 237 F.3d 1368, 1376-1377 (2001). 38 U.S.C. § 1131, which applies to this claim given that the Veteran served during peacetime, states: For disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in the active military, naval, or air service during other than a period of war, the United States will pay to any Veteran thus disabled who is discharged or released under conditions other than dishonorable from the period of service in which said injury or disease was incurred, or preexisting injury or disease was aggravated, compensation as provided in this subchapter...but no compensation shall be paid if the disability is the result of the Veteran’s own willful misconduct or abuse of alcohol or drugs. (Emphasis added.) “[T]he progressive and frequent use of drugs to the point of addiction will be considered willful misconduct.” 38 C.F.R. § 3.301(c)(3). Furthermore, an injury or disease incurred during active service is not deemed to have been incurred in the line of duty if such injury or disease was the result of the abuse of alcohol or drugs by the person on whose service benefits are claimed. For purposes of applying the above rule, drug abuse means “the use of illegal drugs (including prescription drugs that are illegally or illicitly obtained), the intentional use of prescription or nonprescription drugs for a purpose other than the medically intended use, or the use of substances other than alcohol to enjoy their intoxicating effects.” 38 C.F.R. § 3.301(d). Notwithstanding the aforementioned, service connection for a drug abuse disorder is possible if the abuse of drugs was acquired secondary to, or is a symptom of, a service-connected disability. See Allen, 237 F.3d at 1377, 1381. However, “Veterans can only recover if they can adequately establish that their alcohol or drug abuse disability is secondary to or is caused by their primary service-connected disorder ... such compensation would only result where there is clear medical evidence establishing that the alcohol or drug abuse disability is indeed caused by a Veteran’s primary service-connected disability, or the alcohol or drug abuse disability is not due to willful wrongdoing.” Id. at 1381. Given the above, even if the Veteran began his use of cocaine in-service, he is precluded from receiving compensation for cocaine addiction unless the evidence establishes that his cocaine addiction is due to a service-connected disability. In this case, the Veteran is service-connected for the postoperative residuals of nasal bone fracture with scarring. As previously indicated, it is contended that the Veteran’s in-service treatment for his nasal fracture resulted in cocaine addiction. Accordingly, his contentions fall into the exception to the prohibition on service connection for drug abuse disorders set forth in Allen. Analysis A review of service treatment records discloses that, in September 1987, while in-service, the Veteran sustained a nasal bone fracture with laceration for which he received treatment in the form of a closed reduction and splint. During the course of the closed reduction, 4cc’s of 4% cocaine and 5.4cc’s of 1% Lidocaine were administered topically. The Veteran was also prescribed 30 tablets of Tylenol #3 for pain relief. Pertinent evidence of record is to the effect that the Veteran began using cocaine in-service, and, in June 1988, received a general (under honorable conditions) discharge from service for misconduct, specifically, drug abuse. Significantly, in a written statement opposing his discharge, the Veteran contended that, after he was notified of the discharge proceedings, he “began looking at [his] hospital records to try to find some explanation” for his drug abuse. He reported that, after looking at his service treatment records, he discovered that he had been treated for a broken nose and given cocaine. The Veteran thought that since a drug and alcohol counselor told him that it was possible to get “hooked” on cocaine with a single use, it was “possible” that the use of cocaine during his nasal surgery led him to use cocaine illegally. The Veteran also indicated that his nasal injury caused him to become withdrawn and shy, and conjectured that loneliness, in conjunction with the use of cocaine during his nasal surgery, contributed to his illicit drug abuse. At the time of a VA psychiatric examination in April 2003, the Veteran reported that he had begun abusing cocaine while he was in-service. The Veteran additionally reported that in-service, medical cocaine was used to numb his nose after he split his nostril and fractured his nose, and that he believed that this led to his cocaine addiction. The Veteran reported that he felt out of place in-service, and that he felt that it was unfair that he had been discharged for using cocaine. The Veteran continued to abuse cocaine after service, and went through several detoxification programs, finally becoming clean in 2001. Significantly, in the opinion of the examining psychiatrist, he was unaware of any medical studies which documented that medical cocaine could cause cocaine addiction, though he could not determine in the Veteran’s case whether medical cocaine caused the Veteran’s cocaine addiction. On subsequent VA psychiatric examination in May 2007, the Veteran again reported that he had fractured his nose in-service and had it reset. According to the Veteran, he had been given some Lidocaine plus a topical cocaine preparation for anesthesia. Significantly, according to the Veteran, he had undergone no further procedures on his nose, and was never again administered Lidocaine or any cocaine preparation. According to the Veteran, he began to experience “cravings” about a week later. One or two weeks following his surgery, the Veteran reportedly began using cocaine illicitly. The Veteran was subsequently discharged from military service due to his cocaine abuse. The Veteran continued to use cocaine sporadically since that time, with his most recent use being three weeks prior to the examination. According to the Veteran, he attended treatment programs six or seven times, but continued to abuse cocaine. Significantly, by the psychiatrist’s own admission, because he was not an ear, nose and throat doctor who utilized topical cocaine preparations, he was unable to provide an opinion as to