An accusation has been filed against the medical license of an Orange family medicine physician due to his treatment of a patient with a history of drug addiction.
The Medical Board of California accusation states the following as facts of the case:
From Feb. 19, 2014, through Jan. 21, 2015, Smith treated a 22-year-old male with a history of obsessive compulsive disorder, addiction with episodic cannabis abuse, depression with anxiety, anxiety disorder, atypical paranoid disorder, gastritis, minimal scoliosis and right foot pain. During an appointment on the first date above, the patient complained of neck and upper back pain from a motor vehicle accident where he was a backseat passenger.
Smith recommended physical therapy and ice and heat treatments, and he prescribed ibuprofen, the muscle relaxant baclofen and 63 tablets of 5/325 miligram (mg) hydrocodone/acetaminophen to be taken three times daily with one refill. The patient was also instructed to return in three weeks.
At the time of the visit, hydrocodone-acetaminophen was a Schedule III Controlled Substance. On Oct. 6, 2014, it was reclassified a Schedule II Controlled Substance and a dangerous drug. But the compound was apparently not strong enough for the patient, who returned on March 5, 2014, complaining that he was not feeling well and the medications did not seem to be working. What did work well, the man said, was “morphone” that a friend had given him after the friend’s grandmother assisted in “apportioning” the medication due to the patient’s addiction history.
Smith discontinued the hydrocodone/acetaminophen script, replacing it with 90 tablets of 4 mg hydromorphone to be taken three times a day with no refills. Based on the respective daily doses, the morphine equivalency had become three times higher than it had been with the hydrocodone/acetaminophen, according to the accusation.
“The medical records do not reflect consideration of increasing the hydrocodone-acetaminophen dose or frequency, changing the short-term oxycodone, short term lower dose hydromorphone, or intention of rotating opiods at future visits,” reads the state document. “The medical records do not reflect consideration of medication adjustments after the patient saw the recommended psychiatrist or an increase of ibuprofen dose and/or frequency.”
There is documentation of Smith’s Nov. 11, 2014, discussions with the patient about pain management and the use of opiates. Prescriptions were renewed for the hydromorphone as well as the anti-anxiety clonazepam, with a new script added for the antidepressant duloxetine.
Smith also ordered a urine drug screen, noting it was necessary “to build faith” with the doctor and the patient’s parents. A positive test came back for oxycodone, a highly addictive opiod pain medication that Smith did not prescribe to the patient. In what appears to be a Nov. 23, 2014, message to the patient, Smith noted “let’s talk next month. Did they give you oxycodone after the hospitalization?” His records reflect no response from the patient.
The patient saw Smith again on Dec. 17, 2014, but while the records from that visit reflect the narrative of the Nov. 23 message, there are no notes about the inconsistent urine test actually being addressed. It is noted that the duloxetine was discontinued due to “weird thoughts and mild depression,” while the hydromorphone was continued at 4 mg to be taken three times daily.
The same thing happened at a Jan. 21, 2015, appointment, which produced the last available office notes regarding the patient. The Nov. 23 narrative was again incorporated into the progress report that day, but there is no indication the urine test was addressed. It is noted that the hydromorphone was increased to four times a day and that the patient was referred to physical medicine and rehabilitation or physiatry, which is a branch of medicine that aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities.
During Smith’s medical board interview, the doctor said the patient had admitted to him he took someone else’s oxycontin or oxycodone for pain after he left a drug rehab program. That is not reflected in the doctor’s notes from the visits, however.
For Smith’s treatment of the patient, he is accused of repeated negligent acts and failure to maintain accurate and adequate medical records.
The medical board staff seeks a hearing to consider the revocation or suspension of Smith’s license to practice medicine in California.