whether a single topical administration of cocaine could cause cocaine addiction. Nor did he know the strengths of such preparations. According to the psychiatrist, he was neither trained nor experienced in addiction treatment to the point where he had firsthand knowledge of the propensity for addiction from a single use of cocaine. However, he was unaware of any psychiatric literature which would substantiate the one-time use of a topical cocaine preparation as being the significant causative force in a person’s 20-some year abuse problem with cocaine. Accordingly, the psychiatrist suggested that an opinion be obtained from someone trained in that area. Following a review of the Veteran’s claims folder in October 2007, a VA psychologist concluded that it was not possible to state with any medical certainty whether the Veteran’s single use of the preparations in question for a medical procedure while in the military could have resulted in his involvement with cocaine over the past 20 years. However, she was unaware of any research findings which supported the Veteran’s contentions that a one-time use of these preparations at the dosage noted and for the purpose indicated would be a significant causative force in his lengthy involvement with cocaine. Rather, in her opinion, the Veteran’s problems with addiction most likely could not be attributed to his in-service operative procedure. In correspondence of December 2007, the Veteran’s private physician wrote that he had treated the Veteran for his cocaine addiction. He further indicated that the Veteran had reported that he had been treated with intranasal cocaine and Lidocaine to externally fixate his nasal fracture, following which he became “agitated and sweaty,” and went to get cocaine for the first time ever within a few days of his surgery. Moreover, according to the Veteran, he had intense cravings for cocaine ever since his surgery. According to the Veteran’s private physician, the Veteran suffered from a chronic cocaine addiction which began immediately after medical treatment for a fractured nose with Lidocaine and cocaine. He further indicated that Lidocaine enhances and prolongs the action of cocaine, adding to the reinforcing properties of that drug, and that Tylenol #3 “adds to the addictive nature of cocaine as another drug that is reinforcing in the addictive center of the brain.” Finally, according to the Veteran’s private physician, it was at least as likely as not that the Veteran’s chronic cocaine addiction was due to the medical administration of cocaine to externally fixate the Veteran’s nasal fracture in September 1987. In correspondence of August 2009, a private Master’s-level “licensed clinical addiction specialist” offered her opinion that: A major adverse reaction occurred during the ingestion of cocaine and Lidocaine triggering [the Veteran’s] chemical dependency. Cocaine is one of the most addictive narcotics there is. An additional risk is presented when Lidocaine is given in combination with cocaine. I feel confident stating that an individual can become addicted after a single use of this powerful combination. She further indicated that it was more likely than not that the Veteran’s cocaine addiction was caused by the administration of cocaine and Lidocaine, as well as Tylenol #3. She reasoned that medical cocaine was likely more potent than contaminated street cocaine, and that it was “reasonable” that the Veteran had an “allergic reaction” or genetic predisposition which made him vulnerable to developing “the disease of addiction.” In September 2009, the Board sought an expert medical opinion concerning whether the topical use of cocaine and Lidocaine at the time of the Veteran’s nasal procedure could have caused his cocaine addiction. In December 2009, that VA medical expert, an ear, nose, and throat surgeon, replied that it was “unlikely and actually not reported that a one-time use of cocaine can cause addiction to cocaine. As ear, nose, and throat surgeons, we use this routinely to reduce nose fractures and have never had a problem.” The VA physician additionally reported that Lidocaine was commonly used in ear, nose, and throat surgeries, sometimes with cocaine, and that while she was not certain of any prolonged effects, the one-time use was not likely to cause cocaine addiction. In order to obtain a more comprehensive opinion, the Board sought another medical expert opinion. In August 2010, that medical expert, a VA otolaryngologist, reported that he had conducted an extensive review of the literature and medical management of the Veteran’s case. He noted that the American Academy of Otolaryngology and Head and Neck Surgery (AAOHNS) had indicated that they considered cocaine to be a valuable anesthetic and vasoconstriction agent when used in the management of a patient. The otolaryngologist further noted that the U.S. Drug Enforcement Administration (DEA) had indicated that cocaine could be administered by a doctor for legitimate medical uses such as local anesthesia for some eye, ear, and throat surgeries. Significantly, while potential side effects of the drug had been established, there were no reported cases of a one-time topical use leading to cocaine addiction. Moreover, notwithstanding his review of several hundred publications, he had failed to find a single report relating potential for addiction when cocaine was used on a one-time basis as a topical anesthetic agent. Significantly, while the combined use of Lidocaine would enhance the anesthetic effect, there was nothing in the literature to indicate that it would enhance the potential for cocaine addiction. Finally, there were no reports from DEA and nothing in the literature to support that Tylenol #3 use reinforced the use of cocaine when it was used on a one-time topical anesthetic basis. The evaluating VA otolaryngologist further indicated that he had over 40 years of personal experience with the use of cocaine as a topical anesthetic and vasoconstriction agent in combination with Lidocaine, as well as with the use of Tylenol #3 for postoperative pain relief. Moreover, while during the course of his practice, he had had the opportunity to follow many of his patients for many years, he saw no instance of cocaine addiction arising from this practice. Significantly, according to the evaluating otolaryngologist, he had considerable experience managing the nasal effects of cocaine while in private practice in the 1970’s, and became very familiar with the nasal symptoms of such patients. However, he had not seen similar signs in patients who had nasal surgery with a one-time use of topical cocaine combined with Lidocaine. The physician concluded that it was unlikely that the Veteran’s lifelong cocaine addiction was caused by the use of 4cc’s of 4% cocaine with Lidocaine, followed by the use of Tylenol #3 for treatment of a nasal fracture in-service. Finally, the evaluating otolaryngologist indicated that he had reviewed the opinions of the Veteran’s private physician and the clinical addiction specialist, but “found no evidence to support their opinion.” Moreover, there was nothing he had found through literature review and no cautions from AAOHNS or the DEA that such use carries with it the potential for cocaine addiction. In a response to the aforementioned VA otolaryngologist’s opinion, the Veteran submitted a written statement reiterating that he believed that his cocaine addiction was caused by the one-time administration of topical cocaine and Lidocaine during his nasal reduction procedure in combination with being prescribed Tylenol #3. In addition, he submitted internet article which generally stated that a single use of cocaine can cause cocaine addiction. As discussed above, the claim was denied by the Board in February 2011. That decision was appealed to the United States Court of Appeals for Veterans Claims (Court). It was returned to the Board and further development was undertaken. In correspondence of June 2013, the same “licensed clinical addiction specialist” who provided the August 2009 opinion wrote that she had conducted a second assessment of the Veteran, in addition to performing an “extensive review” of the Veteran’s claims file, including previous medical opinions and medical articles pertaining to cocaine addiction. She further indicated that she had reviewed the Veteran’s medical records, including past/present medical diagnoses and substance abuse treatment records, as well as the types and dosages of medications the Veteran received during his in-service nasal surgery in September 1987. In her opinion, the Veteran suffered from “chronic addiction to cocaine as a disease entity.” She further indicated, based on her experience and research, “it was her professional opinion” that it was “very probable” which is to say, at least as likely as not the case, that the Veteran developed cocaine addiction as the result of the administration of 4cc’s of 4% cocaine and 5.4cc’s of 1% Lidocaine during the procedure to externally fixate his fractured nose (in 1987). She made reference to some literature which was said to support her opinion. In an attempt to further clarify the apparent ambiguity surrounding the Veteran’s claim, the Board, in September 2013, sought the opinion of an independent medical expert. That expert, in early January 2014, offered the following opinion: I am a board-certified Otolaryngology-Head and Neck Surgeon with additional training in facial plastic and reconstructive surgery. Throughout my medical training at three institutions, I have been exposed to many surgeons in my field who utilize 4% topical cocaine for its excellent vasoconstrictive and decongestant properties in nasal surgery such as closed reduction. These well-established physicians used the drug for the duration of their careers. It has not been my practice to utilize topical cocaine for nasal surgery only because of the onerous paperwork associated with obtaining the medication in our hospital and for the close effect achievable with alternate medications. In a different setting, I would have no reservation about using the drug in the appropriate patient, one that does not have underlying cardiovascular disease. After reviewing your excellent summary and [the Veteran’s] medical chart, I performed my own review of the medical literature, with careful attention to papers that your previous reviewer ... would have reviewed plus any additional newer works in the medical literature. Despite the temporal relationship to [the Veteran’s] nasal surgery and the start of his cocaine usage-which seemed to vary in patient reported length from one to two weeks after surgery to within a few days-there is insufficient evidence in the medical literature to document the causal relationship between operative use and addiction. Whereas the addiction specialists you cite give compelling circumstantial evidence, and I understand the powerfully addictive properties of cocaine, it is notable that there is not a single citation or piece of peer-reviewed literature which documents iatrogenic cocaine addiction after nasal surgery. As you note, the American Academy of Otolaryngology-Head and Neck Surgery considers cocaine to be a valuable anesthetic and vasoconstricting agent when used as part of the treatment of a patient by a physician. No other single drug combines the anesthetic and vasoconstricting properties of cocaine.’ [Citation omitted]. This policy was adopted on December 4, 1988, with (the) most recent revision on May 6, 2013. Numerous peer-reviewed publications cite the widespread use by U.S. physicians. Also, two-thirds of United Kingdom otolaryngologists administer topical cocaine according to a 2003 survey [citation omitted]. Therefore, based on absent literature establishing a relationship with 4% topical cocaine and subsequent use or addiction in the large body of medical works; the endorsement of its use for over 25 years by our Academy; and widespread intra-operative use by physicians I have worked with throughout the world, it is my belief that the Veteran’s lifelong addiction to cocaine is unlikely (less than 50 percent likely) to have been caused by the one-time topical administration of cocaine and Lidocaine during his in-service nasal surgery, with or without Tylenol #3. This opinion is consistent with the psychiatric examination in April 2003, psychiatric examination in May 2007, and psychology examination in October 2007 [all of which were] unaware of any psychiatric literature that would substantiate the claim; and the otolaryngology reviews … in December 2009 and … August 2010 [which] also failed to find evidence of causation or a single publication relating nasal administration for surgery and addiction. I am in disagreement with [the Veteran’s private physician’s] assessment in December 2007 and the [clinical addiction specialist’s] assessment in August 2009 [and later in June 2013] which opined on the pharmacokinetics and addiction, but failed to show causation to the nasal surgery. I would respectfully ask these two dissenters to provide any peer-reviewed literature or other scientific works. Barring this, I conclude the cocaine addiction is unlikely related to [the Veteran’s] nasal surgery. Following receipt of that opinion, the Board again denied the claim. Appeal to the Court resulted in additional remand. In pertinent part, it was asserted that it was not clear that the last examiner had reviewed the entire claims file, as opposed to a review of the “medical chart.” Specifically, as the last opinion did not include a discussion of the literature cited by the addiction specialist, it was not clear that the entire claims folder had been reviewed. The fact that the examiner asked the dissenters to provide peer reviewed literature or other scientific works in support of the claim was taken to indicate that the literature mentioned by the additional specialist were not reviewed. In an attempt to further clarify the apparent ambiguity surrounding the Veteran’s claim, the Board, in April 2017, sought the opinion of another independent medical expert. In July 2017, the expert provided the following opinion: I am a board-certified Otolaryngologist with additional subspecialty training in Rhinology, Sinus, and Skull Base Surgery. I have reviewed the entirety of the Veteran’s claims file, including the various internal and external opinions contained therein, as well as the cited medical articles submitted on behalf of the Veteran. I do not have expertise in drug abuse disorders, anxiety disorders, or drug addiction. I do not believe that the Veteran’s lifelong addiction to cocaine was as likely as not caused by the one-time topical administration of cocaine and lidocaine during his in-service nasal surgery, alone or in combination with the administration of Tylenol #3 for the relief of postoperative pain. In September of 1987, the Veteran sustained a nasal bone fracture with laceration and underwent a closed reduction and splint; the laceration was also repaired. During the procedure, 4cc’s of 4% cocaine and 5.4cc’s of 1% lidocaine were administered. [The Veteran] was also given 30 tablets of Tylenol #3 for post-operative analgesia. Per [the Veteran’s] account, he had no prior history of cocaine abuse, but shortly after the procedure he felt he needed to procure more, and thus an extensive pattern of abuse began. Per [the Veteran’s] account, after his discharge from the military for drug abuse, he first began to explore the origins of his cocaine addiction, at which point he learned that he had been given cocaine during his procedure the year before. He also notes that his injury resulted in an anxiety disorder, which further increased his proclivity to abuse cocaine. [The Veteran] subsequently developed a prolonged and severe cocaine abuse disorder resulting in a multitude of lifelong personal and professional problems. Regarding the procedure itself wherein topical cocaine was administered, I believe one important point has been overlooked. While the opinions and literature expressly discuss the “topical” or “intranasal” administration of cocaine, it is unclear if administration of topical cocaine in a surgical field containing a laceration could have also resulted in some degree of inadvertent intravascular cocaine administration. The Veteran, his Addiction Specialist, and the expert opinions all cite various scientific and non-scientific literature to support their opinion that the one-time medical administration of intranasal topical cocaine can result in lifelong addiction, which will herein be summarized and evaluated with regard to the Veteran’s particular case. A 1991 article in the Annals of Emergency Medicine explores the “Lidocaine potentiation of cocaine toxicity,” but this study examined intraperitoneal injections of high doses of cocaine and lidocaine in rats. It is not at all clear that these data would hold true in an analogous study of intranasal topical cocaine and lidocaine in rats, let alone humans. The claims file includes reference to a 1999 article in Drug Safety “Does Cocaine Still Have a Role in Nasal Surgery?” and a 1995 article in Anesthesia Analgeisa “Cocaine, Lidocaine, Tetracaine: Which is Best for Topical Nasal Anesthesia?” [These articles are] relevant to clinical practice, as they report that safer and equally effective alternatives to intranasal topical cocaine exist, but the articles do not include evidence that a one-time medical administration could result in lifelong addiction. Likewise, the 2010 article “Topical cocaine for relief of mucosal pain” does not address the central question to the Veteran’s case. There are also a number of online articles and personal testimonies also included in the claims file, which should not be considered scientific evidence to support or refute their opinion. The claims file also includes a few references to the notion that cocaine addiction can develop in a person after just one use, which is a notion that I believe has wide consensus in the medical field. In summary, the only claim that I consider scientifically sound based on the evidence and literature cited by those with this opinion is that addiction can develop after only one use. The Otolaryngologists and expert reviewers who have refuted the claim that the onetime medical administration of intranasal topical cocaine can result in lifelong addiction have also referenced several sources, which will herein be summarized and evaluated with regard to the Veteran’s particular case. Some of the Otolaryngologists have attested that they have used cocaine in a similar manner many times, and have never had a problem or addiction develop; however, one surgeon’s experience does not indicate what may or may not be possible for a given patient. Furthermore, the surgeon may not be aware of what has happened to all of the patients to whom he administered cocaine. Likewise, that the American Academy of Otolaryngology – Head and Neck Surgery and Drug Enforcement Administration (DEA) have formal statements on the use of intranasal topical cocaine does not indicate that addiction stemming from the one-time medical use is impossible. Analogously, the American Academy of Otolaryngology – Head and Neck Surgery also has statements on antibiotics and procedures; however, one cannot infer by the existence of those statements that those antibiotics or procedures are without risk. I do agree with these expert reviewers on one important point, which is that there are no reports of lifelong addiction stemming from the one-time medical administration of intranasal topical cocaine. Given that cocaine has been administered in this manner for decades to likely hundreds of thousands of patients, one would expect this complication to have been reported if it were possible. Yet the absence of such a report does not mean that it has not happened, or that it cannot happen. However, I do not believe that the Veteran’s lifelong addiction to cocaine was as likely as not caused by the one-time topical administration of cocaine and lidocaine during his inservice nasal surgery because of the simple fact that the Veteran did not know he had received cocaine during this procedure. Per the Veteran’s account, after his surgery he began to crave the same feeling that he had during the surgery, and thus sought out and procured cocaine. But how did the Veteran know that it was cocaine that he should seek to reproduce that feeling? Per [the Veteran’s] account, after his discharge from the military for drug abuse, he first began to explore the origins of his cocaine addiction, at which point he learned that he had been given cocaine during his procedure the year before. If he had no prior history of cocaine abuse, no prior knowledge of what cocaine feels like, and had no idea that he received it during his procedure, then it seems extremely unlikely to me that he would have known to seek, purchase, and use cocaine to reproduce that feeling. Certainly the medical administration of cocaine may have resulted in some degree of physiologic stimulation and triggered the desire for more, and I agree that the one-time use of cocaine can result in addiction. However, presumably those users know that they used cocaine and therefore then know to use more. It is not at all clear that the one-time unknowing use of cocaine would somehow also instill in the user the knowledge that cocaine is the substance responsible for the feeling, and that more cocaine would be required to replicate the feeling. Therefore, I do not believe that the Veteran’s lifelong addiction to cocaine was as likely as not caused by the one-time topical administration of cocaine and lidocaine during his in-service nasal surgery. A knowledge of the addictive properties of cocaine is essential in order to provide an opinion regarding this matter. As the July 2017 expert stated that a knowledge of addictive properties was essential, and at the outset of the opinion he noted no particular expertise in drug addiction or drug abuse disorders, the Board requested a medical opinion from a certified specialist in addiction and substance abuse. In January 2018, a licensed VA Addiction Medicine Specialist provided the following opinion, which is transcribed below: I have reviewed the VBMS, the articles referenced and conducted a literature search on the use of topical intranasal cocaine. I was unable to find any literature on the isolated use of topical intranasal cocaine use as the precipitant for cocaine addiction. One study conducted by Craig Van Dyke, MD with the San Francisco, California VAMC, ‘Intranasal Cocaine: Dose Relationships of Psychological effects and Plasma Levels’ spoke to the ability of subjects with prior history of recreational cocaine use being able to identify the peak “High” following administration of various doses in relation to mean peak plasma concentrations. If [the Veteran] has prior experience with the use of cocaine it would be more likely than not that he would have been able to identify the drug used during the procedure. Drug variables alone do not fully explain the development of addiction. Most people that experiment with drugs of high addictive potential (addiction liability) do not intensify their drug use and lose control. It is the repeated volitional engagement in drug use resulting in neuroadaptations in the motivational circuitry of the Limbic System that lead to a loss of control or compulsive drug use characteristic of addiction. The addiction percentage of those that have ever used cocaine developing addiction is approximately 2.7%. Goodman & Gilman’s Therapeutics, 12th Edition. Cigarettes smokers, or heavy alcohol drinkers are each at least 10 times more likely to use cocaine than are nonsmokers or moderate (non-binge) drinkers. Cocaine users are also twice as likely to have symptoms of depressive or anxiety disorders than are nonusers. ASAM 5th Edition, p158. Addiction is influenced by the various host factors such as heredity, prior experiences, psychiatric disorders, and propensity for risk-taking behavior and environmental conditions including peer influence, employment, education, conditioned stimuli. That being said, [the Veteran] has significant contribution from these factors per review of VPDM that include first use alcohol at age 16, Nicotine dependence to cigarettes onset age 15 or 16, family [history] “alcohol related difficulties on both sides of his family” and history of sexual abuse all mentioned in the Discharge Summary from the Salisbury VA [on September 22, 2016]. Therefore, it is less likely than not that the one-time use of intranasal dose used in [the Veteran] (4ml of 4% cocaine and 5.4% Lidocaine) resulted in his Stimulant use disorder/cocaine addiction. In the July 2019 remand, the Board determined that an addendum opinion from the January 2018 VA Addiction Medicine Specialist was necessary to resolve the claim. Specifically, it was noted that the January 2018 opinion failed to address the Veteran’s exposure to cocaine in-service, when the Veteran became addicted to cocaine, whether his exposure contributed to that addiction, nor did it address the positive and negative evidence that has been summarized in this regard. Curiously, and during development, the Veteran underwent a VA examination performed by a clinical psychologist in March 2020, wherein he was diagnosed with cocaine dependence. The examiner then determined that the Veteran’s condition is less likely than not attributable to an in-service event. The examiner provided the following rationale: There is no medical or scientific evidence to support that claim that life long addiction would be related to a very limited administration of an extremely low concentration of cocaine/lidocaine topical along with the limited use of Tylenol #3. Additional development was requested and the January 2018 VA Addiction Medicine Specialist was eventually contacted. In April 2020, she provided the following report: I am and Addiction Medicine Specialist, certified by ASAM, ABAM, and the AOA. I have had the opportunity to review this Veteran’s claims file including the various opinions referenced, in addition to cited medical articles submitted. I have also conducted an independent search of literature on the use of topical intranasal cocaine during surgery with/without lidocaine and on Stimulant use disorder with cocaine. It is my opinion that the Veterans lifelong addiction to cocaine is not likely due to the one-time administration of intranasal dose of cocaine and lidocaine for his in-service nasal surgery, alone or in combination with Tylenol #3 for postoperative pain. I have reviewed the various expert opinions. As stated in my Independent Medical Opinion, I am not aware of any literature that speaks to the isolated use of topical intranasal cocaine during surgery as a precipitant for cocaine addiction. I therefore agree with the Otolaryngologists consistent opinion that there is not sufficient evidence in the medical literature documenting iatrogenic cocaine addiction following nasal surgery. I therefore do not agree with the opinion of the licensed clinical addiction specialist August 2009 or this Veteran’s private physician December 2007 that this Veterans cocaine addiction to be “very probable” a result of a one time in-service use of intranasal cocaine and lidocaine for surgery in Sept 1987. I do agree however that this Veteran likely had a genetic predisposition based on his family hx of “alcohol related difficulties on both sides of his family”. The rationale for my opinion has been previously stated in my Independence Medical Opinion Dated 1/25/18. Addiction is a chronic disorder whose development is due to the interaction of various host, environmental, genetic factors in addition to the drug pharmacokinetics. I do not consider myself qualified to discuss the merits of the other specialist’s opinion than that stated above. None of the articles cited speak to or validate the Veterans claim that one time use of intranasal cocaine and lidocaine predisposes one to a life long addiction to cocaine. The Board notes that in a separate correspondence, the same VA Addiction Medicine Specialist stated that if her opinion is not sufficient, it would be of assistance to get an opinion from another Addiction Medicine Specialist, “possibly one with a pharmacology or forensics background.” Pursuant to the Board’s most recent remand, additional opinions were later obtained. After a review of the Veteran’s electronic claims file, a VA psychologist determined that the Veteran’s condition is less likely than not attributable to service. The psychologist stated: There has been conflicting opinions as to the impact of the cocaine exposure during nasal surgery. The best conclusion is supportive of the more recent opinions that a lifetime addiction can NOT be attributed to a 1-time exposure to a very low concentration of topical cocaine, and that there is no known “literature that speaks to the isolated use of topical intranasal cocaine during surgery as a precipitant for cocaine addiction”. Veteran’s lifelong addiction to cocaine is less likely than as not (less than 50 percent probability) caused by the one-time topical administration of cocaine and lidocaine during his in-service nasal surgery, alone or in combination with the administration of Tylenol #3 for the relief of postoperative pain. Another opinion was obtained from a VA psychiatrist in January 2021. After a review of the Veteran’s electronic claims file and summary of the pertinent treatment records, the psychiatrist also determined that the Veteran’s condition is less likely than not incurred in or caused by military service. The psychiatrist provided the following rationale: I am board certified by the American Board of Psychiatry and Neurology in Addiction Psychiatry, effective 2012 to current date. I have had the opportunity to review the claimants file including the previous referenced opinions and medical articles submitted on behalf of the veteran. I have additionally conducted a literature search regarding stimulant use disorder, and intranasal cocaine/lidocaine. Based on review of the recent medical literature in addition to the claimants file, previously referenced opinions and medical articles submitted on behalf of the veteran, it is my opinion that the veteran’s lifelong addiction to cocaine was less likely than not (less than 50% probability) caused by the one time topical administration of cocaine and lidocaine during his in-service nasal surgery, alone or in combination with the administration of Tylenol #3 for the relief of postoperative pain. Development of substance use disorders, such as stimulant/cocaine use disorder, is based on a number of predisposing factors including neurobiology, genetics, environment. There is no current medical literature supporting that a one time use of an intranasal or topical combination of cocaine and lidocaine is sufficient to cause a lifelong substance use disorder. As such, I disagree with the two prior medical opinions, which were offered by non-physician and non-addiction specialized clinicians without sufficient training in substance use disorders, that the claimants one time exposure may have caused or contributed to his stimulant/cocaine use disorder. I concur with the multiple other medical opinions offered by psychologists and physicians that the claimants stimulant/cocaine use disorder is less likely than not incurrent in or caused by his one time exposure to topical cocaine intraoperatively. There are varying accounts in his medical records with regard to when he began to use cocaine. Prior medical opinions suggest the veteran reported initiating cocaine use within weeks of intraoperative exposure to cocaine, though other records including 4/2/98 discharge summary from ADATC suggest it was later in 1988. Records appear consistent that he did not use cocaine prior to the military. There is ample evidence in the literature that the claimant suffered from alcohol use disorder prior to enlistment, suggesting a predisposition to substance use disorders. Records also suggest that the claimant experienced childhood sexual trauma, which is common among those who go on to develop substance use disorders such as stimulant/cocaine use disorder and is more likely contributor to his development of stimulant use disorder than a one time exposure to topical administration of cocaine and lidocaine during his in-service nasal surgery. After carefully considering the Veteran’s contentions and reviewing the evidence of record, the Board finds that the preponderance of the most probative evidence is against the claim of entitlement to service connection for cocaine addiction, to include as related to the postoperative residuals of nasal bone fracture with scarring. When evaluating medical opinions it is the province of the Board to weigh the evidence and decide where to give credit and where to withhold the same, and in so doing, to also accept certain medical opinions over others. See Evans v. West, 12 Vet. App. 22, 30 (1999). The Board cannot make its own independent medical determinations, and there must be plausible reasons for favoring one opinion over another. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail and whether there was review of the Veteran’s claims file. Prejean v. West, 13 Vet. App. 444 (2000). An evaluation of the probative value of a medical opinion or diagnosis is based on the medical expert’s personal examination of the patient, the examiner’s knowledge and skill in analyzing the data, and the medical conclusions reached. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When confronted with conflicting medical opinions, the Board must weigh each and favor one competent medical expert over another if its statement of reasons and bases is adequate to support that decision. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board must also determine which of the competing medical opinions is more probative of the medical question at issue. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300 (2008). Here, the Board finds that the opinions of multiple VA psychiatrists, psychologists, and otolaryngologists are highly probative, because those opinions were based upon a review of the Veteran’s entire electronic claims file, as well as other pertinent medical records, and, in most cases, full examinations, to include both history and clinical findings. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). The VA physicians and psychologists reviewed the Veteran’s claims folder, discussed the Veteran’s medical history, provided well-reasoned medical opinions, and alluded to the evidence and medical studies which supported those opinions. Significantly, in those instances where the examiners were unable to state categorically that the Veteran’s cocaine addiction was unrelated to the in-service topical administration of cocaine/lidocaine, they universally indicated that they were unaware of any medical studies that the one-time use of a topical cocaine preparation could result in lifetime addiction to cocaine. Moreover, at least two VA otolaryngologists, who would presumably have considerable expertise in the field, including one who reviewed “several hundred publications,” found no relationship between the Veteran’s lifelong cocaine addiction and the use of cocaine with Lidocaine followed by the use of Tylenol #3 for treatment of his nasal fracture in-service. Also noted above, an independent medical expert unaffiliated with VA offered his opinion that the Veteran’s lifelong addiction to cocaine was unlikely (which is to say, less than 50 percent likely) to have been caused by the one-time topical administration of cocaine and Lidocaine during his inservice nasal surgery, with or without Tylenol #3. According to the independent medical expert, while the Veteran’s private physician and “addiction specialist” provided compelling circumstantial evidence, they failed to provide a single citation or piece of peer-reviewed literature documenting iatrogenic cocaine addiction following nasal surgery. Under the circumstances, the medical expert was in disagreement with their opinion regarding the pertinent pharmacokinetics and addiction, which failed to show any causation to the Veteran’s nasal surgery. The Board observes that the independent medical expert noted a review of the Veteran’s “medical chart” instead of the electronic claims file. The Board acknowledges that the Court has indicated that it is not entirely clear whether this expert had access to the entirety of the Veteran’s electronic claims file. However, the expert provided a thorough and reasoned analysis, so the opinion is afforded some probative value. Moreover, the expert addressed all the pertinent evidence in the claims folder, leading to the conclusion that he reviewed it all. As indicated above, the Board obtained an opinion from another independent medical expert in July 2017. The expert stated that he had reviewed the entirety of the Veteran’s claims file, including the various medical opinions discussed above and described them in great detail. The expert noted that while the VA and private opinions differed as to the cause of the Veteran’s cocaine addiction, they all agreed on one important point. Namely, the expert commented that “there are no reports of lifelong addiction stemming from the one-time medical administration of intranasal topical cocaine. Given that cocaine has been administered in this manner for decades to likely hundreds of thousands of patients, one would expect this complication to have been reported if it were possible.” Further, the expert remarked that the Veteran was unaware that he was administered cocaine during the original nasal procedure. Notably, the expert stated that “It is not at all clear that the one-time unknowing use of cocaine would somehow also instill in the user the knowledge that cocaine is the substance responsible for the feeling, and that more cocaine would be required to replicate the feeling.” For these reasons, the expert opined that the Veteran’s addiction to cocaine was less likely than not caused by the one-time topical administration of cocaine and lidocaine during his in-service nasal surgery. The expert also remarked that a knowledge of the addictive properties of cocaine is essential to provide an opinion regarding the matter. As the expert provided a lengthy and complete analysis, the Board affords the July 2017 opinion some probative value as well. Importantly, the Board obtained an opinion from an addiction medicine specialist in January 2018. The Board places substantial probative value on the report as the specialist indicated a complete review of the Veteran’s electronic claims file along with adequate reasons and bases for reaching her decision that it is less likely than not that the one-time use of intranasal cocaine resulted in the Veteran’s cocaine addiction. Here, the specialist stated that she was unable to find any medical literature on the isolated use of topical intranasal cocaine as the precipitant for cocaine addiction. The specialist then cited to medical articles which suggested that if the patient has prior experience with cocaine, then the patient is more likely to be able to identify the drug used during the procedure and seek it out again. Further, the specialist noted that addiction is influenced by several other external risk factors which can make it more likely to develop an addiction. The specialist then explained that the Veteran has a history of an early onset of smoking and alcohol consumption in his family, as well as a history of sexual abuse, all of which can lead to an addiction disorder. As previous examiners have suggested that an opinion on the addictive properties of cocaine is essential in determining this issue, the addiction medicine specialist’s opinion is afforded substantial probative value. The Board also affords the January 2021 VA opinion substantial probative value. The examiner, an addictive psychiatry specialist, opined that: There is no current medical literature supporting that a one time use of an intranasal or topical combination of cocaine and lidocaine is sufficient to cause a lifelong substance use disorder. As such, I disagree with the two prior medical opinions, which were offered by non-physician and non-addiction specialized clinicians without sufficient training in substance use disorders, that the claimants one time exposure may have caused or contributed to his stimulant/cocaine use disorder. I concur with the multiple other medical opinions offered by psychologists and physicians that the claimants stimulant/cocaine use disorder is less likely than not incurrent in or caused by his one time exposure to topical cocaine intraoperatively. It is noted that the January 2021 examiner, as well as several of the other examiners discussed above, have all indicated a review of the claims file and synthesized the pertinent evidence and treatment history. They have also discussed and reconciled the assorted private opinions of record. Nearly all of the VA and independent examiners have emphasized that they are unaware of any medical literature that supports the theory that a one time exposure to topical cocaine can result in addiction. Moreover, the January 2021 examiner disagreed with the private reports submitted in support of the claim, at least in part, because they were authored “by non-physician and non-addiction specialized clinicians without sufficient training in substance abuse disorders.” The VA and independent opinions of record also tend to suggest that the Veteran’s cocaine addiction may have stemmed from his history of alcohol use disorder prior to enlistment, suggesting a predisposition to substance use disorders. The records also indicate that the Veteran experience childhood sexual trauma, which is frequently found among those who go on to develop substance use disorders such as stimulant/cocaine use disorder and is therefore more likely contributor to his development of stimulant use disorder than a one time exposure to topical administration of cocaine and lidocaine during his in-service nasal surgery. For these reasons, the private opinions of record are afforded minimal probative value. The Board acknowledges the Veteran’s statements and testimony regarding the origin of his cocaine addiction. However, as a lay person, the Veteran is not competent to provide a medical diagnosis or to determine the etiology of his cocaine addiction. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Thus, the opinions of competent medical professionals are entitled to greater probative weight, and are found by the Board to be far more probative than the Veteran’s lay assertions as the relationship between the in-service topical application of cocaine/Lidocaine and his subsequent cocaine addiction. In sum, there exists no persuasive evidence that the Veteran’s cocaine addiction is in any way causally related to the one-time topical application of cocaine/Lidocaine in-service. While the Board is cognizant of the reports from the Veteran’s private physician and clinical addiction specialist, these reports are afforded less probative value as they fail to address the contentions and conclusions provided by multiple and more recent examiners. In this regard, the overwhelming amount of articles discussed by the various examiners of record demonstrate that there is little evidence to support a finding that a one-time medical administration of cocaine solution could result in lifelong addiction. It has also been suggested that he may have been predisposed to cocaine addiction based on his childhood experiences and history of alcohol use disorder prior to service. Again, the private opinions discussed at length above were authored by clinicians without sufficient training in analyzing and treating substance abuse disorders.   For the above reasons, the Veteran’s claim is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. 38 U.S.C. § 5107. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Miller, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.